奶嘴形主动脉瓣支架经导管植入动物实验研究

【摘要】 目的 探讨经导管植入奶嘴形带瓣膜主动脉瓣支架置换动物主动脉瓣的可行性。方法 选择健康实验山羊3只,全麻下分离腹主动脉,经腹主动脉穿刺送入加硬导丝至左心室建立轨道。透视下沿加硬导丝将预载有奶嘴形支架的20 F输送鞘管的头端送至左心室内,缓慢后撤外鞘,定位准确后释放整个支架,手术后即刻观察实验效果。结果 3只实验羊经导管主动脉瓣植入术均获得成功,术后即刻DSA及解剖学评价表明人工主动脉瓣膜植入位置理想,代替原瓣膜工作。结论 新型奶嘴形主动脉瓣支架经导管植入可行,操作简单,效果理想。     

小切口开胸经导管肺动脉瓣置换术实验研究

目的 探讨小切口开胸经导管植入自膨胀式带瓣膜支架置换动物肺动脉瓣的可行性和有效性.方法 使用国产自主研发的酒杯状镍钛合金自膨胀支架,将新鲜的猪心包经脱细胞、防钙化等处理后裁剪成人工瓣膜,缝合在自膨胀支架上,制成自膨胀式带瓣膜肺动脉瓣支架.选择健康山羊8只,非体外循环下右侧小切口开胸暴露右室前壁,穿刺右心室前壁送入加硬钢丝建立右心室-肺动脉轨道,X线引导下沿加硬导丝通过18 F输送鞘管将自膨胀式带瓣膜支架送至羊肺动脉瓣原位,释放支架置换动物原肺动脉瓣,术后即刻和术后6个月,通过DSA和心脏彩色多普勒超声(彩超)检测人工瓣膜的功能.结果 8只羊手术均获成功,无明显手术并发症.术后即刻DSA显示带瓣膜支架植入位置理想,人工瓣膜无明显反流.术后6个月,心脏超声和DSA证实支架在位,人工瓣膜启闭正常,无明显返流,代替原瓣膜工作.结论 非体外循环下小切口开胸经导管植入国产自膨胀式带瓣膜支架置换肺动脉瓣方法可行,有效.     

经皮肺动脉瓣置换动物实验研究

目的 探讨新型带瓣膜雕刻支架经皮植入置换肺动脉瓣的可行性和疗效.方法 自行设计圆柱状网状支架,用医用316 L不锈钢激光雕刻而成.将新鲜的猪心包经脱细胞处理后置0.6%戊二醛浸泡36 h,生理盐水洗净,裁剪成人工瓣膜,缝合在不锈钢支架上,制成带瓣膜肺动脉支架.手术前将带瓣膜支架压缩至定制的相应大小的球囊导管上.选择健康犬8只,体重(15.5 ± 3.1)kg,穿刺右股静脉,将带瓣膜支架经导管植入至肺动脉瓣处,置换自身肺动脉瓣膜.手术后通过DSA和超声等方法即刻观察实验效果.结果 1只犬死于术中麻醉意外,7只犬经皮瓣膜置换术均获得成功,术后即时影像和超声检查结果表明人工肺动脉瓣膜功能正常.结论 自制新型带瓣膜支架经导管植入置换肺动脉瓣方法可行,效果理想.     

经导管肺动脉瓣膜植入的实验研究

目的探讨经导管植入带瓣膜支架置换肺动脉瓣的可行性。方法以新鲜的羊心包为材料,予0.6%戊二醛浸泡36h后缝合在瓣膜环上,将其固定在镍钛形状记忆合金自膨胀支架上,制成带瓣膜肺动脉支架。选择体重为(23.5±3.1)kg的健康羊8只,通过开胸,穿刺右心室前壁,将带瓣膜支架经导管送到肺动脉,植入肺动脉瓣处,置换自身肺动脉瓣膜。结果8只羊中即时成功7只,术后即刻以及90d的影像学以及血流动力学检测支架的位置及瓣膜功能良好,无相关并发症。结论直视下经导管植入肺动脉瓣膜是可行的。     

