主动脉内球囊反搏治疗心脏瓣膜置换术后低心排综合征的疗效比较

目的 比较主动脉内球囊反搏(IABP)治疗单纯主动脉瓣狭窄及其他心脏瓣膜病换瓣术后低心排综合征疗效的差异,探讨提高心脏瓣膜病IABP治疗效果的可行途径.方法 回顾性分析2004年6月至2009年1月本科室心脏瓣膜置换术后出现低心排综合征21例患者的临床资料,均采用经皮股动脉穿刺法行IABP治疗.其中单纯主动脉瓣狭窄患者10例,其他瓣膜病患者11例,比较2组IABP治疗的成功率.因低心排综合征致无法脱离体外循环术中紧急置入IABP 10例,其余11例均为术后在重症监护病房(ICU)紧急置入,比较2组IABP治疗的成功率.结果 21例换瓣术后低心排综合征患者IABP治疗成功11例.IABP对单纯主动脉瓣狭窄患者及其他心脏瓣膜病患者换瓣术后低心排综合征的治疗成功率分别为90.0%(9/10)和18.2%(2/11),前者明显高于后者(P＜0.05).术中和术后IABP置入的成功率分别为80.0%(8/10)和27.3%(3/11),术中IABP置入的成功率明显高于术后(P＜0.05).结论 针对性地尽早应用IABP有望提高其对心脏瓣膜置换术后低心排综合征的疗效.     

内皮素-1水平与单纯行主动脉瓣置换术患者术后新发房颤的相关性分析

目的探讨内皮素-1水平与单纯行主动脉瓣置换术患者术后新发房颤的关系。 方法回顾性分析2017年6月至2019年6月于首都医科大学附属北京安贞医院结构性心脏病外科中心单纯行主动脉瓣置换术的119例患者的临床资料，根据患者术后是否新发房颤分为术后房颤组(n＝28)和无术后房颤组(n＝91)。2组患者均于全身麻醉成功后取仰卧位，常规消毒铺巾，作胸部正中切口并劈开胸骨。切开心包并悬吊，肝素化后升主动脉、右心房二阶梯引流管插管建立体外循环，转机、降温，阻断循环，切开主动脉，探查主动脉瓣病变情况，剪除病变主动脉瓣，选择合适大小的人工主动脉瓣(机械瓣或生物瓣)进行置换，全周间断缝合。关闭主动脉切口。复温、排气，开放循环。并行稳定后停止体外循环，拔出动静脉管路。常规止血关胸，结束手术。统计患者术前各项资料中最可能影响术后房颤发生的因素[性别、年龄、体重指数、内皮素-1水平、基础疾病、美国纽约心脏病协会(NYHA)心功能分级、超声心动图指标]、术中资料(术中体外循环时间、主动脉阻断时间)及术后资料[术后机械通气时间、术后住院时间、行开胸止血术例数、使用何种类型人工瓣膜(机械瓣或生物瓣)]。数据比较采用t检验、非参数检验、χ²检验；通过受试者工作特征(ROC)曲线确定内皮素-1预测术后新发房颤的截断值；采用单因素和多因素Logistic回归分析与术后新发房颤相关的危险因素。 结果(1)术后房颤组患者的年龄为(53.0±12.1)岁，高于无术后房颤组[(47.1±13.6)岁]，术前内皮素-1水平为0.43±0.19，高于无术后房颤组(0.27±0.14)，NYHA分级≥3级患者比例为14.3%(4/28)，高于无术后房颤组[4.4%(4/91)]，左心房直径为(40.6±4.8) mm，大于无术后房颤组[(36.7±5.2 ) mm]，主动脉瓣狭窄患者比例为39.3%(11/28)，低于无术后房颤组[60.4%(55/91)]，2组比较差异均有统计学意义(P<0.05)；其他术前资料比较差异均无统计学意义(P>0.05)。(2)术后房颤组患者术中体外循环时间为(113.9±41.7) min，主动脉阻断时间为(75.3±24.1) min，无术后房颤组患者术中体外循环时间为(108.6±46.3) min，主动脉阻断时间为(72.5±31.4) min，2组比较差异均无统计学意义(t＝－0.547、－0.432，P＝0.59、0.67)。(3)术后房颤组患者术后机械通气时间、术后住院时间分别为(24.7±14.3) h、(9.1±3.6) d，均大于无术后房颤组[(19.6±9.5) h、(7.6±2.9) d]；置换机械瓣患者比例为85.7%(24/28)，低于无术后房颤组[96.7%(88/91)]，置换生物瓣膜患者比例为14.3%(4/28)，高于无术后房颤组[3.3%(3/91)]，2组比较差异均有统计学意义(P<0.05)；术后房颤组患者术后行开胸止血术的比例为3.6%(1/28)，高于无术后房颤组[2.2%(2/91)]，2组比较差异无统计学意义(P>0.05)。(4)采用ROC曲线对内皮素-1预测术后新发房颤的价值进行分析可得，曲线下面积为0.76，95%CI：0.66～0.85，截断值0.265 pmol/L，特异度0.75，敏感度0.63。根据截断值将患者分为内皮素-1>0.265组(n＝55)和内皮素-1<0.265组(n＝64)，对2组患者术前、术中资料和术后资料进行比较，结果可得内皮素-1>0.265组患者左心房直径大于内皮素-1<0.265组患者，主动脉瓣狭窄患者比例低于内皮素-1<0.265组患者，术后新发房颤的发生率(38.2%)明显高于内皮素-1<0.265组(10.9%)，差异均有统计学意义(P<0.05)，其他各项比较差异均无统计学意义(P>0.05)。对收集到的患者资料进行单因素Logistic回归分析，发现年龄、NYHA分级≥3级、左心房直径、主动脉瓣狭窄、术后机械通气时间、置换生物瓣及内皮素-1>0.265 pmol/L均与术后新发房颤的发生相关；对以上指标进行多因素Logistic回归分析结果可得左心房直径、置换生物瓣和内皮素-1>0.265 pmol/L与患者术后新发房颤的发生呈独立相关。 结论在单纯行单纯主动脉瓣置换术的患者中，除左心房直径、置换生物瓣外，较高的内皮素-1水平也是患者发生术后新发房颤的独立危险因素。     

