经导管Edwards-Sapien主动脉瓣植入术临床应用

经导管主动脉瓣植入术(TAVI)可用于主动脉瓣严重狭窄需换瓣但传统开胸手术风险太大而难以实施的患者,第一个前瞻性大样本多中心的TAVI临床试验PARTNER研究已经完成.该研究显示,与药物治疗相比,经股动脉或经心尖途径植入Edwards-Sapien人工主动脉瓣膜,能显著降低患者的术后1年死亡率、改善预后并提高生活质量...     

经导管主动脉瓣植入术治疗主动脉瓣疾病患者的经验总结

目的回顾性评估广东省人民医院采用经导管主动脉瓣植入术(transcatheter aortic vavle implantion,TAVI)治疗主动脉瓣相关疾病患者的临床效果。方法回顾性分析广东省人民医院于2017年6月到2019年12月行TAVI手术患者86例的临床资料,其中男52例(60.5%),女34例(2%),年龄(74.6±6.9)岁,美国胸外科医师学会(Society of Thoracic Surgeons predicted risk of mortality,STS)评分为(11.2±4.3)分。术后30 d对患者进行随访,分析TAVI的手术效果及TAVI术后患者近期预后情况。结果 86例患者中有70例(87.5%)诊断为重度主动脉瓣狭窄(aortic stenosis,AS),其中有38例(44.1%)为二叶式主动脉瓣,19例(22.1%)诊断为主动脉瓣重度反流,3例(3.5%)因生物瓣衰败导致主动脉瓣重度反流。TAVI经股动脉路径75例(87.2%),经颈动脉路径6例(7%),经心尖路径5例(5.8%);86例(100%)手术成功,9例(10.3%)术中需植入第2枚支架瓣膜。术后主动脉瓣轻中度瓣周漏5例(6.2%),中度瓣周漏3例(3.7%)。术后30 d死亡1例(1.3%),脑卒中1例(1.3%),急性心包填塞3例(3.4%),7例(8.0%)患者术后因Ⅲ度房室传导阻滞在本院行永久起搏器植入术。结论对于有外科手术禁忌症或不愿意行外科手术的二叶式及三叶式重度AS患者,TAVI手术可以得到满意的临床效果,而对于主动脉瓣重度反流的患者,经心尖途径放置特殊瓣膜的TAVI治疗可能也是一种有效的方案。     

实时三维超声心动图在经导管主动脉瓣植入术中对主动脉瓣环检测意义的研究

目的：分析实时三维超声心动图（real-time three-dimensional echocardiography,RT3DE）在经导管主动脉瓣植入术（transcatheter aortic valve implantation,TAVI）围术期的应用价值。方法：选择本院2018年10月至2021年10月，住院的100例TAVI手术患者作为研究对象，年龄在65～80岁，平均（72.9±5.0）岁。根据患者主动脉瓣的瓣膜形态、功能进行分组研究，分为先天性主动脉瓣发育异常组（n=45）与后天获得性主动脉瓣病变组（n=55），主动脉瓣关闭不全组（n=41）与主动脉瓣狭窄组（n=59），主动脉瓣狭窄合并主动脉瓣钙化组（n=44）与不合并主动脉瓣钙化组（n=56）。统计主动脉瓣前向血流平均压差、左心室腔大小及LVEF值；主动脉瓣环三维视图周长C3D、主动脉瓣环投影平面中二维视图周长及面积（C2D及A2D）、主动脉瓣环二维周长与三维周长之比（C2D/C3D）等数据进行统计学分析，然后采用Peason相关性分析主动脉瓣环参数与术中测瓣器测值的相关性。结果：100例患者均成功完成TAVI手术治疗...     

