球囊再扩张治疗经导管主动脉瓣置入术后瓣周漏效果

<正>背景:经导管主动脉瓣置入术(TAVI)术后严重的主动脉瓣瓣周漏与患者死亡直接相关,术后即刻使用球囊再扩张瓣膜成形术可使主动脉瓣膜支架充分扩张治疗瓣周漏。在导管室通过升主动脉造影和超声心动图测量血流动力学指标:主动脉瓣反流指数(AR-Index),可快速、准确、客观地反映TAVI术后即刻瓣周漏的严重程度。目的:测量ARIndex,是否可以判断主动脉瓣球囊再扩张术治疗TAVI术后     

经导管国产化主动脉人工瓣膜支架“瓣中瓣”置入的实验研究

目的使用国产镍钛合金自膨式主动脉瓣膜支架行"瓣中瓣"二次置入,验证使用国产化主动脉瓣膜支架行"瓣中瓣"技术的安全性和有效性,初步探讨国产瓣膜支架经导管"瓣中瓣"治疗衰败生物瓣膜的可行性。方法使用国产瓣膜支架系统进行经导管主动脉瓣膜置入手术,将首次置入的瓣膜支架置于主动脉瓣上,瓣膜支架瓣环与实验羊自身瓣环距离大于10mm,实验羊的主动脉瓣因不同程度受压后出现中～大量的反流。当即运用"瓣中瓣"技术经导管在主动脉瓣区原位置入第二枚瓣膜支架,恢复主动脉瓣功能,对存活山羊在术后即刻和3个月行造影及左心导管评估。结果在所有8只实验羊中,6只山羊成功完成"瓣中瓣"置入,术后3个月随访存活良好。1只山羊在二次置入瓣膜支架定位过低,产生大量瓣周漏导致急性左心衰竭死亡;另1只山羊由于首枚瓣膜支架置入位置过高,造成右冠状动脉开口阻塞,在置入第二枚支架过程中发生室颤死亡。存活实验羊术后复查心电图未出现传导阻滞。"瓣中瓣"手术成功的实验羊造影可见首枚瓣膜支架位置不良,二次置入的瓣膜支架套叠于首枚置入支架内,置入位置理想,瓣膜启闭正常,左右冠状动脉均显影,提示冠状动脉口未见堵塞。左心室造影未见瓣膜明显狭窄,主动脉逆行造影未见瓣膜明显反流,可见支架整体随心脏搏动有明显的收缩和舒张。在"瓣中瓣"置入术后即刻和术后3个月后进行左心导管检查,其收缩期主动脉跨瓣压差分别为(23.5±2.5)mmHg和(24.1±2.6)mmHg,与瓣膜支架置入前收缩期主动脉跨瓣压差比较,差异无统计学意义(P=0.17和P=0.07)。结论经导管置入国产化主动脉瓣膜支架出现定位不良时,运用"瓣中瓣"技术紧急置入另一瓣膜支架,可有效恢复瓣膜功能;国产化主动脉瓣膜支架也可用于治疗生物瓣膜衰败后的"瓣中瓣"二次置入。     

经导管主动脉瓣置入术3例中期随访

经导管主动脉瓣置入术(TAVI)是近来研发的新兴心脏介入技术。自2002年Cribier等实施首例人体TAVI术以来,TAVI发展迅速。截至目前,全球已有40000多例患者接受TAVI术。总的来讲,欧美地区TAVI发展较快,各国积累较多的病例,相     

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...     

