经皮肺动脉瓣置换术研究进展

近年来,经皮肺动脉瓣置换术因其创伤小、手术简便等优点得到了快速发展,已成为心血管疾病介入治疗领域新的热点,现通过复习相关文献对该技术的应用现状及研究进展做一介绍。     

Transcatheter Pulmonary Valve Replacement: Current State of Art

Purpose of Review

The past couple of decades have brought tremendous advances to the field of pediatric and adult congenital heart disease (CHD). Percutaneous valve interventions are now a cornerstone of not just the congenital cardiologist treating patients with congenital heart disease, but also—and numerically more importantly—for adult interventional cardiologists treating patients with acquired heart valve disease. Transcatheter pulmonary valve replacement (tPVR) is one of the most exciting recent developments in the treatment of CHD and has evolved to become an attractive alternative to surgery in patients with right ventricular outflow tract (RVOT) dysfunction. This review aims to summarize (1) the current state of the art for tPVR, (2) the expanding indications, and (3) the technological obstacles to optimizing tPVR.

Recent Findings

Since its introduction in 2000, more than ten thousands tPVR procedures have been performed worldwide. Although the indications for tPVR have been adapted earlier from those accepted for surgical intervention, they remain incompletely defined. The new imaging modalities give better assessment of cardiac anatomy and function and determine candidacy for the procedure. The procedure has been shown to be feasible and safe when performed in patients who received pulmonary conduit and or bioprosthetic valves between the right ventricle and the pulmonary artery. Fewer selected patients post trans-annular patch repair for tetralogy of Fallot may also be candidates for this technology. Size restrictions of the currently available valves limit deployment in the majority of patients post trans-annular patch repair. Newer valves and techniques are being developed that may help such patients.

Summary

Refinements and further developments of this procedure hold promise for the extension of this technology to other patient populations.

     

法洛氏四联症根治术后肺动脉瓣置换术研究进展

法洛氏四联症根治术后肺动脉瓣置换术手术时间,目前尚存在争议。指征包括显著的肺动脉瓣反流合并重度右心室扩大（右心室舒张末容积指数〉150ml／m^2或〉2倍左心室舒张末容积指数）、持续性心房扑动／心房颤动或持续性室性心动过速及QRS间期〉180ms等。术后右心室功能迅速改善,表现为右心室容量、质量的减少,QRS间期缩短等。反流的肺动脉瓣常用同种移植物、生物瓣、机械瓣代替。经导管人工肺动脉瓣置换手术及镶嵌治疗可作为外科手术的补充治疗。     

A Systematic Approach to Pulmonary Valve Replacement in the Current Era

Background: Pulmonary valve replacement (PVR) can be accomplished via surgical, transcatheter, or hybrid approaches. There are inherent advantages to transcatheter PVR and hybrid PVR without cardiopulmonary bypass. We review the methods and results of a standardized institutional approach to PVR. Methods: Retrospective review of all PVR cases between February 2017 and February 2020. Hybrid PVR entailed off-pump RVOT plication with percutaneous transcatheter PVR. Results: Primary transcatheter PVR was attempted in 37, hybrid PVR was performed in 11, and on-pump surgical PVR was performed in 9. Median age at PVR was 27 years (6–65). Primary transcatheter PVR was successful in 35/37 (2 converted to surgical). Standard surgical PVR was utilized for positive coronary compression testing (n = 4), stent/valve system migration (n = 2), or patient preference (n = 3). In the hybrid group mean RVOT diameter was 34 mm (32–38). Median length of stay was 1 day for transcatheter PVR, 5 for surgical, and 3 for hybrid (p = 0.02). Median follow-up was 1.5 years. Re-interventions were one balloon valve dilation in a transcatheter PVR, and one valve dilation with subsequent transcatheter valve-in-valve PVR in the surgical cohort. One hybrid patient expired 11 months post procedure. Conclusions: A systematic approach to PVR utilizing all approaches in pre-defined order of preference leads to consistent outcomes in a wide variety of anatomic configurations. Transcatheter PVR may be accomplished in the majority of patients. When necessary, hybrid off-pump RVOT plication with transcatheter PVR avoids the need for cardiopulmonary bypass.     