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。     

经导管主动脉瓣置入术后抗栓治疗研究进展

2002年首例患者接受经导管主动脉瓣置换术（TAVI）以来,目前全球已有超过1万人从中获益。然而,TAVI术后可出现出血、血栓、心律失常、脑血管事件甚至死亡等许多并发症。尽管当前经验和技术均有所提高,围手术期及TAVI术后的缺血和出血并发症仍然普遍存在,并严重影响患者的预后。因此,权衡出血与血栓风险对指导接受TAVI手术患者的抗栓策略至关重要。但目前并无针对此问题的专家共识和推荐,相关指南的证据水平相对较低。本文对TAVI术后抗栓治疗的现有文献进行综述,旨在为临床诊疗及开展进一步研究提供思路。     

经导管主动脉瓣植入术治疗重度主动脉瓣狭窄的护理

目的探讨经导管主动脉瓣植入术(transcatheter aortic valve implantation,TAVI)治疗主动脉瓣狭窄患者的护理体会。方法回顾性分析2例主动脉瓣狭窄的患者在经导管主动脉瓣植入术后,术前完善专科评估及术前准备、心理护理,术后进行严密的病情观察、加强呼吸道管理与预防感染、穿刺部位的护理和相关并发症的观察与预防。结果 2例患者经过精心护理,预后良好,均康复出院。结论 TAVI操作难度大,术中、术后并发症多,护理做到周密细致,对并发症做到有预见性护理措施,能有效减少并发症的发生,促进患者早日康复。     

经导管主动脉瓣置入术的初步经验

目的 评估经导管主动脉瓣置入术( TAVI)的安全性及有效性,并对初步的操作经验做一总结.方法 2010年10月至2011年5月,使用18 F Corevalve瓣膜系统对3例外科手术高危的重度钙化性主动脉瓣狭窄患者实施TAVI.分析3例患者的手术效果及并发症,总结相关的手术经验.结果 3例患者均完成手术,顺利出院.手术时间(109.0±22.6)min,X线曝光时间(24.0±9.5)min.术后患者的主动脉跨瓣压差从(84±15)mm Hg(1 mm Hg =0.133 kPa)降至(6±3)mm Hg,并有轻微至轻度瓣周漏.病例1围手术期未发生并发症;病例2术后出现一过性完全性左束支传导阻滞;病例3出现三度房室传导阻滞(置入永久心脏起搏器)、心包填塞(经心包穿刺引流等保守治疗后好转)及急性肾功能损害.结论 初步经验显示,使用18 F Corevalve瓣膜系统对高危的严重钙化性主动脉瓣狭窄患者行TAVI安全有效,但有一定的手术并发症.严格筛选患者、熟练掌握手术的技巧及相关注意事项可减少并发症的发生.     

经导管主动脉瓣植入术后左束支起搏的临床应用初探

目的:探讨左束支区域起搏（LBBP）运用于经导管主动脉瓣植入术（TAVI）后患者的可行性和安全性。方法:本研究为回顾性研究。连续入选2018年1月至2020年12月在中国医学院科学院阜外医院接受TAVI治疗、术后置入永久起搏器的患者35例。根据心室电极放置位置,分为LBBP组（12例）和右心室心尖部起搏（RVAP）组（...     

经导管主动脉瓣置换术围手术期心电图表现及临床意义

目的 探讨经导管主动脉瓣置换术围手术期心电图表现及临床意义.方法 选择我院自2018年1月-2018年12月收治的50例行经导管主动脉瓣置换术治疗的患者作为研究对象,按照患者病情的不同分别采用Venus-A瓣膜、J-Valve瓣膜对其行手术治疗,观察患者术前及术后24 h心电图表现,并统计其术后并发症发生情况.结果 采用Venus-A瓣膜行经导管主动脉瓣置换术治疗患者,围手术期有3例患者发生新发左束支传导阻滞,1例患者发生新发右束支传导阻滞,1例患者发生新发III度房室传导阻滞.采用J-Valve瓣膜行经导管主动脉瓣置换术治疗患者,围手术期有3例患者发生新发左束支传导阻滞,2例患者发生新发多源室性心动过速及室性早搏,1例患者发生新发右束支传导阻滞.经对症治疗后,所有患者传导功能均于术后7-12 d恢复正常.结论 经导管主动脉瓣置换术围手术期对患者行心电图监测,能有效检出其异常传导情况,从而能指导临床尽早采取有效方案对患者进行干预,进而能保障其术后安全.     