CT TAVI Planning技术在经导管主动脉置换术前的预测性研究

目的:探讨使用飞利浦CT TAVI Planning软件对主动脉瓣膜狭窄的患者在经导管主动脉置换术(TAVI)围手术期的术前指导价值,对主动脉进行综合测量评估,根据测量结果对TAVI瓣膜支架的型号进行预测性研究,并与术中经食道超声测量结果对比分析。方法:回顾性研究,搜集我院2017年1月至2019年6月经临床诊断严重主动脉瓣病变,并具有外科治疗的高危因素和手术禁忌证,最终行TAVI手术的患者32例,男性18例,女性14例,年龄68～84岁,平均年龄(70.82±6.07)岁,使用TAVI Planning软件测量主动脉瓣环、主动脉窦、窦管交界、主动脉瓣环下5 mm左心室流出道、窦管交界上方4 cm升主动脉、冠状动脉开口、主动脉窦高度及最佳投影角度,根据测量结果对患者手术瓣膜支架型号进行预测分析,计算CT预测准确率;根据经食道超声测量结果,计算超声预测准确率。结果:CT TAVI Planning软件测量主动脉瓣环直径大于经食道超声瓣环直径,CT预测准确率为87.5%,经食道超声预测准确率56.3%,将两者准确率使用卡方检验进行比较分析,差异有统计学意义(P均0.05)。将CT和超声测量主动脉瓣环直径建立ROC曲线,CT敏感度及特异度均高于经食道超声。结论:使用CT TAVI Planning软件进行主动脉CTA检查要优于经食道超声检查,可以为TAVI手术提供重要的参考价值。     

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     

经股动脉经导管主动脉瓣置换术治疗单纯主动脉瓣关闭不全

【摘要】 目的 探讨Venus-A支架瓣膜行经股动脉经导管主动脉瓣置换术治疗单纯主动脉瓣关闭不全患者的可行性。方法 回顾性调阅2018年12月至2019年12月在阜外医院接受经股动脉经导管主动脉瓣置换术的15例单纯主动脉瓣关闭不全患者的床资料。其中男性12例, 女性3例,年龄68—83岁,平均年龄(74.65±5.52)岁。患者术前均有左心功能不全症状,且术前心脏超声诊断均为单纯主动脉瓣重度返流。结果 患者行经股动脉经导管主动脉瓣置换术。所有病例成功植入Venus-A支架瓣膜。全组病例无死亡。出院前对患者进行临床评估和超声心动图检查。术中行瓣中瓣治疗3例,少量瓣周返流2例。其余病人均无明显瓣周返流,并且顺利出院。结论 经股动脉经导管主动脉瓣置换术治疗单纯主动脉瓣关闭不全患者是可行的,术后早期结果满意。     

主动脉瓣狭窄合并疾病对经导管主动脉瓣置入术的影响

近年来,经导管主动脉瓣置入术(TAVI)在不宜行外科手术的高风险主动脉狭窄患者中广泛开展。TAVI能在主动脉瓣狭窄合并冠状动脉粥样硬化性心脏病、心力衰竭、肺动脉高压等的患者中安全开展,显示了该手术良好的安全性及有效性。该文介绍常见合并疾病对TAVI治疗的影响。     

经导管主动脉瓣植入术后抗血栓治疗中国专家共识

经导管主动脉瓣植入术(TAVI)现已成为治疗有症状重度主动脉瓣狭窄患者的有效措施,且适用人群也从老年高风险患者逐步扩展到中、低风险及较年轻患者,但其术后缺血性及出血性并发症仍不少见,并有一定的致死率和致残率。该专家共识复习了相关资料及研究进展,结合我国具体情况及国际指南,给出了TAVI术后抗血栓治疗的建议,以期提高我国TAVI术后患者生存率及生存质量,减少缺血及出血并发症。该共识从TAVI术后血栓形成及出血的危险因素和机制、缺血及出血风险评估、抗凝与抗血小板治疗的选择、抗血小板治疗的方案、抗血栓时程、瓣叶血栓及出血并发症的处理等方面进行了详尽的阐述。强调TAVI术后应综合评估患者缺血及出血事件发生的风险,方案的制定应个体化,进而改善患者预后。     

经导管主动脉瓣置入术的并发症

经导管主动脉瓣置入术(Transcatheter aortic valve implantation,TAVI)已成为高危主动脉瓣重度狭窄患者的有效治疗手段之一,在国内尚处于起步阶段。本文就TAVI的术中、术后的并发症进行综述,以期为临床提供参考。通过本文研究发现,术前严格筛选患者、充分的影像学评估至关重要,是避免TAVI严重并发症的必要条件。     

