经导管主动脉瓣置换术后抗栓治疗的现状

<正>退行性主动脉瓣狭窄是最常见的瓣膜性心脏病，在老年患者中发生率2.5%～7%^[1],经导管主动脉瓣置换术(transcatheter aortic valve replacement, TAVR)日益成为代替外科主动脉瓣置换术(surgical aortic valve replacement, SAVR)治疗重度症状性主动脉瓣狭窄(aortic stenosis, AS)的常用方法。     

经导管主动脉瓣置换术相关并发症的现状与进展

正自2002年Cribier等~([1])将一个球囊扩张式瓣膜成功应用于临床治疗,完成人类历史上首例经导管主动脉瓣置换术(transcatheter aortic valve replacement,TAVR)以来,迄今已有多个中心完成近30万例TAVR。作为外科主动脉瓣置换术(surgical aortic valve replacement,SAVR)的补充,TAVR主要针对重度主动脉瓣狭窄(aortic stenosis,AS)合并高龄、左心功能不全或存在多种合并症等原因,不能耐受外科手术的患者。作为微创介入手术,TAVR实施过程中也需规避及处理并发症。本文针对目前TAVR的临床研究中所报道的并发症及防治原则进行阐述分析。     

经导管主动脉瓣置换术的入径选择

正主动脉瓣狭窄(aortic stenosis,AS)是65岁以上人群最常见的心脏瓣膜疾病~([1])。过去对于晚期或症状性AS的治疗选择仅限于外科主动脉瓣置换术(surgical aorticvalve replacement,SAVR);近十年来,经导管主动脉瓣置换术(transcatheter aortic valve replacement,TAVR)在此类患者     

主动脉瓣生物瓣毁损后行经导管主动脉瓣置换术的安全性及可行性初步研究

目的观察主动脉瓣生物瓣毁损后行经导管主动脉瓣置换术(transcatheter aortic valve replacement,TAVR)的安全性及可行性。方法总结2016年11月至2018年10月因主动脉瓣生物瓣毁损在阜外医院接受TAVR治疗患者,共10例。观察手术成功率及并发症,并随访患者血流动力学改善情况、主要心脏不良事件发生情况。结果 10例患者行TAVR治疗成功。1例因Ⅲ°房室传导阻滞行永久起搏器治疗,其余无围手术期死亡、心肌梗死、脑卒中、严重瓣膜反流、急性肾损伤、大出血、血管夹层并发症发生。术后1个月的平均跨瓣压差和峰值流速较术前显著下降[(18.1±8.4)mmHg vs (39.7±22.9)mmHg,(2.3±0.8)m/s vs(4.0±1.0)m/s,P均0.05]。术后6个月的平均跨瓣压差为(14.8±7.7)mmHg,较术前明显下降(P=0.005)。术后NT-proBNP较术前明显下降[(808.6±358.5)pg/L vs(11050.3±13557.5)pg/L,P 0.05]。出院日常生活能力评分较入院显著增加[(94±8.4)分vs (71±23.1)分,P 0.05]。术后NYHA心功能分级Ⅰ级者为60%,较术前有明显改善(P 0.05)。结论主动脉瓣生物瓣毁损后行TAVR治疗是一种安全可行的手术替代方式。     

主动脉瓣狭窄合并冠心病患者行单纯介入治疗与单纯外科治疗的疗效对比分析

目的:对比分析经导管主动脉瓣置换术(transcatheter aortic valve replacement, TAVR)同期行冠状动脉介入治疗(percutaneous coronary intervention, PCI)与外科主动脉瓣置换术(surgical aortic valve replacement, SAVR)同期行冠状动脉旁路移植术(coronary artery bypass grafting, CABG)治疗主动脉瓣狭窄合并冠心病患者的早期临床疗效及预后,总结相关临床经验。方法:回顾性分析2018年—2023年于河北医科大学第二医院心脏大血管外科接受治疗的主动脉瓣狭窄合并冠心病患者的临床资料,共有29例,其中行TAVR+PCI 11例,行SAVR+CABG 18例。比较两组患者术前及术后的相关临床数据。结果:TAVR+PCI组较SAVR+CABG组术前NYHA心功能分级Ⅳ级(54.55%vs 5.56%,P<0.05)、术前胸腔积液(27.27%vs 0%,P<0.05)患者占比更高。TAVR+PCI组均只进行了1支冠脉血管的血运重建,SAVR+C...     

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。     

主动脉瓣狭窄合并冠心病患者的经导管主动脉瓣置换联合介入治疗

经导管主动脉瓣置换术(transcatheter aortic valve replacement,TAVR)作为主动脉瓣狭窄(aortic stenosis,AS)重要的治疗方式目前已获得诸多研究证据支持,而冠心病是TAVR患者常见的合并症之一.经皮冠状动脉(冠脉)介入治疗(percutaneous coronary...     

主动脉瓣狭窄患者经导管主动脉瓣置换术尺寸策略和手术结局分析

目的：旨在分享近几年接受接受经导管主动脉瓣置换术(transcatheter aortic valve replacement,TAVR)的症状性严重主动脉瓣狭窄(aortic stenosis,AS)患者的尺寸策略和手术结局。方法：2017年10月到2021年10月,在北京安贞医院接受TAVR术的132例严重AS患者进行回顾性评估,包括主动脉根部的解剖结构和形态及手术策略。“缩小尺寸”策略是在患者有复杂形态时实施的,例如二叶式主动脉瓣(bicuspid aortic valve,BiAV)、小叶水平严重钙化、小叶明显增厚和融合。将采用缩小尺寸策略的患者与采用瓣环尺寸策略的患者临床结果进行比较。结果：在132例患者中,41例(31.1%)为BiAV形态。根据TAVR手术策略,38例患者选择瓣环尺寸策略,94例患者选择缩小尺寸策略。缩小尺寸组BiAV患者比例更高(P=0.046)。主动脉根部的钙体积为449.9(243.2,782.2)mm³,主要分布在小叶水平上。TAVR术后1个月,主动脉瓣口面积(aortic orifice area,AVA)从(0.7±0.2...     

