成人主动脉瓣关闭不全行主动脉瓣成形术研究现状

主动脉瓣成形术(aortic valve repair,AVr)最早报道于1958年并用于室间隔缺损引起的主动脉瓣反流(aortic insufficiency,AI)[1];然而由于没有超声心动图对主动脉瓣空间结构和解剖清楚的认识,手术的早期临床效果有限.随着瓣膜置换的发展,人工瓣膜几乎替代了成形手术成为更佳的选择....     

经导管主动脉瓣置换术在单纯自体主动脉瓣返流患者中的应用

经导管主动脉瓣置换术（transcatheter aortic valve replacement,TAVR）已经彻底改变了重度主动脉瓣狭窄的治疗方式。然而,单纯自体主动脉瓣返流（native aortic valve regurgitation,NAVR）一度被认为是TAVR的禁忌证,这是由于大部分患者主动脉瓣无钙化以及随之造成的锚定人工瓣膜困难。与主动脉瓣狭窄相比,TAVR的第一代瓣膜治疗NAVR,器械成功率较低,这是因为需要“瓣中瓣”比率以及术后中重度主动脉瓣返流复发几率较高。然而,随着新一代可回收、有裙边且有特殊固定机制瓣膜的研发与应用,此类患者的手术预后得到改善。本文对TAVR在单纯NAVR患者中的应用及两代瓣膜的临床预后进行了回顾和总结。     

经导管主动脉瓣置换的并发症

自2002年进行了世界上首例经导管主动脉瓣膜置换(transcatheter aortic valve implant,TAVI)治疗主动脉狭窄,世界各地的研究均表明:对于无法进行外科主动脉瓣膜置换(aortic valve replacement,AVR)或外科AVR手术存在高风险的患者,这项新技术是安全有效的。尽管进行TAVI手术的多为高风险患者,但手术成功后30 d生存率高于90%,     

主动脉瓣狭窄患者治疗的终生策略

经导管主动脉瓣置换术（TAVR）已成为主动脉瓣狭窄患者治疗的重要方式之一。未来重度主动脉瓣狭窄患者的干预治疗面临多种选择,包括瓣膜类型选择（机械心脏瓣膜或生物心脏瓣膜）及治疗方式选择（外科治疗或TAVR）。基于终生管理的角度,为每一例患者制定最佳的治疗策略需要综合考虑多种因素,了解每一种治疗策略的优劣及目前的循证医学证据进展能够帮助我们进行临床决策。     

经导管主动脉瓣植入术最新研究进展

经导管主动脉瓣植入术（transcatheter aortic valve implantation,TAVI）是一种对于伴有严重主动脉瓣狭窄和行传统开胸手术并发症发生率高、风险大的患者的新型治疗手段,现在国外一些发达国家已经广泛地使用于临床,并收到良好的效果.由于TAVI在这类患者中取得了较好的疗效,因此,受到人们很大的关注.国外许多文献也证明TAVI的1年死亡率、再入院率及并发症发生率都低于传统开胸手术,现就近年TAVI的瓣膜系统、临床应用优势、并发症和进展做简要综述.     

经导管主动脉瓣置换术治疗二叶式主动脉瓣狭窄的现有证据和研究进展

二叶式主动脉瓣（BAV）畸形是一种先天性瓣膜发育异常,在我国主动脉瓣狭窄患者中较常见,且该人群具有年轻、瓣膜钙化严重等特征。随着循证医学证据的积累和医疗器械的迭代更新,经导管主动脉瓣置换术（TAVR）的适应证不断扩大,未来将会有更多的BAV狭窄患者接受TAVR治疗,但BAV复杂的解剖结构对TAVR治疗提出巨大挑战。通过术前充分了解瓣膜解剖形态和制定手术策略,BAV狭窄患者在我国行TAVR治疗获得良好的临床效果,而在远期预后、新一代瓣膜的应用等方面仍需更多的研究。本文就TAVR治疗BAV狭窄的现有证据和研究进展进行综述。     

