2014年德国心血管年会热点报道(二)

<正>重度主动脉瓣狭窄患者接受经导管主动脉瓣植入术后出现新发左束支传导阻滞对预后的影响(作者:Panagiotis Tzamalis)经导管主动脉瓣植入术(TAVI)是患有严重主动脉瓣狭窄的手术高危患者的首选术式。TAVI后发生心脏传导阻滞的发病率高于常规主动脉瓣置换手术。其中最常出现的是左束支传导阻滞(LBBB)和房室传导阻滞,并需植入永久起搏器。目前的资料显示:根据植入瓣膜的类型不同,术     

顺向导丝结合导丝抓捕技术应用于经导管主动脉瓣植入术3例

经导管主动脉瓣植入术（TAVI）已成为重度主动脉瓣狭窄（AS）的主要治疗方法之一,尤其是对于具有外科手术禁忌或中、高危风险的高龄患者。手术过程中,部分患者由于瓣膜口极度狭小且瓣膜结构不清、瓣叶冗长/黏连/严重钙化等,导丝逆向跨主动脉瓣进入左心室建立轨道的难度较大,由此导致并发症发生率增高、手术成功率降低。该文报道3例重...     

高危重度主动脉瓣狭窄经颈动脉途径行经导管主动脉瓣置换术治疗的安全性和有效性

目的分析高危主动脉瓣重度狭窄患者经颈动脉途径行经导管主动脉瓣置换术(TAVR)治疗的安全性和有效性。方法选择2017年9月～2019年2月于北京阜外医院、空军军医大学西京医院、南昌大学第二附属医院、大连医科大学第一附属医院、北京医院经颈动脉途径TAVR的症状性重度主动脉瓣疾病患者21例,男性13例,年龄58～91(72.8±8.5)岁。对入选患者临床资料、手术方法及效果进行回顾性分析。结果 21例患者中,12例接受全麻手术,9例在局麻下完成手术。20例患者经右颈动脉途径TAVR,1例经左颈动脉行TAVR治疗。置入Venus A瓣膜20例,VitaFlowⅡ瓣膜1例。其中1例患者出现颈动脉血肿,经局部处理后,血肿吸收好转,其余患者手术过程顺利。21例患者均完成术后随访,其中2例患者出现Ⅲ度房室传导阻滞,行永久起搏器置入术。患者术后随访(30±7)d,均未发生短暂性脑缺血发作、脑卒中、血管并发症、心肌梗死、瓣周漏等不良事件。术后超声心动图显示,未见中量及以上反流;且术后1个月LVEF较术前明显改善[(61.44±6.48)%vs (51.90±13.17)%,P0.05];术后1周和术后1个月平均跨瓣压差较术前明显下降[(14.90±8.03)mm Hg(1mm Hg=0.133kPa)vs (59.48±22.43)mm Hg,P0.01;(13.11±8.45)mm Hg vs (59.48±22.43)mm Hg,P0.01]。结论对不适合行股动脉入路的患者以及主动脉瓣病变复杂,尤其是严重钙化、二叶式主动脉瓣患者、既往曾行二尖瓣瓣膜置换术的症状性重度主动脉瓣狭窄患者,实施经颈动脉途径TAVR安全有效。     

国内首例经导管主动脉瓣置入Edwards SAPIEN 3瓣膜

<正>经导管主动脉瓣置入术(transcatheteraorticvalve implantation, TAVI)是主动脉瓣狭窄的有效治疗手段,已成为外科主动脉瓣置换术手术禁忌或高危患者的一线治疗手段。在我国,TAVI正在逐步开展,普遍使用的是国产自膨胀式瓣膜[1]。随着人工瓣膜器械的不断改良,爱德华瓣膜公司(Edwards Lifescience)也推出了SAPIEN系列的最新一代产品SAPIEN 3。SAPIEN 3的低瓣周漏发生率、低血管并发症发生率及低死亡率已在多项国际临床研究中得到证实[2-3]。     