PCI联合TAVR一站式手术治疗重度主动脉狭窄合并冠心病患者的围手术期护理

回顾性总结5例一站式经皮冠状动脉支架植入术(Percutaneous Coronary Intervention,PCI)联合经导管主动脉瓣置换术(Transcatheter Aortic Valve Replacement,TAVR)治疗重度主动脉狭窄合并冠心病患者的围手术期护理经验。护理要点聚焦术前衰弱与跌倒评估,术后并发症预防与护理,术后康复运动指导。PCI联合TAVR一站式手术术程复杂,手术风险大,围手术期护理难度高。经过医护一体化的精心治疗及护理,5例患者成功完成手术,术后症状改善明显,随访至今,情况可。     

经导管主动脉瓣置换术的新进展

近年来,经导管主动脉瓣置换(TAVI)术发展迅猛。对于外科手术风险很高的严重主动脉瓣狭窄患者,TAVI术已成为一种替代治疗。随着器械的不断改进和临床经验的积累,一些新的技术开始应用于TAVI领域,如非传统的支架输送途径、新材料的带瓣膜支架、局部麻醉下的TAVI术、经导管"瓣中瓣"技术等等。本文将TAVI领域近年来出现的一些新技术作一介绍。     

Early Experience of Transaortic TAVI—The Future of Surgical TAVI?

BackgroundTrans-catheter aortic valve implantation (TAVI) is now a well recognised procedure for the high risk surgical patient with native or bioprosthetic aortic valve stenosis. Transfemoral and transapical implantation techniques are well described. With increasing referral of more marginal transapical patients, we describe our experience of a transaortic TAVI approach which we believe reduces the postoperative wound pain, respiratory complications, operative risk and hospital stay.MethodsPatients referred for surgical TAVI underwent trans-catheter aortic valve implantation via an upper sternotomy and direct cannulation of the ascending aorta.ResultsThirteen patients with a mean age of 81 years underwent transaortic Edwards SAPIEN valve implantation. There was no in hospital mortality in our series. One patient required insertion of a permanent pacemaker for complete heart block. There were no aortic cannulation complications.ConclusionThe transaortic TAVI approach provides good exposure of the distal ascending aorta, a familiar cannulation site for cardiac surgeons. Our initial experience demonstrates the approach to be a safe technique with the potential for faster and less complicated recovery in patients undergoing surgical TAVI procedures. With further experience and greater acceptance, the transaortic approach may ultimately become the procedure of choice for patients unsuitable for a transfemoral approach.     

Delayed aortic dissection and valve thrombosis after transcatheter aortic valve implantation

We report a case of a 78‐year‐old female who presented with type A aortic dissection 22 months following transcatheter aortic valve implantation (TAVI). In addition, preoperative echocardiogram showed high gradients across the aortic prosthesis which was found to be thrombosed. At surgery, the intimal tear appeared to be non‐acute and anatomically related to the rim of the valve cage. The thrombosed valve was not replaced and the patient received anticoagulation therapy following surgery with significant improvement in valve gradients.     

Transcatheter aortic valve implantation 10 years after valve‐in‐valve transcatheter aortic valve implantation for failing aortic valve homograft root replacement

Valve‐in‐valve transcatheter aortic valve implantation (ViV‐TAVI) is an established therapy for a degenerated surgical bioprosthesis. TAVI‐in‐TAVI following ViV‐TAVI has not been previously performed. We report a high‐risk patient presenting with severe left ventricular failure secondary to undiagnosed critical aortic stenosis due to degeneration of the implanted transcatheter heart valve more than a decade after initial ViV‐TAVI for a failing stentless aortic valve homograft. Successful TAVI‐in‐TAVI reversed the clinical and echocardiographic changes of decompensated heart failure with no evidence of coronary obstruction.     

Prognostic benefit of transcatheter aortic valve implantation compared with medical therapy in patients with inoperable aortic stenosis