解读"国际心血管CT协会TAVI/TAVR相关CT成像的专家共识"

经导管主动脉瓣植入术(TAVI)/经导管主动脉瓣置换术(TAVR)的临床应用日趋成熟和广泛,CT成像与TAVI/TAVR深度整合,对于术前指导和术后随访均具有重要价值。2019年,国际心血管CT协会发表了《国际心血管CT协会TAVI/TAVR相关CT成像的专家共识》,从检查技术到报告内容,提出了规范化的指南。     

经导管主动脉瓣膜置入1例

经导管主动脉瓣膜置入术(TAVI)是近年来出现的一种治疗重度主动脉瓣狭窄(AS)的新兴技术。对于高龄且合并多脏器功能不全的患者,传统外科手术换瓣治疗风险大,且部分患者存在手术禁忌证,而经导管置换主动脉瓣膜具有微创、无需体外循环及输血、住院时间缩短等优点。国内目前仅有阜外医院及解放军总医院心内科第一批启动了该项目。本文报告了解放军总医院2011年2月对1例重度AS患者行TAVI治疗并随访1个月的结果。     

经导管主动脉瓣置换的实验方法和影像分析

目的 建立经导管主动脉瓣置换的动物实验方法,确定主动脉窦部造影的最佳体位.方法 选用健康杂种犬10只,分别测量股动脉、髂总动脉、腹主动脉直径,穿刺置入12、14、16 F输送导管,经右颈动脉送入猪尾巴导管,行左心室造影,确定主动脉窦部造影最佳体位,并作影像分析.结果测得股动脉直径(3.14±0.39)mm,髂总动脉直径(3.65±0.45)mm,腹主动脉直径(5.07±0.63)mm.经腹主动脉可置入16 F输送导管,主动脉造影示左前斜位32°±5°、头足位10°±3°可清楚显示左右冠脉开口及主动脉窦部.结论 经腹主动脉可建立经导管主动脉瓣置换实验的血管径路,左前斜位32°±5°、头足位10°±3°可获得清晰的主动脉窦部影像.     

经导管主动脉瓣置换术治疗主动脉瓣狭窄应用进展

【摘要】 主动脉瓣狭窄（AS）是在解剖层面导致心脏射血受阻、心脏负荷增加以及冠状动脉、脑血管和全身脏器供血受限的疾病,对患者产生重要影响。随着我国老龄化进程加快,老年主动脉瓣钙化、退变导致AS患者越来越多,针对这类患者采取合适的治疗方案非常重要。AS根本治疗是瓣膜置换。外科主动脉瓣置换术（SAVR）对年轻AS患者耐受性良好,但仍存在创伤大等缺陷,对老年患者风险很高,并发症发生率也很高。微创经导管主动脉瓣置换术（TAVR）是老年AS患者的重要选择。该文就AS,TAVR手术患者、手术入路、人工瓣膜类型选择,术后抗栓策略,术后并发症及其处理及术后康复治疗等应用进展作一综述。     