主动脉瓣环扩大联合环上型生物瓣膜替换治疗老年小瓣环主动脉瓣狭窄的近中期结果

目的:总结主动脉瓣环扩大联合环上型生物瓣膜替换策略,治疗老年小瓣环主动脉瓣狭窄的近中期结果,探讨老年小瓣环主动脉瓣狭窄的治疗策略。方法:2010年1月至2017年1月,28例老年小瓣环主动脉瓣狭窄患者应用主动脉瓣环扩大联合环上型生物瓣替换策略进行治疗,主动脉瓣关闭不全或多个瓣膜病变等排除在本研究之外。男性8例,女性20例,年龄65～77岁,平均(70. 5±3. 48)岁,体表面积1. 55～1. 72 m~2,平均(1. 63±0. 05) m~2。按病因分类,退行性主动脉瓣狭窄17例,先天性二叶畸形6例,风湿性改变4例,其他病变1例。患者术前心功能分级(NYHA分级):Ⅱ级6例,Ⅲ级20例,Ⅳ级2例。同时合并疾病包括冠心病5例,2型糖尿病8例,高血压病7例,慢性肾功能不全5例,慢性阻塞性肺疾病3例,心房颤动7例,既往卒中史6例。手术前超声心动图测主动脉瓣环径(17. 5±1. 02) mm,平均跨瓣压差(59. 8±10. 2) mm Hg (1 mm Hg=0. 133 k Pa)。结果:体外循环时间(105. 0±18. 8) min,心肌血运阻断时间(71. 0±17. 1) min。实测主动脉瓣环径(18. 1±0. 87) mm,应用Nick法扩环25例,Nuez法3例,扩环后主动脉瓣环径(22. 2±0. 93) mm,平均增加(4. 13±0. 78) mm,平均替换瓣膜尺寸(21. 8±0. 99) mm,预期有效瓣口面积指数(1. 10±0. 07) cm~2/m~2。同期行冠状动脉旁路移植术5例,心房颤动射频消融术7例,左心耳切除术7例。围手术期死亡1例(3. 6%),死因为低心排血量综合征。开胸止血术1例,急性肾衰竭1例,肺部感染2例,切口并发症1例,临时起搏治疗6例。出院时平均跨瓣压差(13. 14±2. 14) mm Hg,超声实测有效瓣口面积指数(1. 12±0. 07) cm~2/m~2,仅1例发生轻度患者-人造瓣膜不匹配。手术后2年,常规超声心动图检查及临床评估。24例患者心功能Ⅰ级,3例Ⅱ级。患者平均跨瓣压差及左心室质量指数较术前明显改善[(59. 8±10. 18) vs.(13. 8±1. 93) mm Hg,P 0. 01;(151. 3±9. 95) vs.(110. 6±6. 95) g/m~2,P0. 01]。5例患者主动脉瓣听诊区可闻及2/6级收缩期杂音,19例患者左心室肥厚得到逆转,8例患者仍存在轻度左心室肥厚。随访时平均有效瓣口面积指数(1. 09±0. 09) cm~2/m~2,1例发生轻度患者-人造瓣膜不匹配。结论:主动脉瓣环扩大联合环上型生物瓣替换策略治疗老年小瓣环主动脉瓣狭窄近中期疗效良好,既有效避免患者-人造瓣膜不匹配现象,又避免了长期抗凝所致的血栓栓塞及出血风险。     

过渡性经皮球囊主动脉瓣成形术在治疗危重主动脉瓣狭窄患者的临床应用——单中心经验

目的:探讨过渡性经皮球囊主动脉瓣成形术(PBAV)治疗危重主动脉瓣狭窄患者的临床应用经验。方法:回顾性分析2011-03至2017-03在阜外医院行PBAV的37例暂不适宜行瓣膜置换术的危重主动脉瓣狭窄患者,年龄(74±12)岁。观察患者临床及解剖特点、手术有效及安全性,并进行随访。结果:本组患者基线外科风险高心功能差,二叶式主动脉瓣占比约50%,瓣叶钙化程度重[钙化体积CT值850(HU850)=(856.0±658.2)mm3]。术中参考瓣环上平均内径选择球囊,术后7天主动脉瓣瓣口面积从(0.37±0.10)cm2增大至(0.87±1.10)cm2,主动脉瓣平均跨瓣压差从(55.1±22.9)mm Hg(1 mm Hg=0.133 k Pa)降至(44.8±17.8)mm Hg(P0.001),左心室射血分数从(35.8±14.3)%增加到(41.0±12.2)%(P0.001)。术后住院期间发生死亡4例,1例安装永久起搏器,1例主动脉瓣重度反流。术后平均随访(16.5±11.1)个月,共有13例(35.1%)患者过渡到外科或经导管瓣膜置换术治疗。结论:对于暂不宜行外科主动脉瓣置换术和经导管主动脉瓣置换术(TAVR)的危重主动脉瓣狭窄患者,PBAV可取得良好的早期临床结果,有望成为过渡性治疗手段,对于中国二叶式主动脉瓣比例高,瓣叶钙化重特点,采用瓣环上内径选择较小球囊安全有效。     