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。     

St.Jude Medical Regent主动脉瓣应用于小主动脉瓣环患者的初步经验

目的总结对小主动脉瓣环患者行St.JudeRegent主动脉瓣替换的初步经验。方法对11例小瓣环主动脉瓣病变患者行St.JudeRegent主动脉瓣替换。患者平均年龄(42.9±13.1)岁,体重(68.2±10.1)kg,体表面积(1.71±0.13)m2。术前主动脉瓣跨瓣峰值压差平均(74.4±34.3)mmHg。替换19号St.JudeRegent主动脉瓣7例,21号4例。结果本组患者无手术死亡,无严重并发症。平均输血量227.3ml,4例未输血。随访无远期死亡。术后患者心功能较术前明显改善。术后6个月复查超声心动图,提示肥厚的左心室显著退缩,人工瓣跨瓣峰值压差为(20.8±5.0)mmHg。19号瓣平均有效瓣口面积为(1.68±0.17)cm2,21号瓣为(1.96±0.25)cm2。结论小瓣环主动脉瓣病变患者行St.JudeRegent主动脉瓣替换的近期效果良好。     

The design and development of a stented tissue mitral and aortic heart valve replacement for human implantation

A study was conducted into the development of a mitral and aortic heart valve replacement that caters for patients having suffered valve damage due to stenosis or rheumatic fever. The appeal of the valve is that it is constituted from a solid frame housing pericardial tissue leaflets, and allows the patient freedom from post-operative blood-thinning medication. The valve is designed to appeal to patients in developing areas of the world, as it features a clip-in mechanism to secure the valve assembly into the sewing ring, which is stitched in independently of the frame and leaflets. Re-operative valve replacement would then be made possible when the pericardial leaflets began to calcify. Novel aspects of the design added value to the science of heart valve replacements, through the use of sintered chrome cobalt in the valve components, the insights gained into mechanical testing of pericardium, and the patient benefits offered by the complete design. Further work is planned to fatigue test the assembly, undergo animal trials and make the valve available for commercial use.     

经导管主动脉瓣置换的介入瓣膜的现状及展望

经导管主动脉瓣置换术（TAVR）经过最近几年快速发展已经取得巨大进步。迄今为止全球接受TAVR的患者数已近3万例,已成为无法耐受传统手术患者的标准备选治疗措施。从目前已临床应用的介入瓣膜到正在实验研究的新型介入瓣膜可以看出,未来介入瓣膜的发展目标是尺寸更小、长期有效、安全性高、并发症少、操作简单及定位精准。随着TAVR的推广,新型介入瓣的研发,操作者经验的积累,以及长期随访的开展,将给TAVR提供更科学的病例选择标准,减少介入手术的相关并发症,提高更安全有效的治疗效果。未来此项技术还会逐渐扩大适用人群的范围,成为代替传统的主动脉瓣置换术举足轻重的治疗措施。     

Direct comparison of rapid deployment versus sutureless aortic valve replacement: a meta-analysis

BackgroundThis meta-analysis was conducted to compare the procedural and early outcomes of aortic valve replacement (AVR) using rapid deployment valve (RD group) versus sutureless valve (SU group).MethodsA literature search of 5 online databases was conducted. The primary outcomes were mean transvalvular pressure gradient (MPG) after AVR, the incidence of paravalvular leak (PVL) and the need for a permanent pacemaker implantation (PPI). The secondary outcomes included aortic cross-clamp (ACC) and cardiopulmonary bypass (CPB) times, early mortality and other postoperative complications, such as atrial fibrillation, bleeding reoperation and stroke.ResultsEight articles were included, and all outcomes except MPG after AVR in matched valve sizes were extracted from 7 studies (RD group =842 patients and SU group =1,386 patients). The pooled analysis demonstrated a lower MPG in the RD group than in the SU group, with mean difference (MD) of 2.64 mmHg. The pooled risk ratios of any PVL and grade ≥2 (or moderate) PVL were not significantly different between the groups; however, the incidence of PPI was significantly lower in the RD group than in the SU group, with a risk ratio of 0.69. The pooled analyses showed that the ACC and CPB times were significantly longer in the RD group than in the SU group, with weighted MDs of 8.74 (P<0.001) and 9.94 (P<0.001) minutes, respectively. The risks of early mortality and other postoperative complications were not significantly different between the groups.ConclusionsAVR using RD valve was associated with better valve hemodynamics in terms of the MPG than AVR using SU valve, and better outcomes were observed in the RD group regarding PPI. Procedural times were longer in AVR using RD valve than SU valve. Early clinical outcomes showed no difference between RD and SU valve.     

Melody valve implantation in the pulmonary and tricuspid position

Percutaneous implantation of valved stents is now routinely performed to treat pulmonary valve regurgitation and stenosis. In addition, there are isolated reports of implantation of valved stents in the tricuspid position to treat prosthetic tricuspid stenosis or regurgitation when a prosthetic valve ring exists. We present a case in which a patient with combined severe tricuspid valve and pulmonary valve disease was successfully treated with sequential implantation of percutaneous valved stents in a single procedure. The procedure was straightforward, of short duration, and dramatically improved the patient's functional status. © 2012 Wiley Periodicals, Inc.