经心尖经导管主动脉瓣置换术治疗极度横位心主动脉瓣关闭不全一例

患者,男,81岁,因“活动后胸闷、气促半年”入广东省人民医院。入院后检查提示：主动脉瓣重度关闭不全,三叶瓣,主动脉成角99°,为极度横位心。美国胸外科医师学会评分7%,结合患者及家属的强烈要求,经多学科评估后决定行经心尖经导管主动脉瓣置换术治疗。术中采用留置Prolene线牵拉及低位释放的方法,顺利完成手术。术后3个月,主动脉支架瓣膜功能正常,无反流。本病例为极度横位心患者的介入治疗提供了参考。     

二叶式主动脉瓣疾病患者经心尖经导管主动脉瓣置换术后院内结局分析

目的 比较经心尖经导管主动脉瓣置换术(transapical transcatheter aortic valve replacement,TATAVR)治疗二叶式主动脉瓣(bicuspid aortic valve,BAV)和三叶式主动脉瓣(tricuspid aortic valve,TAV)患者的院内结局。方法 连续性纳入2014年7月—2020年7月在四川大学华西医院使用J-Valve ^TM瓣膜行TA-TAVR的患者(包括BAV和TAV患者)。分析患者的临床结果。结果 共纳入354例患者,其中BAV患者75例、TAV患者279例,男229例、女125例,平均年龄(72.2±6.0)岁。手术过程中无死亡发生,总技术成功率97.7%,全因住院死亡率为1.4%。20例(26.7%)BAV患者和46例(16.5%)TAV患者术后即刻出现轻度及以上瓣周漏;无BAV患者需植入永久起搏器,13例(4.7%)TAV患者术后需植入永久起搏器,总需起搏器植入率为3.7%;1例(1.3%)BAV患者和7例(2.5%)TAV患者术后出现急性肾损伤;1例(1.3%)BAV患者和1例...     

经心尖途径经导管主动脉瓣置换术治疗主动脉瓣关闭不全的早期疗效分析

目的 探讨经心尖经导管主动脉瓣置换术（transcatheter aortic valve replacement,TAVR）治疗主动脉瓣关闭不全的早期疗效。方法 回顾性纳入2020年10月—2022年10月在安徽医科大学第一附属医院心脏大血管外科行经心尖TAVR的主动脉瓣病变患者,其中主动脉瓣狭窄患者作为A组,单纯主动脉瓣关闭不全患者作为B组,分析术后早期心功能改善及手术并发症情况。结果 共纳入56例患者,其中男32例、女24例,平均年龄（73.34±5.10）岁。A组31例,B组25例。两组患者在年龄、性别、身高、体重、高血压、冠状动脉粥样硬化性心脏病、外周血管病史、慢性阻塞性肺疾病、肾功能不全、心功能分级方面差异均无统计学意义（P>0.05）。两组患者在植入永久起搏器、中转外科开胸手术、植入瓣中瓣、瓣周漏方面差异也无统计学意义（P>0.05）。与术前相比,两组患者术后30 d的左室舒张末期内径、左室射血分数、合并中度及以上二尖瓣反流、中度及以上三尖瓣反流均有显著改善（P<0.05）,但组间比较差异均无统计学意义（P>0.05）。结论 使用介入瓣膜（J-Va...     

应用Ken-Valve经心尖入路经导管主动脉瓣置换术治疗单纯主动脉瓣重度反流一例

经导管主动脉瓣置换术（transcatheter aortic valve replacement,TAVR）已成为老年严重主动脉瓣狭窄患者的首选治疗方法。目前临床上应用的大多数介入瓣膜植入依赖钙化的自身主动脉瓣的定位和锚定。我们为1例82岁无钙化性单纯主动脉瓣重度反流男性患者成功植入Ken-Valve介入支架瓣膜。术后3个月随访,患者心功能明显好转,超声心动图提示人工瓣膜流速、跨瓣压差处于正常范围,无瓣周漏,短期临床效果满意。拥有三个定位件设计的Ken-Valve介入支架瓣膜适合应用于单纯主动脉瓣反流患者。     