经皮主动脉瓣球囊扩张术在钙化型重度主动脉瓣狭窄合并左心功能不全患者中的临床应用

目的:评估经皮主动脉瓣球囊扩张术(PBAV)在合并左心功能不全的钙化型重度主动脉瓣狭窄患者中的应用。方法:2014-12至2017-02我院共为15例重度主动脉瓣狭窄患者实施PBAV。患者的基线情况、超声参数、围手术期情况及后期随访均有详细的记录。结果:15例PBAV患者术前均合并严重心力衰竭[纽约心脏协会(NYHA)心功能Ⅲ级3例,Ⅳ级12例],其中2例术前合并心原性休克,1例术前曾发生心原性猝死。15例中6例患者计划为姑息性PBAV,9例为过渡性措施(1例为非心脏手术术前过渡)。15例PBAV均顺利完成,术中平均扩张(2.6±1.3)次,2例患者术后即刻出现完全性左束支传导阻滞,1例患者术中发生室性心动过速,1例患者术后3天发生缺血性脑卒中,未发生其他并发症。PBAV后即刻导管测得有创跨主动脉瓣峰值压差由术前(75.0±24.0)mm Hg降至(39.8±14.2)mm Hg(P0.01)。出院前超声心动图评估跨主动脉瓣最大流速由术前(4.98±0.76)m/s降至(4.20±0.75)m/(sP0.01),峰值跨瓣压差由(101.3±30.4)mm Hg降至(72.9±23.3)mm Hg(P0.01),平均跨瓣压差由(62.4±19.0)mm Hg降至(44.9±15.1)mm Hg(P0.01),术前与术后的左心室舒张末期内径(LVDD)及左心室射血分数(LVEF)差异无统计学意义(P0.05)。N末端B型利钠肽原(NT-pro BNP)由术前(13 889±12 303)pg/ml降至术后(5 412±4 923)pg/ml(P0.01)。术后平均随访(10.9±7.1)个月(3~27个月),NYHA心功能分级中位数由Ⅳ级提升至Ⅱ级。结论:对合并左心功能不全的主动脉瓣狭窄患者进行姑息性或过渡性PBAV的短期疗效可靠且安全,并发症发生率低,应是高危主动脉瓣狭窄患者的可选治疗方案。     

德国心血管年会会议热点研究报道(五) 低心排量低压差性主动脉瓣狭窄患者也受益于经皮主动脉瓣植入术

<正>背景:经皮主动脉瓣植入术(TAVI)是高危重度主动脉瓣狭窄患者的首选治疗方案。在欧美的治疗指南中,重度主动脉瓣狭窄的定义是瓣口面积小于1.0 cm2或小于0.6cm2/m2;心排量正常,跨瓣压差<40 mm Hg并且主动脉瓣血流速度<4 m/s时,诊断重度主动脉瓣狭窄的可能性很小。但是临床中约有5%~10%的重度主动脉瓣狭窄的患者有     

15例拟行经导管主动脉瓣置换术患者主动脉根部影像学与临床应用--单中心早期经验

目的：15例拟行经导管主动脉瓣置换术（TAVI）患者主动脉根部影像学与临床应用的单中心早期临床经验。
　　方法：入选我院2011-03至2013-11拟行TAVI的主动脉瓣重度狭窄患者15例,分别进行计算机断层摄影术（CT）扫描、经胸超声心动图采集主动脉根部解剖数据,并对比主动脉瓣环测量差异。根据CT测量结果选择植入瓣膜型号,通过术后6个月随访,评估术前测量准确性。
　　结果：15例患者术前CT测量主动脉瓣环短径（21.5±2.4）mm,主动脉瓣环长径（27.3±2.7）mm,瓣环平均内径（24.4±2.4）mm,左心室流出道长径（28.3±4.5）mm,左心室流出道平均内经（24.±3.5）mm;升主动脉内径（35.3±4.4） mm。置入A-Venus人工瓣膜26号瓣膜8例,29号瓣膜7例。CT测量主动脉瓣环内径均值大于经胸超声心动图主动脉瓣环内径均值,差异有统计学意义（P<0.001）。经6个月随访,15例患者均未出现主动脉根部破裂、阻挡冠状动脉、主动脉瓣及瓣周中量及以上反流,有4例患者因房室传导阻滞行永久起搏器置入。
　　结论：CT及经胸超声心动图对于主动脉瓣环测量结果存在差异,CT测量可准确有效评估主动脉根部形态及毗邻,为TAVI提供有力支持。     