自膨式Venus-A瓣膜和VitaFlow瓣膜治疗重度主动脉瓣狭窄的临床效果北大核心CSCD

目的 对比两种国产经导管自膨式主动脉瓣膜置换系统Venus-A、VitaFlow治疗重度主动脉瓣狭窄(AS)的临床效果。方法 回性顾分析2018年3月至2021年7月华中阜外医院采用一代Venus-A瓣膜/VitaFlow瓣膜行经导管主动脉瓣置换术(TAVR)治疗的79例重度AS患者临床资料,其中Venus-A组54例,VitaFlow组25例。比较两组患者手术结果和1年随访结果。结果 Venus-A组、VitaFlow组瓣膜植入成功率分别为100%、96%,但差异无统计学意义(P=0.316)。VitaFlow组与Venus-A组相比球囊预扩张比例较低(88%比100%)、后扩张比例较高(12%比0)(均P<0.05)。两组患者TAVR术后血流动力学指标与术前相比显著改善,术后1年Venus-A组中量及以上瓣周漏发生较VitaFlow组少(5.8%比4.2%),但差异无统计学意义(P>0.05)。两组术后脑卒中、严重血管并发症发生率及永久起搏器植入率低(P>0.05)。Venus-A组、VitaFlow组术后30 d无死亡病例,术后1年全因死亡率分别为3.7%、0(P>0.05)。结论 虽然两种自膨胀瓣膜在TAVR治疗重度AS患者术中行球囊预扩张和后扩张比例有差异,但术后近期效果均良好。     

双源多层CT高螺距采集模式血管成像在经导管主动脉瓣植入术(TAVI)的应用

目的经导管主动脉瓣植入术(TAVI)是一种高风险病人外科人工心瓣置换的替代治疗方式。主动脉根部、主动脉和髂动脉血管成像对于选择合适病人非常重要,但是对比剂会造成一定程度肾功能受损。研究目的在于评价用最小     

Real-time interactive MRI-guided cardiac surgery: aortic valve replacement using a direct apical approach.

Minimally invasive cardiac surgery requires arresting and emptying of the heart, which compromises visualization of the surgical field. In this feasibility study a novel surgical procedure is demonstrated in which real-time MRI is used to guide the placement of a prosthetic aortic valve in the beating heart via direct apical access in eight porcine hearts. A clinical stentless bioprosthetic valve affixed to a platinum stent was compressed onto a balloon-tipped catheter. This was fed through a 15-18-mm delivery port inserted into the left ventricular (LV) apex via a minimally invasive subxyphoid incision. Using interactive real-time MRI, the surgeon implanted the prosthetic valve in the correct location at the aortic annulus within 90 s. In four of the animals immediately after implantation, ventricular function, blood flow through the valve, and myocardial perfusion were evaluated with MRI. MRI-guided beating-heart surgery may provide patients with a less morbid and more durable solution to structural heart disease.     

Evaluación de los pacientes candidatos a implante transcatéter de válvula aórtica mediante tomografía computarizada multidetector

In transcatheter aortic valve implantation (TAVI), a biologic valve mounted in a stent is implanted without removing the native valve. This procedure was first done in humans by Alain Cribier in 2002 and was included in clinical guidelines after the multicenter PARTNER (Placement of AoRtic TraNscathetER) randomized clinical trial, which showed that TAVI obtained better outcomes than conservative medical treatment and is an alternative to surgery in patients with high surgical risk.Candidates for TAVI must be assessed to determine whether the procedure is feasible, because TAVI is not ideal for all patients who are considered inoperable. Multidetector computed tomography plays an important role in the anatomic evaluation of candidates and in guiding the procedure in those who are finally selected.     

Computed tomography predictors of mortality,stroke and conduction disturbances in women undergoing TAVR: A sub-analysis of the WIN-TAVI registry