Use of a Melody Pulmonary Valve in Transcatheter Valve-in-Valve Replacement for Tricuspid Valve Bioprosthesis Degeneration

Bioprosthetic heart valves can degenerate and fail over time. Repeat surgery as a means of replacement increases morbidity and mortality rates, and some patients are not candidates for reoperation. A newer treatment, percutaneous transcatheter valve-in-valve implantation, might delay or substitute for invasive procedures. We present the case of a 51-year-old woman, a poor candidate for surgery who had prosthetic tricuspid valve degeneration and stenosis. We successfully performed valve-in-valve placement of a Melody^® valve, using a procedure originally intended to treat pulmonary valve conduit obstruction or regurgitation. To our knowledge, this is among the first case reports to describe the use of the Melody pulmonary valve in transcatheter valve-in-valve replacement for prosthetic tricuspid stenosis that was otherwise not correctable. Additional data and longer follow-up periods are necessary to gain an understanding of ideal indications and selection of patients for the percutaneous transcatheter treatment of tricuspid valve stenosis.     

Mitral Valve Replacement in Patients After Aortic Valve Replacement

Abstract Background: Mitral valve replacement in patients who previously had undergone aortic valve replacement is a technical challenge. The rigid aortic prosthesis limits visualization of the anterior mitral annulus and placement of sutures. Methods: Reoperative mitral valve replacement was performed in five patients after aortic valve replacement. Two patients underwent resternotomy to allow verification of normal aortic prosthetic valve function. Anterolateral right thoracotomy was used for reentry in the remaining three patients. Exposure of the anterior mitral annulus was accomplished by initial traction on the intact anterior leaflet, with resection of this leaflet only after placement of sutures. Results: All patients survived the surgical procedure and are well 2 to 30 months after operation. In one patient it was impossible to open one cusp of the mitral prosthesis, nor was it possible to rotate the valve. The valve was reimplanted, but sutures were tied only after testing for full free cusp motion. Conclusions: When appropriate, right thoracotomy incision offers excellent exposure of the mitral valve with minimal dissection. Placement of sutures along the anterior portion of the annulus is facilitated by traction downwards on the anterior leaflet. Full range of motion of the prosthetic cusps should be verified before tying the sutures.     

风湿性心脏病二尖瓣病变患者瓣膜替换术后肺功能的改变

目的：了解风湿性心脏病二尖瓣病变患者二尖瓣替换术（ＭＶＲ）后肺功能的改变。方法：观察２６例风湿性心脏病二尖瓣病变患者ＭＶＲ术前和术后３～１２个月的肺功能改变。结果：ＭＶＲ后３个月的肺功能与术前相比，无明显好转。术后６～１２个月，患者的各通气功能指标均有明显增加（Ｐ＜０．０５～Ｐ＜０．０１），但肺的一氧化碳弥散功能（ＤＬＣＯ）术后不但无增加，反而有下降的趋势。结论：ＭＶＲ术后３个月患者的肺功能与术前相比，无明显好转，可能与剖胸手术创伤有关。随着心功能的改善，术后６～１２个月，患者的通气功能逐渐改善，但ＤＬＣＯ并不增加，推测可能与患者术后肺泡毛细血管容量减少以及肺组织结构损害不可逆性改变有关。     

Development of an Off-the-Shelf Tissue-Engineered Sinus Valve for Transcatheter Pulmonary Valve Replacement: a Proof-of-Concept Study

Tissue-engineered heart valves with self-repair and regeneration properties may overcome the problem of long-term degeneration of currently used artificial prostheses. The aim of this study was the development and in vivo proof-of-concept of next-generation off-the-shelf tissue-engineered sinus valve (TESV) for transcatheter pulmonary valve replacement (TPVR). Transcatheter implantation of off-the-shelf TESVs was performed in a translational sheep model for up to 16 weeks. Transapical delivery of TESVs was successful and showed good acute and short-term performance (up to 8 weeks), which then worsened over time most likely due to a non-optimized in vitro valve design. Post-mortem analyses confirmed the remodelling potential of the TESVs, with host cell infiltration, polymer degradation, and collagen and elastin deposition. TESVs proved to be suitable as TPVR in a preclinical model, with encouraging short-term performance and remodelling potential. Future studies will enhance the clinical translation of such approach by improving the valve design to ensure long-term functionality.     

Pulmonary Hypertension as a Marker for Perivalvular Regurgitation Following Mitral Valve Replacement

Pulmonary hypertension is frequently present in patients with mitral valve disease. Several longitudinal studies have demonstrated regression of pulmonary hypertension following successful mitral valve replacement. We describe 12 consecutive patients in whom noninvasive detection of pulmonary hypertension following mitral valve replacement provided early evidence of perivalvular regurgitation.     