二叶式主动脉瓣狭窄患者主动脉根部形态学特点对经导管主动脉瓣置换术疗效的影响

目的:探讨二叶式主动脉瓣狭窄患者主动脉根部形态学特点对经导管主动脉瓣置换术(TAVR)疗效的影响。方法:回顾性选取2014年1月至2016年12月在阜外医院、四川大学华西医院及浙江大学附属第二医院行TAVR的二叶式主动脉瓣狭窄患者49例。分析患者主动脉根部形态学特点、手术有效性及安全性,并进行随访。结果:二叶式主动脉瓣无嵴与带嵴类型占比相当(55.1%vs 44.9%),瓣叶钙化程度重[钙化体积HU850=(604.1±318.7) mm~3],平均瓣环周长大于平均瓣环上水平周长[(78.8±7.4) mm vs (67.1±6.7) mm,P0.001],平均左心室流出道(LVOT)周长大于平均瓣环周长[(81.6±10.5) mm vs (78.8±7.4) mm,P=0.003]。置入瓣中瓣患者12例(24.5%),瓣膜置入过深患者14例(34.1%)。置入瓣中瓣患者比无瓣中瓣患者瓣环平均内经[(26.8±2.4) mm vs(23.9±2.0) mm,P0.001]、周长[(85.7±7.0) mm vs (76.6±6.1) mm,P0.001]及LVOT平均内径[(28.4±2.7) mm vs (24.3±3.1) mm,P0.001]、周长[(91.3±9.1) mm vs (78.4±8.9) mm,P0.001]更大,LVOT周长/瓣环上水平周长比值虽差异无统计学意义[(125.5±12.3)%vs (119.4±15.7)%,P=0.067],但趋近阈值。瓣膜置入过深患者比无置入过深患者LVOT周长/瓣环周长比值更大[(108.0±7.4)%vs (101.2±6.7)%,P=0.005]。结论:二叶式主动脉瓣患者的瓣环和LVOT平均内径及LVOT周长/瓣环周长比值对于TAVR中瓣中瓣的置入及瓣膜置入深度具有一定影响。     

Clinical profile, prognostic implication, and response to treatment of pulmonary hypertension in patients with severe aortic stenosis

The incidence, correlates, and prognostic implications of pulmonary hypertension (PH) are unclear in patients with severe aortic stenosis (AS). We studied 509 patients with severe AS evaluated for transcatheter aortic valve implantation (TAVI). Patients were divided into groups based on pulmonary artery systolic pressure (PASP): group I, 161 (31.6%) with PASP <40 mm Hg; group II, 175 (34.3%) with PASP 40 to 59 mm Hg; and group III, 173 (33.9%) with PASP ≥ 60 mm Hg. Group III patients were more symptomatic and had higher creatinine levels and higher left ventricular end-diastolic pressure. Transpulmonary gradient was >12 mm Hg in 17 patients (10.5%), 31 patients (17.7%), and 80 patients (46.2%) in groups I through III, respectively. In a median follow-up of 202 days (73 to 446) mortality rates were 35 (21.7%), 69 (39.3%), and 85 (49.1%) in groups I through III, respectively (p <0.001). Immediately after TAVI, in patients with PASP >40 mm Hg there was significant decrease in PASP (63.1 ± 16.2 to 48.8 ± 12.4 mm Hg, p <0.0001), which remained at 1 year (50.1 ± 13.1 mm Hg, p = 0.04). After surgical aortic valve replacement there was a significant immediate decrease in PASP (66.1 ± 16.3 to 44.7 ± 14.2 mm Hg, p <0.0001), which persisted at 3 to 12 months (44.8 ± 20.1 mm Hg, p <0.001). In patients who underwent balloon aortic valvuloplasty, PASP decreased immediately after the procedure (63.2 ± 14.8 to 51.8 ± 17.1 mm Hg, p <0.0001), yet at 3 to 12 months pressure returned to baseline levels (57.4 ± 17.0 mm Hg, p = 0.29). In conclusion, patients with severe AS have a high prevalence of PH, and in patients with severe AS increased PASP is associated with increased mortality. Surgical aortic valve replacement and TAVI are effective treatments for these patients and result in a significant PASP decrease.     