BackgroundAortic valve calcification patterns were associated with short- and long-term outcomes in previous small observational datasets of patients undergoing transcatheter aortic valve implantation (TAVI). The specific impact of multi detector-row computed tomography (MDCT) findings on outcomes in women has not been reported. We sought to describe the associations between MDCT characteristics and clinical outcomes in a registry of 547 women undergoing TAVI.MethodsWIN-TAVI is the first all-female registry to study the safety and effectiveness of TAVI in women (n = 1019). Thirteen sites participated in the MDCT sub-study and contributed pre-TAVI MDCT studies in 547 consecutive subjects. All MDCT data were analyzed in an independent core lab blinded to clinical outcomes. Key measurements included number of valve leaflets, aortic annulus area and perimeter, left and right coronary artery height, aortic cusp calcium volume, commissural calcification and left ventricular outflow tract (LVOT) calcification. Calcium volume of the aortic valvular complex was quantified using a threshold relative to patient-specific contrast attenuation in the arterial blood pool. We examined univariate and multivariate associations between ECG-gated contrast MDCT characteristics and 1-year mortality or stroke, new pacemaker implantation and new onset atrial fibrillation (AF).ResultsThe CT sub-study sample had a mean age of 82.8 ± 6.3 years, mean logistic EuroSCORE of 17.8 ± 11.3%, and mean STS score of 8.2 ± 7.4%. Transfemoral access was used in 89.6% of patients. After multivariate adjustment, moderate or severe LVOT calcification was an independent predictor of 1-year mortality or stroke (HR = 1.91; 95% CI: 1.11–3.30; p = 0.02). Calcium volume in the right coronary cusp was an independent predictor of new pacemaker (HR = 1.18 per 100 m³ increment; p = 0.04), whereas calcium volume of the non-coronary cusp had a protective effect (HR = 0.78 per 100 mm³ increment; p = 0.004). Severe calcification of the non-coronary/right-coronary commissure was an independent predictor of new AF (HR = 5.1; p = 0.008).ConclusionComputed tomography provides important prognostic information in women undergoing TAVI. Moderate or severe LVOT calcification is associated to an almost two-fold increased risk of mortality or stroke at one year. Different calcification patterns of the aortic valve may predict diverse rhythm abnormalities.     

Rotura de raíz aórtica con formación de shunt intracardíaco secundaria a implante valvular aórtico transcatéter

Transcatheter aortic valve implantation (TAVI) is an alternative to surgical valve replacement in patients with high surgical risk. Although TAVI is becoming more and more common, it is not without complications. Rupture of the aortic root after implantation is an uncommon, but lethal complication; few cases have been described in the literature. Multidetector computed tomography is fundamental before TAVI to evaluate factors that predispose to complications; however, its role after the procedure is still controversial.     

Variables affecting the accuracy of MDCT in prediction of the proper prosthesis deployment projection for transcatheter aortic valve implantation

Objective

We evaluated multidetector computed tomography (MDCT) accuracy for the prediction of the optimal prosthetic aortic valve deployment angle in trans-catheter aortic valve implantation (TAVI) with the different variables.

Bicuspid aortic valve sizing for transcatheter aortic valve implantation: Development and validation of an algorithm based on multi-slice computed tomography

BackgroundNo indication are available for transcatheter aortic valve implantation (TAVI) sizing in bicuspid aortic valve (BAV). Aim of the study is to develop and validate a Multi-Slice Computed Tomography (MSCT)-based algorithm for transcatheter heart valve (THV) sizing in patients with stenotic BAV under evaluation for TAVI.MethodsA two steps method was applied: 1)evaluation of a cohort of 19 consecutive patients with type I BAV stenosis undergoing TAVI through pre and post-procedural MSCT, and development of an algorithm for THV sizing; 2)validation of the algorithm on a new cohort of 21 patients.ResultsIn the first cohort, a high correlation was found between the raphe-level area measured at pre-procedural MSCT and the smallest THV area measured at post-procedural MSCT (p < 0.001). Moreover, reduced THV expansion was observed among patients with higher calcium burden (p = 0.048). Then, a new algorithm for TAVI sizing in BAV was develop (CASPER: Calcium Algorithm Sizing for bicusPid Evaluation with Raphe). This algorithm is based on the reassessment of the perimeter/area derived annulus diameter, according to three main anatomical features: 1) the ratio between raphe length and annulus diameter; 2)calcium burden; 3)calcium distribution in relation to the raphe.The algorithm was then validated in a new cohort of 21 patients, achieving 100% of procedural success and excellent TAVI performance.ConclusionMSCT assessment of raphe length, calcium burden and its distribution is of crucial relevance in the pre-procedural evaluation of patients with BAV. These anatomical features can be combined in a new and simple algorithm for TAVI sizing.     