经皮主动脉瓣置换术进展

主动脉瓣瓣膜病变有较高的发病率及病死率。每年全球有200000例患者接受外科瓣膜置换术。还有更多患者因风险太高或有些老年患者害怕生活方式会被改变而未接受传统外科手术治疗,而且这一人群在不断扩大。自20世纪90年代经皮主动脉瓣置换术(percutaneous aortic valve replaceme     

经导管主动脉瓣置换术在二叶式主动脉瓣狭窄患者中的应用

二叶式主动脉瓣狭窄是经导管主动脉瓣置换术(transcatheter aortic valve replacement, TAVR) 的相对禁忌证， 其异常的解剖结构和病理特点增加了TAVR 的难度和风险，手术成功率低于三叶瓣患者。但随着手术策略的不断 优化和新一代人工瓣膜的应用，这类患者的TAVR 治疗效果得到改善。本文将对二叶式主动脉瓣狭窄的特点及其 TAVR 治疗策略的进展进行介绍。     

经导管主动脉瓣置换术临床应用现状及进展

<正>主动脉瓣膜狭窄(aortic stenosis, AS)是最为常见的原发性心脏瓣膜疾病,病变进展后期可能需要外科手术或者经导管瓣膜置入进行治疗。在过去的十年间,随着技术的进步,严重AS患者的治疗发生了显著改变。自2012年欧洲心脏病学会(European Society of Cardiology,ESC)和欧洲心胸外科学会(European Association of Cardio Thoracic Surgery,EACTS)制定     

经皮主动脉瓣置换术中的二尖瓣反流

主动脉瓣狭窄（aortic stenosis,AS）已成为最为常见的心脏瓣膜病变之一。经皮主动脉瓣置换术（transcatheter aortic valve replacement,TAVR）为无法进行外科手术或外科手术高危的重度/中-重度AS患者提供了一种创伤更小的治疗方法,是近年来国内外发展的热点。由于TAVR手术自身特点,二尖瓣反流（mitral regurgitation,MR）的评价和改变对其尤为重要。目前针对TAVR手术的MR的研究主要集中于术后MR的变化及其影响,但TAVR术中可能出现明显的MR程度的变化,其变化趋势、影响因素及其对患者预后的影响应受到更多重视。超声心动图是评价和监测MR的重要手段,可以较为准确地反映MR变化趋势,对其对预后的影响进行判断,探讨术中MR变化的可能机制。随着超声心动图技术的发展,需要引进更为灵敏客观的指标预测及监测TAVR术中MR的变化趋势,进一步寻找术中MR可能的影响因素。     

Procedural and clinical outcomes of the valve‐in‐valve technique for severe aortic insufficiency after balloon‐expandable transcatheter aortic valve replacement

Objective : To describe the clinical and procedural outcomes of patients treated with the valve‐in‐valve technique for severe aortic insufficiency (AI) after balloon‐expandable transcatheter aortic valve replacement (TAVR). Background : Severe AI immediately after valve implantation is a notable complication of TAVR. It can be treated with a valve‐in‐valve technique which involves deploying a second valve within the first one to crush the leaflets of the first implant leaving a new functional valve. Methods : We analyzed data on 142 consecutive patients at our institution undergoing TAVR with the Sapien valve between November of 2007 and April of 2011. Etiologies of acute AI, procedural and intermediate term clinical outcomes were reported for those in whom a valve‐in‐valve procedure was necessary. Post‐hoc analysis of these cases with C‐THV imaging (Paieon Medical Ltd.) was performed to elucidate the mechanism for successful AI treatment. Results : A total of 5 of 142 (3.5%) patients were treated with the valve‐in‐valve technique. Etiologies of the aortic valve insufficiency included bioprosthesis malposition (n = 3), valve dysfunction (n = 1), and valve undersizing (n = 1). With placement of the second valve, the first valve dimensions increased to approach the nominal valve size while the second valve size remained less than nominal. Conclusions : The valve‐in‐valve technique is an appropriate bailout measure for patients with acute valvular AI after balloon‐expandable TAVR. © 2012 Wiley Periodicals Inc.     