Minimising permanent pacemaker implantation (PPI) after TAVI

Increased demand for transcatheter aortic valve implantation (TAVI) procedures for patients with severe aortic stenosis has not been matched with a proportional increase in available resources in recent years. This article highlights the importance of developing integrated care pathways for TAVI, which incorporate standardised protocols for permanent pacemaker implantation (PPI) to ensure best practice, increase service efficiency and reduce rates of PPI post-TAVI.Key words: aortic valve stenosis, artificial transcatheter aortic valve replacement, heart valve diseases, pacemaker     

Transcatheter Aortic Valve Implantation in a Patient With Severe Aortic Insufficiency and Minimal Aortic Annular Calcification

Severe aortic insufficiency with minimal aortic annular calcification has been considered a relative contraindication to transcatheter aortic valve implantation (TAVI) because of a lack of calcium for fluoroscopic visualization and radial stent fixation. We report a patient with severe aortic insufficiency after previous coronary artery bypass and aortic valve repair who underwent successful TAVI. Intraoperative transesophageal echocardiography was critical to guide valve implantation and previous surgical pledgets were used to seat an oversized TAVI prosthesis within the aortic annulus. In follow-up, the patient remained New York Heart Association class I and echocardiography demonstrated a well-functioning TAVI prosthesis with no aortic insufficiency.     

Transseptal Mitral Valve Replacement after Transcatheter Aortic Valve Implantation

We report a case of mitral valve replacement in a patient who had previously undergone transcatheter aortic valve implantation. A transseptal approach was used to avoid displacing the aortic prosthesis. Because of the small mitral annulus, a bioprosthetic aortic valve was used in reverse position for mitral valve replacement. The procedure did not interfere with the existing prosthesis, and a follow-up echocardiogram showed that both prosthetic valves were functioning well.To the best of our knowledge, this is the first report of mitral valve replacement in a patient who had a preceding transcatheter aortic valve implantation. We believe that the transseptal approach is promising for mitral valve replacement in such patients. Moreover, using a bioprosthetic aortic valve in reverse position is an option for mitral valve replacement when the mitral annulus is too small for placement of a standard bioprosthetic mitral valve.Key words: Aged, 80 and over; aortic valve; bioprosthesis; calcinosis/complications; cardiac surgical procedures; heart atria/surgery; heart valve prosthesis implantation; mitral valve insufficiency/surgeryTranscatheter aortic valve implantation (TAVI) is currently emerging as a valuable option to treat high-risk patients with severe, symptomatic aortic stenosis.¹ The number of patients receiving TAVI has increased dramatically over a short period of time because of the promising advances in this new technology and the growing number of high-risk, elderly patients with multiple comorbidities, who are better suited for a minimally invasive procedure. Consequently, cardiac surgeons must care for an increasing number of patients who have undergone TAVI. Subsequent cardiac procedures in the setting of previous TAVI pose a challenge due to the risks of procedural interference with—and postprocedural functional impairment of—the previous aortic prosthesis. The following case illustrates an effective method of performing a mitral valve replacement in the setting of previous TAVI.     

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.     

From pressure overload to volume overload: aortic regurgitation after transcatheter aortic valve implantation