经心尖经导管主动脉瓣置换术围术期超声心动图评估规范

经导管主动脉瓣置换术（transcatheter aortic valve replacement,TAVR）在我国经过近20年的飞速发展,目前已进入崭新而关键的阶段。TAVR瓣膜种类繁多,各有特色,其手术有经股动脉、经心尖、经颈动脉或经升主动脉多种入路,以前两者较为常见。超声心动图在TAVR围术期起至关重要的作用。相对于经股动脉TAVR,经心尖TAVR在围术期超声心动图观察中有不同的要点,但目前尚缺乏统一标准。为了推进经心尖TAVR安全有效地应用于临床,特制定本规范,重点阐述超声心动图在术前筛选、术中监测和术后随访中的观测内容和技术要点。     

经导管主动脉瓣置换术治疗主动脉瓣关闭不全有效性及安全性的系统评价与Meta分析

目的 评估经导管主动脉瓣置换术治疗主动脉瓣关闭不全的有效性及安全性。方法 计算机检索PubMed、EMbase、The Cochrane Library、Web of Science、中国知网、万方和维普数据库,检索时限均从建库至2021年8月。由2名研究员按照纳入与排除标准独立筛选文献、提取资料和评价纳入研究的质量,然后,采用Stata 16.0软件进行Meta分析。根据使用瓣膜的种类、研究类型进行亚组分析。结果 最终纳入25篇文献,其中12篇文献为队列研究、13篇文献为单臂研究,共4 370例患者。Meta分析结果显示：成功率为87%[95%CI(0.81,0.92)]。亚组分析,新一代瓣膜的成功率为93%[95%CI(0.89,0.96)],早一代瓣膜的成功率为66%[95%CI(0.56,0.75)]。此外术后30 d死亡率为7%[95%CI(0.05,0.10)],术后30 d心源性死亡率为4%[95%CI(0.01,0.07)],术后起搏器植入率为10%[95%CI(0.08,0.13)],中转开胸率为2%[95%CI(0.01,0.04)],术后中度及重度瓣膜反流率为6%...     

经导管主动脉瓣植入术治疗单纯主动脉瓣反流的系统评价与Meta分析

目的 评价经导管主动脉瓣植入术（transcatheter aortic valve implantation,TAVI）治疗单纯主动脉瓣反流的疗效与安全性。方法 计算机检索The Cochrane Library、PubMed、EMbase、Cochrane对照试验注册库、ClinicalTrials.gov和中国生物医学文献数据库。检索时限为2002年1月—2021年5月。收集TAVI或经导管主动脉瓣置换术治疗单纯主动脉瓣反流的文献,由2名评价员独立按照纳入和排除标准筛选文献、提取资料和评估文献质量,采用STATA 14.0软件进行Meta分析。结果 共纳入15项回顾性队列研究,含1 394例患者。纳入研究的纽卡斯尔-渥太华量表评分均≥6分。人工瓣膜植入成功率为72.0%～100.0%,未见手术死亡、心肌梗死或瓣环破裂等严重并发症报道。30 d全因死亡率为6.3%[95%CI(3.4%,9.1%)],30 d内卒中发生率和术后永久起搏器植入率均在可接受范围内,分别为2.0%[95%CI(1.0%,4.0%)]和6.0%[95%CI(4.0%,10.0%)]。结论 对于单纯高危主动脉...     

Ken-Valve经心尖途径导管主动脉瓣置换术治疗主动脉瓣重度狭窄合并重度反流一例

经导管主动脉瓣置换术（transcatheter aortic valve replacement,TAVR）在治疗重度主动脉瓣狭窄中的应用不断增加。新一代介入瓣膜器械的应用,增强了手术的安全性和有效性。本文报道了1例72岁主动脉重度反流合并中度狭窄的男性患者,经评估为外科中高风险,应用Ken-Valve瓣膜经心尖途径TAVR。手术导管操作时间8 min,术中失血量50 mL,术后手术室即刻拔除气管插管,术后第4 d复查超声心动图,主动脉瓣叶活动良好,无瓣口及瓣周漏,术后第5 d出院。经心尖入路Ken-Valve瓣膜治疗主动脉瓣疾病,操作简单,手术时间短。     