Objectives : To compare survival in patients with inoperable aortic stenosis who undergo transcatheter aortic valve implantation against those managed medically. Background : Without surgical correction, survival of patients with severe symptomatic aortic stenosis is poor. It is unknown whether patients undergoing transcatheter aortic valve implantation (TAVI) have a better prognosis than similar patients who are treated with medical management. Methods : Survival rates were compared in consecutive patients with severe symptomatic aortic stenosis who either underwent TAVI or continued on medical management following multidisciplinary team assessment. All patients had been turned down, or considered at unacceptably high risk, for conventional aortic valve surgery. Patients were reviewed in clinic or by telephone six monthly. Mortality data was obtained from the United Kingdom Office of National Statistics. Results : The study group included 85 patients aged 81 ± 7 years (range 62–94), of whom 48 were male. Thirty eight patients underwent TAVI while 47 patients were deemed unsuitable based on echocardiographic, angiographic, or clinical criteria and remained on medical therapy. The calculated EuroSCORE for the TAVI group was 11 ± 2 and for the medical group 9 ± 2 (P < 0.001). TAVI‐related procedural mortality was 2.6%, and 30‐day mortality was 5.2%. Among the medically‐treated patients, 14 (30%) underwent palliative balloon aortic valvuloplasty, with a trend toward improved survival (P = 0.06). During overall follow‐up of 215 ± 115 days there were a total of 18 deaths; TAVI N = 5 (13%); Medical N = 13 (28%) (P = 0.04). Conclusions : Patients with severe aortic valve disease who are not suitable for surgical aortic valve replacement have an improved prognosis if treated with transcatheter aortic valve implantation rather than continuing on medical management alone. © 2010 Wiley‐Liss, Inc.     

Trans‐apical aortic valve implantation complicated by left main occlusion

Transcatheter aortic valve implantation (TAVI) is a highly effective procedure for selected patients who are at high risk for aortic valve replacement; however, the incidence of severe complications is still relevant. Coronary occlusion during TAVI is a life‐threatening complication that requires immediate diagnosis and treatment. We report the case of an 87‐years‐old woman affected by severe aortic stenosis, symptomatic for refractory heart failure, who underwent urgent balloon aortic valvuloplasty and subsequent elective transapical aortic valve implantation. Valve deployment was complicated by cardiac arrest and hemodynamic collapse, and left main coronary artery occlusion was recognized and successfully recovered by balloon angioplasty and stent implantation. Patient is alive and well 6 months after procedure. © 2011 Wiley‐Liss, Inc.     

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.     

Development of transcatheter aortic valve implantation (TAVI): A heart-warming adventure

The development of transcatheter aortic valve implantation (TAVI) spearheaded by our group has been a great adventure since we validated the concept in the early 1990s in aortic stenosis (AS) postmortem studies. We first tested prototypes in animal models before performing the daring first-in-man implantation in 2002. Prospective compassionate use series followed, accompanied by ongoing technological innovation of devices and of delivery systems. High surgical risk patients were enrolled in feasibility studies, which led to the Conformité Européenne (CE) mark being granted in 2007. Data from post-marketing registries involving thousands of patients have shown remarkable results and increasingly smaller complication rates, as a result of growing experience and improved technology. Survival and quality of life results from the landmark randomized PARTNER Edwards SAPIEN study have confirmed the important place of TAVI in non-operable and high surgical risk patients. To date, more than 50,000 patients have benefited from TAVI worldwide. TAVI is now recommended in the European Society of Cardiology (ESC), the European Association for Cardio-Thoracic Surgery (EACTS) guidelines, and by the Food and Drug Administration in the United States for the treatment of AS patients who are not suitable or at high risk for surgery, as assessed by a multidisciplinary heart team, and in whom a less invasive approach is favored. Multidisciplinary heart teams are critical in patient selection and in successful procedures. In future, TAVI may be extended to use in lower risk patients, although further clinical investigation is necessary. Just over 10 years after the first-in-man case, TAVI has quickly become an established AS treatment option.     

Infective endocarditis following transcatheter aortic valve implantation

Trans-catheter aortic valve implantation (TAVI) has recently emerged as a less invasive alternative to surgical aortic valve replacement (SAVR) in high risk patients. Although several procedures have been performed worldwide, infective endocarditis (IE) has been reported to be a rare TAVI complication, nevertheless if IE occurs it represents a life-threatening condition and treatment is challenging. TAVI-IE are thus normally treated conservatively by targeted antibiotic therapy with a high reported mortality (40%). Surgical explant represent the definitive strategy but, the intervention is at a high risk (risk of complication 87%, with an in hospital mortality of about 47%). In the present paper, we report the case of a 71-year-old patient affected by an early endocarditis after TAVI (TAVI-IE) treated at our Institution by surgical explant. The case highlights a paradox: if TAVI procedures are indicated over traditional surgical valve replacement in treatment of high surgical risk patients, what should be the best management when TAVI-IE occurs in these same population of patients?