Severe aortic valve stenosis is a common valvular heart disease that is characterized by left ventricular (LV) pressure overload. A lasting effect of pressure overload is LV remodeling, accompanied by concentric hypertrophy and increased myocardial stiffness. Transcatheter aortic valve implantation (TAVI) has emerged as an alternative to surgical aortic valve replacement for patients with severe symptomatic aortic valve stenosis and high surgical risk. Although TAVI has favorable hemodynamic performance, aortic valve regurgitation (AR) is the most frequent complication because of the specific technique used for implantation of transcatheter valves. During implantation, the calcified native valve is pushed aside, and the prosthesis usually achieves only an incomplete prosthesis apposition. As a consequence, the reported prevalence of moderate and severe AR after TAVI is 6% to 21%, which is considerably higher than that after a surgical valve replacement. Although mild AR probably has minor hemodynamic effects, even moderate AR might result in serious consequences. In moderate and severe AR after TAVI, a normal-sized LV with increased myocardial stiffness has been exposed to volume overload. Because the noncompliant LV is unable to raise end-diastolic volume, the end-diastolic pressure increases, and the forward stroke volume decreases. In recent years, an increasing number of patients have successfully undergone TAVI. Despite encouraging overall results, a substantial number of patients receive neither symptomatic nor prognostic benefits from TAVI. Aortic valve regurgitation has been considered a potential contributor to morbidity and mortality after TAVI. Therefore, various strategies and improvements in valve designs are mandatory to reduce the prevalence of AR after TAVI.     

Transcatheter aortic valve implantation: a revolution in the therapy of elderly and high-risk patients with severe aortic stenosis

Transcatheter aortic valve implantation (TAVI) represents a real revolution in the field of interventional cardiology for the treatment of elderly or high-risk surgical patients with severe symptomatic aortic valve stenosis. Today, TAVI seems to play a key and a reliable role in the treatment of intermediate and maybe low-risk patients with severe aortic stenosis. TAVI has also evolved from a complex and hazardous procedure into an effective and safe therapy by the development of new generation devices. This article aims to review the background and future of TAVI, clinical trials and registries with old and new generation TAVI devices and to focus on some open issues related to post-procedural outcomes.     

Frequency of congenitally bicuspid aortic valves in patients ≥80 years of age undergoing aortic valve replacement for aortic stenosis (with or without aortic regurgitation) and implications for transcatheter aortic valve implantation

The purpose of the present report was to determine the frequency of a congenitally bicuspid aortic valve in patients ≥80 years of age old with aortic stenosis (AS) severe enough to warrant aortic valve replacement. Transcatheter aortic valve implantation (TAVI) has traditionally been reserved for patients ≥80 years of age with severe AS involving a 3-cuspid aortic valve. Traditionally, AS involving a 2-cuspid aortic valve has been a contraindication to TAVI. We examined operatively excised stenotic aortic valves in 364 patients aged ≥80 years to determine the frequency of an underlying congenitally bicuspid aortic valve. Of the 347 octogenarians and 17 nonagenarians, 78 (22%) and 3 (18%) had stenotic congenitally bicuspid aortic valves, respectively. In conclusion, because the results of TAVI are less favorable in patients with stenotic congenitally bicuspid valves than in patients with stenotic tricuspid aortic valves, proper identification of the underlying aortic valve structure is important when considering TAVI as a therapeutic procedure for AS in older patients.     

Clinical and silent stroke following aortic valve surgery and transcatheter aortic valve implantation

Transcatheter aortic valve implantation (TAVI) has been introduced as an alternative to conventional surgery for high-risk patients with aortic stenosis. A recently published randomized clinical trial demonstrated reduction of mortality in high-risk or inoperable patients when compared to medical treatment or balloon aortic valvuloplasty. Despite this evidence of superiority, the rate of TAVI complications is high, and perhaps the most devastating of the nonfatal complications is cerebral injury. This review will compare the incidence of stroke and “silent” cerebral injury after surgical aortic valve replacement and after TAVI and will discuss mechanisms that can lead to cerebral injury during these procedures and subsequently how to prevent this with new protection devices.     

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.     

新型口服抗凝药在经导管主动脉瓣膜植入术中应用的研究进展

经导管主动脉瓣膜植入术(TAVI)已经被广泛应用于具有临床症状的主动脉瓣严重狭窄且无法手术或手术风险较高的患者。目前,各指南推荐TAVI术后以抗血小板为主的抗血栓治疗方案,抗凝治疗尤其是新型口服抗凝药(NOACs)在TAVI中应用的有效性及安全性有待进一步研究。本文旨在探讨近年来NOACs在TAVI中应用的最新研究进展。