经导管主动脉瓣置换治疗单纯主动脉瓣反流的研究进展

经导管主动脉瓣置换术（transcatheter aortic valve replacement,TAVR）治疗主动脉瓣狭窄已被证明有较好的安全性和有效性,其地位随着指南的不断更新逐渐提高,但对于单纯主动脉瓣重度反流,长期以来被视为TAVR治疗的相对禁忌证。然而许多高龄、高危单纯主动脉瓣反流患者由于外科手术禁忌或不耐受,也通过标签外使用经导管人工瓣膜,得到了TAVR治疗并改善了预后,但由于解剖特点的复杂性和挑战性、手术技术要求高、器械成功率有限、手术并发症多等因素,且缺乏随机对照研究证实其安全和有效性,单纯主动脉瓣反流的TAVR治疗一直在争论中发展。近年来,随着新一代瓣膜的应用和研究数量的增多,对于TAVR治疗主动脉瓣重度反流又有了一些新的认识,本文将对TAVR治疗单纯主动脉瓣重度反流的研究进展作一综述。     

心尖入路经导管主动脉瓣植入手术操作规范

近年经导管主动脉瓣植入术（transcatheter aortic valve replacement,TAVR）技术快速发展。目前的指南及研究多集中于经股动脉路径主动脉瓣狭窄患者,然而对需经心尖入路的单纯主动脉瓣反流患者或其他需要经心尖入路的患者并不完全适用,影响该类患者的规范化治疗。因此,专家组在充分查阅国内外文献的基础上,结合国内开展心尖入路经导管主动脉瓣植入术（transapical transcatheter aortic valve replacement,TA-TAVR）经验较丰富的15家中心专家的意见,提出TA-TAVR手术操作规范,旨在为临床医生提供经心尖入路的规范化诊疗原则,提高我国TA-TAVR规范化诊疗水平。     

Transapical minimally invasive aortic valve implantation; the initial 50 patients

OBJECTIVE: To evaluate the feasibility of minimally invasive transapical beating heart aortic valve implantation (TAP-AVI) for high-risk patients with aortic stenosis. METHODS: TAP-AVI was performed via a small anterolateral minithoracotomy in 50 patients from February 2006 to March 2007. A balloon expandable transcatheter xenograft (Edwards SAPIEN THV, Edwards Lifesciences, Irvine, CA, USA) was used. Mean age was 82.4+/-5 years and 39 (78%) were female. Implantation was performed in a hybrid operative theatre using fluoroscopic and echocardiographic visualization. Average EuroSCORE predicted risk for mortality was 27.6+/-12%. Seven (14%) patients were re-operations with patent bypass grafts. RESULTS: TAP-AVI (13 patients 23 mm and 37 patients 26 mm) was successfully performed on the beating heart under temporary rapid ventricular pacing in 47 (94%) patients, and implantation was performed completely off-pump in 34 (68%) patients. Three patients required early conversion; two of them were successfully discharged. There was no prosthesis migration or embolization observed. Echocardiography revealed good hemodynamic function in all and minor incompetence in 23 patients, mostly paravalvular, without any signs of hemolysis. Mortality was due to the overall health condition and non-valve related in all patients. Actuarial survival at 1 month, 6 months and 1 year was 92+/-3.8%, 73.9+/-6.2% and 71.4+/-6.5%, respectively. CONCLUSIONS: Transapical minimally invasive aortic valve implantation is feasible using an off-pump technique. Good results have been achieved in the initial 50 patients, especially when considering the overall high-risk profile of these patients.     

经导管植入国产自膨式主动脉瓣膜治疗老年性主动脉瓣狭窄(附3例报告)

正75岁以上的老年人退行性心脏瓣膜病发病率高达4.6%~([1])。老年性主动脉瓣狭窄(aortic valve stenosis,AS)发病率越来越高。目前外科主动脉瓣膜置换术(surgery aortic valve replacement,SAVR)仍是治疗重度AS的首选方法,但30%~50%的患者因存在严重合并症、无法承受外科手术而出现心力衰竭和心源性猝死。2002年Cribier等~([2])采用经导管主动     

Aortic regurgitation after transcatheter aortic valve implantation of the edwards SAPIENtm valve