Pulmonary Valve Replacement after Repair of Tetralogy of Fallot： A Review

Tetralogy of fallot （TOF） occurs in approximately 1 in 5000 live births and accounts for 12% - 14% of congenital heart disease. Surgical repair was first introduced in the 1950s and there is now a large population of adults with repaired TOF. Some of them may suffer from significant pulmonary regurgitation （PR）, progressive right ventricle （RV） dilation, RV dysfunction and restrictive right ventricular physiology（RRVP）.     

Adverse Events,Radiation Exposure,and Reinterventions Following Transcatheter Pulmonary Valve Replacement

BackgroundTranscatheter pulmonary valve replacement (TPVR) is associated with a risk of procedural serious adverse events (SAE) and exposure to ionizing radiation.ObjectivesThe purpose of this study was to define the risk of, and associations with, SAE and high-dose radiation exposure using large-scale registry data.MethodsThe analysis of the multicenter C3PO-QI registry was limited to patients who underwent TPVR from January 1, 2014, to December 31, 2016. SAE were defined as the occurrence of ≥1 moderate, major, or catastrophic events. Radiation dose was reported as dose area product adjusted for weight. Associations with outcome measures were explored in univariate and multivariable analyses.ResultsA total of 530 patients (59% male) underwent TPVR at a median age of 18.3 years (interquartile range [IQR]: 12.9 to 27.3 years) and weight of 58 kg (IQR: 43 to 77 kg) at 14 centers. Implant substrate included homograft (41%), bioprosthesis (30%), native right ventricular outflow tract (RVOT) (27%) and other (2%). TPVR indications were pulmonary insufficiency (28%), stenosis (23%), and mixed (49%). AE and SAE occurred in 26% and 13% of cases, respectively, including 1 mortality. SAE were more frequent in homograft conduit than other RVOT substrates, although SAE type and severity differed between implant substrates. Median radiation dose was 198 μGy·m²/kg (IQR: 94 to 350 μGy·m²/kg). Higher radiation dose was associated with older age, greater RVOT obstruction, and concomitant interventions (p < 0.001). During a median follow-up duration of 1 year, 13.3% underwent catheterization, surgery, or both, unrelated to infection. Younger age, smaller size, and hemodynamic and anatomic factors indicative of greater RVOT obstruction were associated with TPV reintervention.ConclusionsThe incidence of SAE during TPVR in the C3PO-QI registry is high, but mortality is uncommon. Radiation dose is greater than for other congenital interventions and is associated with patient and procedural factors. Reintervention is common during early follow-up.     

Tricuspid Intervention Following Pulmonary Valve Replacement in Adults With Congenital Heart Disease

BackgroundTricuspid regurgitation (TR) is common among adults with corrected tetralogy of Fallot (TOF) or pulmonary stenosis (PS) referred for pulmonary valve replacement (PVR). Yet, combined valve surgery remains controversial.ObjectivesThis study sought to evaluate the impact of concomitant tricuspid valve intervention (TVI) on post-operative TR, length of hospital stay, and on a composite endpoint consisting of 7 early adverse events (death, reintervention, cardiac electronic device implantation, infection, thromboembolic event, hemodialysis, and readmission).MethodsThe national Canadian cohort enrolled 542 patients with TOF or PS and mild to severe TR who underwent isolated PVR (66.8%) or PVR+TVI (33.2%). Outcomes were abstracted from charts and compared between groups using multivariable logistic and negative binomial regression.ResultsMedian age at reintervention was 35.3 years. Regardless of surgery type, TR decreased by at least 1 echocardiographic grade in 35.4%, 66.9%, and 92.8% of patients with pre-operative mild, moderate, and severe insufficiency. In multivariable analyses, PVR+TVI was associated with an additional 2.3-fold reduction in TR grade (odds ratio [OR]: 0.44; 95% confidence interval [CI]: 0.25 to 0.77) without an increase in early adverse events (OR: 0.85; 95% CI: 0.46 to 1.57) or hospitalization time (incidence rate ratio: 1.17; 95% CI: 0.93 to 1.46). Pre-operative TR severity and presence of transvalvular leads independently predicted post-operative TR. In contrast, early adverse events were strongly associated with atrial tachyarrhythmia, extracardiac arteriopathy, and a high body mass index.ConclusionsIn patients with TOF or PS and significant TR, concomitant TVI is safe and results in better early tricuspid valve competence than isolated PVR.