Restenosis is a common feature of the angiographic follow-up after balloon valvoplasty of calcified aortic stenoses

Balloon dilatation of calcified aortic stenosis was attempted in 12 patients, 6 men and 6 women, aged 38-82 years. Two patients underwent emergency surgery because of myocardial injury or pericardial tamponade. One patient with severe depressed left ventricular function in whom the procedure was attempted in cardiogenic shock died during the procedure. One patient experienced severe aortic insufficiency after dilatation. The remaining pressure gradient was higher than 50 mm Hg in another patient. Seven dilatations were considered to be successful with a remaining pressure gradient below 50 mm Hg and a mean gradient reduction of 53 mm Hg. In one of these 7 patients, who suffered from severe heart failure, valvoplasty had been carried out to make aortic valve replacement possible. The operation was performed 2 weeks later without complications. Five of 6 patients treated medically after successful valvoplasty had restenosis within 3 to 12 months. One of them exhibited a good result at 3 months but severe restenosis after one year. It is concluded that balloon valvoplasty of calcified aortic stenosis cannot be considered an alternative to surgery. If, however, left ventricular function improves after successful valvoplasty, valve replacement will then carry less risk.     

Feasibility and outcomes of transcatheter aortic valve implantation in high-risk patients with stenotic bicuspid aortic valves

Little is known about transcatheter aortic valve implantation (TAVI) in patients with bicuspid aortic valve stenosis, which usually represents a contraindication. The aim of this study was to assess the feasibility and the results of TAVI in this patient subset. Of 316 high-risk patients with severe aortic stenosis who underwent TAVI from January 2009 to January 2012, 15 (5%) had documented bicuspid aortic valves. They were treated using a transarterial approach, using the Medtronic CoreValve system. Patients were aged 80 ± 10 years, in New York Heart Association functional classes III and IV. The mean aortic valve area was 0.8 ± 0.3 cm(2), and the mean gradient was 60 ± 19 mm Hg. The mean calcium score, calculated using multislice computed tomography, was 4,553 ± 1,872 arbitrary units. The procedure was successful in all but 1 patient. Major adverse events, according to Valvular Academic Research Consortium definitions, were encountered in 1 patient (death). The mean postimplantation prosthetic gradient was 11 ± 4 mm Hg, and ≤1+ periprosthetic leaks were observed in all but 2 patients. The mean prosthetic ellipticity index was 0.7 ± 0.2 at the level of the native annulus and 0.8 ± 0.2 at the level of the prosthetic leaflets. After a mean follow-up period of 8 ± 7 months, 1 patient had died from aortic dissection; there were no additional adverse events. All but 2 hospital survivors were in New York Heart Association class I or II. In conclusion, the present series suggests that transarterial Medtronic CoreValve implantation is feasible in selected patients with bicuspid aortic valve and may lead to short-term hemodynamic and clinical improvement.     

Treatment of a degenerative stenosed CoreValve® aortic bioprosthesis by transcatheter valve‐in‐valve insertion