Abstract

Introduction. Transcatheter aortic valve implantation (TAVI) is established as an attractive treatment option for high-risk patients with aortic valve stenosis. One concern is the high risk of prosthetic valve regurgitation. This study aimed to examine for potential preoperative risk factors for postprocedural transcatheter heart valve regurgitation and to quantify the risk, degree, and consequences of postprocedural regurgitation. Materials and methods. 100 consecutive patients who underwent femoral (n = 22) or transapical (n = 78) TAVI were retrospectively reviewed. Echocardiographic valve regurgitation and clinical parameters were analyzed over the first year after TAVI. Results. Seventy-five percent of all patients had prosthetic valve regurgitation. It was, however, only mild or absent in 64% of patients and did not require re-intervention in any of the patients in the series. The severity of the regurgitation appeared unchanged over the one-year follow-up period. Moderate to severe regurgitation was associated with significant yet stable dilatation of the left ventricle over one year and lesser NYHA class improvement three months after TAVI. Asymmetrical native valve calcification increased the risk of paravalvular regurgitation non-significantly. Conclusion. Transcatheter heart valve regurgitation seems to be mild in the majority of cases and unchanged over a 12 months follow-up period. While affecting left ventricular dimensions in moderate or severe cases, we observed no obvious undesirable consequences of the prosthetic valve regurgitation within the first year.     

Simultaneous transcatheter treatment of ascending aortic aneurysm with aortic and mitral regurgitation: an in vitro study

 Open in a separate windowOBJECTIVESWe sought to explore the efficacy of the endovascular repair of an ascending aortic aneurysm with aortic and mitral regurgitation by 2 novel valved stents.METHODSWe established models of ascending aortic aneurysms combined with aortic and mitral regurgitation in 10 pig hearts, then implanted self-expanding aortic fenestrated and mitral valved stents via the transapical approach. We applied a fluoroscopy-guided in vitro setting to test the approach, then analysed continuous circulating flushing at 37°C. Finally, we determined operating times, echocardiography and changes of coronary flow as well as fenestration alignment with the coronary ostia.RESULTSThis approach resulted in a 100% overall technical success rate, excellent handling properties and precise positioning. The time taken to implant the 2 valved stents was 59 ± 12 min. Flow of the left and right coronary arteries did not significantly decrease after the stents were implanted (330.4 ± 12.06 ml/min vs 289.4 ± 5.29 ml/min, P < 0.001; 376.8 ± 10.5 ml/min vs 350.0 ± 14.5 ml/min; P < 0.001). We found no obvious regurgitation and perivalvular leakage; nor did the gradients of the aortic and mitral valves as well as of the left ventricular outflow tract increase significantly. The final angiographic examination and profile of the coronary opening confirmed the good position of the valved stents, the exclusion of the aneurysm and the patency of both coronary arteries.CONCLUSIONSThese findings indicate the potential for combined transcatheter aortic root and mitral valve replacement in treating aortic root pathologies. In future, in vivo studies are expected to validate this approach and ascertain its durability.     

经导管主动脉瓣植入术的麻醉管理

背景 对于有临床症状的严重主动脉瓣狭窄患者而言,实施标准主动脉瓣置换术(surgical aortic valve replacement,SAVR)可能有禁忌或高风险.经导管主动脉瓣植入术(transcatheter aortic valve implantation,TAVI)是一种可供选择的治疗方式. 目的 阐述TAVI围手术期的麻醉管理与监测. 内容 实施TAVI患者的术前评估、风险分级、麻醉的准备和麻醉方法的选择以及行TAVI术中和术后监测管理. 趋向 设备更新与开发、进一步的研究和经验的积累将促使TAVI成为一种在心脏导管室开展的经皮入路微创手术,以后可以更加广泛地应用于有手术禁忌、合并并发症以及严重、不稳定心脏病的危重主动脉瓣狭窄患者.     

Transapical combined transcatheter aortic valve-in-valve implant and ascending aorta endovascular repair

We report the case of a 64-year-old patient who previously had an aortic valve replacement with a stentless aortic valve and an ascending aorta replacement for a DeBakey type II aortic dissection. The patient was referred to us for symptomatic aortic regurgitation related to bioprosthesis degeneration and a pseudoaneurysm at the distal anastomotic site of the vascular graft. Due to the presence of several comorbidities, the patient had a combined transapical transcatheter aortic valve-in-valve implant and an ascending aorta endovascular repair.     