Prolapse of the "floppy" aortic valve as a cause of aortic regurgitation. A clinico-morphologic study

A clinico-pathologic study was performed in 25 patients undergoing aortic valve replacement because of regurgitation, caused by myxoid degeneration of the valve leaflets. Associated cardiac anomalies were floppy mitral valve (2 cases), floppy mitral valve and idiopathic hypertrophic subaortic stenosis (1), left atrial myxoma (1), and aortic coarctation at the isthmus (1). Three patients died (2 immediately and 1 on the 30th postoperative day). Pathological studies of the explanted valves showed deformities characterized by redundant thin leaflets which appeared soft and gelatinous. On histologic examination the fibrous layer of the leaflets was seen to be infiltrated by myxomatous tissue. Echocardiography showed the aortic root to be dilated in 13 patients and normal in the others. In those with normal aortic root, the histological examination of aortic wall disclosed minimal cystic medial necrosis in two cases. In contrast, more severe forms of cystic medial necrosis were evident in all patients having a dilated aortic root. Aortic valve replacement was performed in all cases. It was accompanied by a Bentall procedure (1 case), repair of ascending aorta dissection (2), replacement of the ascending aorta (1), mitral valve replacement (2), mitral valve replacement and apico-ascending aorta conduit (1) and excision of a left atrial myxoma (1). Our experience suggests that prolapse of the aortic valve due to floppy leaflets is a common degenerative disease which is generally associated with noninflammatory aortic root degeneration. This, together with aortic root dilatation, contributes to valve insufficiency. Nevertheless, the disease, when isolated (with normal aortic root), is liable in itself to produce aortic regurgitation. The need for early diagnosis is stressed, so as to be able to perform valve replacement.     

超声心动图在主动脉瓣狭窄经导管主动脉瓣植入术中的应用价值

目的探讨超声心动图在主动脉瓣狭窄患者经导管主动脉瓣植入术中的作用。方法3例重度主动脉瓣瓣膜狭窄患者接受经导管主动脉瓣人工瓣膜植入术。使用PhilipS iE33型彩色多普勒超声诊断仪,配备经胸探头S5—1和经食道探头S7—2,X7—2t。超声观察内容包括明确主动脉瓣膜病变范围和程度,测量主动脉瓣环前后径,人工瓣膜植入术后瓣膜功能等。结果3例患者经导管主动脉瓣植入术均取得了成功,人工瓣膜位置稳定,常规超声心动图3例患者术前经胸超声心动图与术中经食管超声心动图诊断相符,跨瓣压差较术前明显下降,主动脉瓣瓣上流速明显下降,瓣周漏瞬时反流量平均约1．2mL。结论经导管主动脉瓣人工瓣膜植入术在治疗严重主动脉瓣瓣膜狭窄中方法可行,效果良好;超声心动图在这项工作中具有重要的辅助作用。     

Hybrid treatment of aortic aneurism,type-A dissection,and aortic valve stenosis

Hybrid multidisciplinary interventions are attractive care options for heart valve and vascular diseases in high-risk patients. We describe the feasibility of staged hybrid aortic arch repair to treat a type Ia endoleak and transcatheter aortic valve replacement to treat an aortic valve stenosis, achieving an escape strategy to treat an unexpected type-A aortic dissection.     

Mixed aortic valve disease treated with transcatheter aortic valve replacement in a high risk patient presenting with acute decompensated heart failure

Mixed aortic valve disease refers to the combination of aortic regurgitation (AR) and aortic stenosis (AS). Commonly etiologies include a bicuspid aortic valve, rheumatic heart disease, and endocarditis superimposed upon a stenotic aortic valve. Treatment depends upon the severity of disease, the presence of symptoms and the size and function of the left ventricle. We present a case of a young patient that presented with new onset acute decompensated heart failure with mixed aortic valve disease that was successful treated with transcatheter aortic valve replacement (TAVR). Invasive hemodynamics at baseline and following TAVR provide an insight into the characteristic features of mixed aortic valve disease. TAVR represents a new treatment option for critically ill patients deemed high risk or nonoperable for surgical aortic valve replacement.     