Background : Transcatheter aortic valve insertion (TAVI) is an emerging therapy in patients at high risk for open heart surgery. The long‐term durability of the bioprosthesis is unknown. This is the first report of a severely degeneratively stenosed 2nd generation 26 mm CoreValve^® aortic bioprosthesis which occurred five and a half years after TAVI. Methods and Results : A 92‐year‐old patient presented with decompensated heart failure NYHA class IV, pulmonary edema, and severe pulmonary hypertension. Echocardiography revealed critical AV‐stenosis due to heavily calcified bioprosthetic valve leaflets. Due to high surgical risk with an EuroSCORE of 64.97% and a STS‐mortality score of 27.0%, we decided to attempt a valve‐in‐valve insertion of a 3rd generation CoreValve^® prosthesis of the same size. Following the delicate retrograde passage of the calcified valve with a preformed stiff wire, balloon valvuloplasty of the severely stenosed CoreValve^® prosthesis under rapid right ventricular pacing was complicated by two balloon catheter ruptures. Insertion of the 3rd generation CoreValve^® prosthesis of the same size was quite complex but finally it was successfully completed. There was mild periprosthetic regurgitation and significant decrease in transaortic pressure without residual transvalvular gradient immediately after TAVI. Echocardiography and clinical follow‐up at 72 hr after TAVI confirmed excellent valve function with a decrease in systolic pulmonary artery pressure from 70 mm Hg to 35 mm Hg, increase in LV‐EF from 35% to 45%, and improvement of functional status from NYHA IV to NYHA II. The patient was discharged in good medical conditions at day eight. Conclusion : Degenerative stenosis of a CoreValve^® bioprothesis may be observed during long‐term follow‐up after successful TAVI for the treatment of severe aortic valve stenosis. A second valve‐in‐valve insertion appears feasible but may require particular interventional approaches. © 2011 Wiley Periodicals, Inc.     

Usefulness of B-type natriuretic peptide to predict outcome of patients treated by transcatheter aortic valve implantation

B-type natriuretic peptide (BNP) has been shown to predict outcomes after conventional aortic valve replacement. The aim of the present study was to investigate whether BNP also predicts the outcomes after transcatheter aortic valve implantation (TAVI). A total of 58 patients (36 men, age 84 ± 5 years) underwent TAVI in our institution for severe aortic stenosis (aortic valve area 0.6 ± 0.1 cm2, mean gradient 41 ± 15 mm Hg) at high risk of surgery (logistic European System for Cardiac Operative Risk Evaluation 34 ± 17%). BNP was measured before and 24 hours after TAVI. The 30-day survival rate was 91%. Although the baseline clinical and hemodynamic characteristics were similar among the 30-day survivors (n = 53) and nonsurvivors (n = 5), the BNP levels were significantly lower in the 30-day survivors, at both baseline (463 ± 265 vs 1,067 ± 655 pg/ml; p = 0.005) and 24 hours after TAVI (488 ± 238 vs 1,632 ± 1,028 pg/ml; p <0.0001). The BNP levels were significantly greater in patients experiencing one major adverse event at 30 days. On multivariate analysis, only BNP levels (baseline value and change at 24 hours) were independent predictors of 30-day survival. Kaplan-Meier analysis showed that 30-day survival was significantly lower in patients with than in those without both a baseline BNP level >428 mg/dl (p = 0.04) and a significant BNP increase of >170 pg/ml at 24 hours after TAVI (p = 0.001). In conclusion, BNP is a strong predictor of 30-day outcomes after transcatheter aortic valve implantation, at both baseline and 24 hours after the procedure.     

Early and late (one year) outcomes following transcatheter aortic valve implantation in patients with severe aortic stenosis (from the United States REVIVAL trial)

Transcatheter aortic valve implantation (TAVI) with the Cribier-Edwards prosthesis may provide an alternative to conventional aortic valve replacement in high-risk patients with aortic stenosis. Previous studies have indicated that TAVI is feasible in this patient population. Transcatheter implantation of a Cribier-Edwards prosthesis was attempted in 55 patients in a United States Food and Drug Administration-approved prospective observational study. Clinical and echocardiographic outcomes were assessed in hospital and at 30 days, 6 months, and 12 months. Fifty-five patients (55% women, mean age 83 years) with a mean aortic valve area of 0.57 ± 0.14 cm(2) and a mean logistic European System for Cardiac Operative Risk Evaluation score of 33.5 ± 17.0% were enrolled. Transcatheter heart valves were implanted successfully in 48 patients (87%). Mean echocardiographic aortic valve area improved from 0.56 ± 0.14 to 1.6 ± 0.48 cm(2) after the procedure (p <0.0001). Thirty-day all-cause mortality and major adverse cardiac and cerebrovascular events were 7.3% and 20%, respectively. There were also 7 major procedural vascular complications (12.7%). Mortality and major adverse cardiac and cerebrovascular events increased to 23.6% and 32.7%, respectively, at 1 year, with most late events related to underlying co-morbidities. Mean New York Heart Association functional class improved from 3.22 ± 0.66 at baseline to 1.50 ± 0.85 at 1 year follow-up (p <0.001). In conclusion, TAVI in high-risk patients with aortic stenosis was feasible, with sustained clinical benefit at 12 months. Procedural complications and late major adverse cardiac and cerebrovascular events, however, overshadowed the overall clinical benefit of TAVI in this high-risk patient population.     