Assessment of aortic annulus dimensions for Edwards SAPIEN Transapical Heart Valve implantation by computed tomography: calculating average diameter using a virtual ring method

Objective: Accurate preoperative assessment of the aortic annulus dimensions is critical in patients undergoing transcatheter aortic valve implantation (TAVI) for severe AS. Using multislice computed tomography (MSCT), we evaluated a novel approach to quantify aortic annulus dimensions using cross-sectional area (CSA) assessment and average diameter calculation compared with the commonly applied electronic caliper measurements in patients undergoing transapical implantation of the Edwards SAPIEN Transcatheter Heart Valve. Methods: Seventy-one patients underwent pre-TAVI MSCT with the following dimensions assessed at the level of the most basal attachment points of all three aortic cusps joined by a virtual ring: CSA, calculated average annulus diameter (CAAD), and minimal, maximum, sagittal and coronal diameters. Measurements were compared with post-TAVI MSCT data sets at the level of the ventricular stent ending in 24 patients. Pre-TAVI measurements were compared to those taken post-TAVI. Eligibility to balloon-expandable TAVI was evaluated based on the different measurements. Results: The Edwards SAPIEN valve (23 mm, n = 8; 26 mm, n = 16) was implanted 2.1 ± 1.1 mm below the non-coronary sinus. Pre-TAVI CAAD was 23.0 ± 1.6 mm; post-TAVI CAAD was 23.0 ± 1.1 mm. Post-TAVI CSA was circular in 18 patients (75%) and ovoid in six (25%). Pre- and post-TAVI assessment showed strong correlation for CSA and CAAD (r = 0.835, p < 0.001; r = 0.841, p < 0.001, respectively). Minimal, maximum, coronal and sagittal dimension correlated weakly between pre- and post-TAVI measurements (r = 0.435–0.632, p = 0.001–0.034). Conclusion: Pre-TAVI CSA assessment and average diameter calculation using a virtual ring method is able to predict the post-interventional configuration of the annulus after balloon-expandable TAVI. We regard this approach as the best-available method to select the appropriate prosthesis size for balloon-expandable TAVI. Specific MSCT-based sizing recommendations should be developed.     

Reverse remodelling after aortic valve replacement for chronic aortic regurgitation

OBJECTIVESThis study aimed to assess the long-term outcomes and investigate the factors related to left ventricular (LV) reverse remodelling after aortic valve replacement (AVR) in patients with chronic aortic regurgitation (AR).METHODSA total of 246 patients who underwent AVR for chronic AR at our institution were included in this retrospective study. Primary end-points included all-cause mortality, cardiac mortality and major adverse cerebral and cardiovascular events. Secondary end-points included cardiac function on echocardiography 1 year after surgery. We explored the predictive factors for reverse remodelling 1 year after surgery.RESULTSThe 10-year survival rate was 86.0%, with no cardiac deaths in 93.8% and no major adverse cerebral and cardiovascular events in 79.9% of patients. Postoperative LV function and symptoms were significantly improved 1 year after surgery, but 34 patients (13.8%) did not recover normal function and structure. A significant negative correlation was found between the incidence of cardiac death and major adverse cerebral and cardiovascular events and reverse remodelling. Multivariate logistic regression identified preoperative LV ejection fraction (P = 0.001, odds ratio = 1.057) and LV end-systolic dimension index (P = 0.038, odds ratio = 0.912) as significant predictive factors of reverse remodelling 1 year after surgery.CONCLUSIONSPreoperative LV ejection fraction and LV end-systolic dimension index were predictive factors for reverse remodelling after surgery, which was associated with late outcomes. Earlier surgery may thus help to restore normal LV function and achieve better late outcomes after AVR for AR.     

经导管主动脉瓣植入术麻醉方式的研究进展

主动脉瓣膜疾病是我国常见的老年退行性心脏瓣膜疾病。经导管主动脉瓣植入术是目前最新、微创且可用于治疗主动脉瓣膜疾病合并高龄或存在严重合并症患者的有效治疗方式,新颖的手术方式给麻醉科医师提出了新的要求。本文结合目前国内外关于经导管主动脉瓣植入术的指南及专家共识对手术及其相关入径、麻醉方式等方面进行详细综述,旨在为麻醉科医师提供参考。