Clinical impact of mitral calcium volume in patients undergoing transcatheter aortic valve implantation

BackgroundMitral annular calcification (MAC) has been associated with mitral valve (MV) disease and cardiovascular events in patients undergoing transcatheter aortic valve implantation (TAVI). We aimed to investigate the incidence and impact of mitral calcium volume (MCV) quantified by multidetector computed tomography (MDCT) on MV function and clinical outcomes after TAVI.MethodsConsecutive patients with exploitable echocardiography and MDCT performed during TAVI screening were enrolled in this retrospective analysis. Mitral calcium was assessed visually and measured using a semi-automatic tool developed for the aortic valve in an off-label fashion.ResultsMCV >0 mm³ was found in 65% of the 875 included patients. Patients with calcification were older (82 ± 6 versus 81 ± 7; P = 0.002) and had high prevalence of renal dysfunction (69% versus 61%; P = 0.017) and mitral stenosis (25% versus 4%, P < 0.001). MCV correlated well with visual MAC severity (r = 0.94; P < 0.001), but showed a greater predictive value for mitral stenosis (AUC = 0.804 vs. 0.780, P = 0.012) , while it was not a predictor of mitral regurgitation (AUC = 0.514). Correlations were found between MCV and echocardiographic parameters including MV area, mean transmitral gradient, and pressure half-time (P < 0.001 for all). MCV did not impact on cardiovascular mortality or new permanent pacemaker implantation after TAVI.ConclusionsCalcification of the mitral apparatus is common in TAVI candidates and results in mitral stenosis in 25% of the patients. Increasing MCV predicts mitral stenosis, but had no impact on clinical outcomes following TAVI.Clinical trial registrationNCT01368250.     

Clinical outcomes following transcatheter aortic valve implantation in patients with porcelain aorta

BackgroundCurrent guidelines favor transcatheter aortic valve implantation (TAVI) over surgical aortic valve replacement in patients with porcelain aorta (PAo). The clinical relevance of PAo in patients undergoing TAVI is however incompletely understood. The purpose of this study is to evaluate clinical outcome of patients with PAo undergoing TAVI.MethodsConsecutive patients undergoing TAVI were enrolled in a prospective single-center registry. Presence of PAo was evaluated by ECG-gated multi-slice computed tomography prior to the intervention. The primary endpoint was disabling stroke.ResultsAmong 2199 patients (mean age, 82.0 ?± ?6.3 years; 1135 females [51.6%]) undergoing TAVI between August 2007 and December 2019, 114 patients (5.2%) met VARC-2 criteria for PAo. Compared to individuals without PAo, patients with PAo were younger (79.4 ?± ?7.4 years vs. 82.1 ?± ?6.2 years; p ?< ?0.001), had a lower left ventricular ejection fraction (51.8 ?± ?14.9% vs. 55.3 ?± ?14.2%; p ?= ?0.009) and higher STS-PROM Scores (6.5 ?± ?4.3% vs. 4.9 ?± ?3.4%; p ?< ?0.001). At 1 year, disabling stroke occurred more often in patients with PAo (7.2%) than in those without (3.0%) (HR_adj, 2.49; 95% CI, 1.12–5.55). The risk difference emerged within 30 days after TAVI (HR_adj, 3.70; 95% CI, 1.52–9.03), and was driven by a high PAo-associated risk of disabling stroke in patients with alternative access (HR_adj, 5.79; 95% CI, 1.38–24.3), not in those with transfemoral (HR_adj, 1.47; 95% CI 0.45–4.85).ConclusionsTAVI patients with PAo had a more than three-fold increased risk of periprocedural disabling stroke compared to patients with no PAo. The difference was driven by a higher risk of stroke in patients treated by alternative access.