Transfemoral Edwards-Novaflex valve implantation in a patient with aorto-iliac endoprosthesis and severely tortuous bilateral external iliac arteries-“Railing track”

Transcatheter aortic valve implantation (TAVI) has nowadays been introduced as an alternative for surgical aortic valve replacement as a treatment for high risk aortic stenosis patients. This procedure is not free of complications: the SOURCE registry, indeed, showed that vascular complications are more frequent with the transfemoral approach. We present the case of an 82-year-old man with known history of severe aortic stenosis at high-risk for surgery. Pre-TAVI screening shows bilateral severely tortuous iliac arteries and aorto-bi-iliac endoprosthesis. Transapical TAVI as a first choice was rejected due to severe lung disease. The patient was then treated by Transfemoral TAVI using a dedicated interventional technique that is described in this case-report.     

经导管主动脉瓣植入术治疗重度主动脉瓣狭窄患者的初步经验

目的分享经导管主动脉瓣植入术（TAVI）治疗重度主动脉瓣狭窄患者的经验。方法分析已完成TAVI患者的基线特征、术后血流动力学变化情况及临床结果。结果 2012年4月至2014年3月共36例患者于四川大学华西医院进行TAVI,平均年龄（73.9±7.2）岁,其中男24例（66.7%）,平均欧洲心脏手术风险回归评分为（20.6±9.9）%。25例（69.4%）患者主动脉瓣叶形态呈二叶式畸形。TAVI成功35例（97.2%）,4例（11.1%）需植入第2枚瓣膜。术后主动脉瓣平均跨瓣压差下降至（10.5±5.7）mmHg（1 mmHg=0.133 kPa）,2例残余瓣周漏接近中度。术后30 d内死亡1例（2.8%）,脑卒中2例（5.6%）。10例（27.8%）患者因出现Ⅲ度房室传导阻滞而植入了永久起搏器。中位随访时间323 d,除2例患者分别于术后374 d和680 d死于恶性肿瘤外,其余患者均保持无症状生存。结论对于不适合进行外科手术的二叶式和三叶式主动脉瓣重度狭窄患者,TAVI是可行、安全和有效的。     

Percutaneous balloon aortic valvuloplasty for aortic stenosis in elderly patients at high risk for surgery

Six elderly patients had percutaneous balloon aortic valvuloplasty for severe, symptomatic calcific aortic stenosis because valve replacement surgery was considered too risky in five patients with severe coexisting cardiac or other medical problems and because one patient refused to have surgery. The procedure resulted in a significant reduction in the mean (+/-SD) aortic valve gradient, from 47 +/- 13 to 32 +/- 12 mm Hg (change, -32%, p less than 0.01), and a significant increase in the mean area of the aortic valve, from 0.64 +/- 0.12 to 0.90 +/- 0.17 cm2 (change, +40%, p less than 0.001). Blood loss from the femoral puncture site was the only major procedural complication. At a mean follow-up of 2 months after the procedure, all patients were alive and dyspnea had improved by two New York Heart Association functional classes in four patients and by one functional class in two patients. A significant short-term increase in aortic valve area and alleviation in symptoms can be achieved safely by percutaneous balloon aortic valvuloplasty in elderly patients with severe calcific aortic stenosis who are at high risk for surgical complications.     

Valve prosthesis distortion after cardiac compression in a patient who underwent transcatheter aortic valve implantation (TAVI)

Transcatheter aortic valve implantation (TAVI) has been developed as an alternative to conventional aortic valve replacement for the treatment of symptomatic severe aortic stenosis in high‐risk patients. Nevertheless, TAVI has been associated with serious complications such as stroke, vascular injury, renal failure, and arrhythmia. Herein we describe a case of distortion of the Edward‐Sapien prosthesis (Edwards Lifesciences, USA), which was mounted on a balloon‐expandable stent, after chest compression for cardiac resuscitation in a patient who underwent TAVI for severe aortic stenosis. © 2012 Wiley Periodicals, Inc.