Transaortic transcatheter aortic valve implantation within a previous bioprosthetic aortic valve replacement

This report documents the first reported case of transaortic transcatheter aortic valve implantation (TAVI) using the CoreValve ReValving system (Medtronic CoreValve System, Luxembourg), within a previous bioprosthetic aortic valve replacement. TAVI has become a recognized percutaneous treatment for patients with severe native or bioprosthetic aortic valve stenosis. However, as the number of patients screened for TAVI increases, a number of patients are found with absolutely no option for peripheral arterial access, either from the femoral or subclavian routes. Transaortic CoreValve placement offers an alternate minimally invasive hybrid surgical/interventional technique when peripheral access is not possible. A CoreValve prosthesis was implanted via the transaortic route in an 81‐year‐old woman with severe bioprosthetic aortic valve stenosis (21 mm Mitroflow pericardial valve, peak instantaneous gradient of 99 mmHg, effective valve orifice area (EOA) of 0.3 cm², as ilio‐femoral and left subclavian angiography revealed small calibre vessels (<6 mm). Access was achieved via a mini thoracotomy via the left anterior second intercostal space. The procedure went without complication. Post procedure the patient was transferred directly to the Cardiac Care Unit for recuperation. Post procedure echocardiography showed that the TAVI was well positioned with no para‐valvular leak and a reduction in peak instantaneous gradient to 30 mmHg and an increase in EOA to 1.5 cm². She was discharged on the third post‐procedural day in sinus rhythm with a narrow QRS complex. CoreValve implantation within previous surgical bioprosthesis is now an established treatment. The transaortic approach to transcatheter implantation is a promising recent development, when due to anatomical reasons, transfemoral or subclavian TAVI is not feasible. © 2011 Wiley‐Liss, Inc.     

Ascending aortic aneurysm and dissection in young adults with bicuspid aortic valve: Implications for echocardiographic surveillance

Bicuspid aortic valve (BAV) is an independent risk factor for aneurysm and dissection of the ascending aorta. Despite this association, routine imaging of the aorta has not been recommended for patients with BAV. We describe two young men who developed life-threatening aneurysm or dissection of the ascending aorta; one had a normally functioning BAV and the other was 10 years after valve replacement. The pathology of this condition is very similar to that found in the Marfan syndrome. We recommend echocardiographic surveillance of the ascending aorta at regular intervals, and consideration of beta-adrenergic blockade among patients with significant dilation.     

二瓣化畸形加速主动脉瓣钙化的机制研究进展

主动脉二瓣化畸形是最常见的先天性主动脉瓣发育异常,发病率约0.5%-2%,易并发主动脉瓣钙化、主动脉夹层、主动脉瘤等疾病。几乎所有的该类患者在成年期后都会出现主动脉瓣钙化,且发病年龄比三瓣化主动脉瓣者提前20年。为何二瓣化畸形容易出现主动脉瓣钙化加速,其机制仍存在许多争议。目前研究认为目前研究认为异常的遗传学表达、血流动力学、炎症反应及内皮功能障碍之间的相互作用可能是重要原因,本综述将从以上几个方面对其进行讨论。     

Bicuspid aortic valves in monozygotic twins

Identical bicuspid valve anomalies were found in monozygotic twins. Screening echocardiography should be considered for first-degree relatives of patients with bicuspid aortic valve.     

Evaluation of aortic valve disorders using stress echocardiography

Stress echocardiography is a safe and valuable test to aid in the diagnosis and management of patients with aortic valve disorders. In patients with suspected severe aortic stenosis (AS) and low aortic gradients secondary to low cardiac output, dobutamine echocardiography distinguishes those patients with contractile reserve (CR) from those without it. By increasing the stroke volume in subjects with CR, true severe AS patients have an increase in transaortic gradients without a significant change in the valve area, whereas patients with pseudostenosis have an increase in the gradients with concomitant increase in the aortic valve area to >1 cm(2). Patients without CR are indeterminate in their AS status and have a poor prognosis. The presence of CR is also important in patients suffering from aortic insufficiency, as it may predict the development of symptoms, myocardial dysfunction, or death in the asymptomatic phase of the disease, and the potential for left ventricular functional recovery after valve replacement. Finally, both exercise and dobutamine echocardiography can help in the assessment of valve malfunction or mismatch in patients with aortic valve prostheses experiencing exercise intolerance by correlating the symptoms with the change in the aortic gradients induced during stress testing.