Incidence and outcomes of infective endocarditis after transcatheter aortic valve implantation versus surgical aortic valve replacement

ObjectivesTranscatheter aortic valve implantation (TAVI) is an alternative to surgical aortic valve replacement (AVR) in aortic stenosis (AS). Infective endocarditis (IE) in patients with prosthetic heart valves is associated with significant morbidity and mortality. Data on the incidence, risk factors, and outcomes of IE after TAVI are conflicting. We evaluated these issues in patients with percutaneous TAVI vs. isolated surgical AVR (SAVR) at a nationwide level.MethodsBased on the administrative hospital discharge database, the study collected information for all patients with aortic stenosis treated with AVR in France between 2010 and 2018.ResultsA total of 47 553 patients undergoing TAVI and 60 253 patients undergoing isolated SAVR were identified. During a mean follow-up of 2.0 years (median (25th to 75th percentile) 1.2 (0.1–3.4) years), the incidence rates of IE were 1.89 (95% confidence interval (CI) 1.78–2.00) and 1.40 (95% CI 1.34–1.46) events per 100 person-years in unmatched TAVI and SAVR patients, respectively. In 32 582 propensity-matched patients (16 291 with TAVI and 16 291 with SAVR), risk of IE was not different in patients treated with TAVI vs. SAVR (incidence rates of IE 1.86 (95% CI 1.70–2.04) %/year vs 1.71 (95% CI 1.58–1.85) %/year respectively, relative risk (RR) 1.09, 95% CI 0.96–1.23). In these matched patients, total mortality was higher in TAVI patients with IE (43.0% 95% CI 37.3–49.3) than in SAVR patients with IE (32.8% 95% CI 28.6–37.3; RR 1.32, 95% CI 1.08–1.60).DiscussionIn a nationwide cohort of patients with AS, treatment with TAVI was associated with a risk of IE similar to that following SAVR. Mortality was higher for patients with IE following TAVI than for those with IE following SAVR.     

个体化治疗预防小主动脉瓣环瓣膜置换后瓣膜与患者的不匹配

背景：小主动脉瓣环主动脉瓣置换是心外科手术的难点,治疗不当可能出现瓣膜与患者不匹配现象,使左室流出道狭窄、跨瓣压差增大,引起左室后负荷增加致心肌肥厚甚至充血性心力衰竭。 目的：总结预防小主动脉瓣环瓣膜置换后发生人工心脏瓣膜与患者不匹配的治疗策略。 方法：小主动脉瓣环均主动脉瓣置换患者85例。瓣口直径>17 mm,≤19 mm的患者,选19 mm SJM Regent 瓣;对瓣口直径≤17 mm的患者,用牛心包补片加宽瓣环,再选19 mm SJM Regent 瓣行瓣膜置换;对于瓣口直径>19 mm,≤21 mm,选21 mm Hancock II ultra生物瓣置换。治疗后应用超声心动图测量有效瓣口面积指数、左心室重量指数、室间隔厚度、左心室后壁厚度、跨瓣峰速、跨瓣压差和跨瓣平均压。出院后通过门诊对患者进行随访,定期复查超声心动图。 结果与结论：治疗后早期无死亡病例,均治愈出院。随访时间为6个月-3年。主要并发症为低心排综合征2例、二次开胸止血1例、呼吸机依赖2例。所以患者均未出现脑栓塞或脑出血等脑部并发症。无瓣膜功能失调或卡瓣。未发现牛心包补片撕裂、瘤样膨出、钙化、血栓形成、免疫反应和感染等情况。81例获随访,随访率为 95%(81/85)。NYHA心功能分级Ⅰ级65例,Ⅱ级16例。各不同瓣环直径患者治疗后跨主动脉瓣峰速和平均压差均明显降低,有效瓣口面积指数明显增加,左心室重量指数、室间隔厚度和左心室后壁厚度均明显降低,均未出现人工心脏瓣膜与患者不匹配。置换21 mm Hancock II ultra 生物瓣和21 mm SJM Regent 瓣组间的比较,前者获得了更好的跨瓣峰速和平均压差,以及更好的左心室重塑指标。19 mm Regent 瓣患者治疗后体质量和体表面积较治疗前明显增加。结果提示对于小主动脉瓣环的患者应采取个体化的治疗策略预防主动脉瓣置换后瓣膜与患者不匹配的发生。 中国组织工程研究杂志出版内容重点：肾移植;肝移植;移植;心脏移植;组织移植;皮肤移植;皮瓣移植;血管移植;器官移植;组织工程全文链接：     

定量组织速度成像评价风湿性心脏病换瓣前后左右心室的功能

目的采用定量组织速度成像(QTVI)测量风湿性心脏病患者换瓣手术前后心脏二、三尖瓣环各时相运动速度,分析心肌收缩舒张功能的变化,指导临床治疗。方法45例风湿性心脏病患者分为A、B两组,A组25例,心功能Ⅰ~Ⅱ级,X线平片心胸比值<0.65;B组20例心功能Ⅲ~Ⅳ级,X线平片心胸比值≥0.65。健康对照组25例。测量A、B组患者术前、术后1个月,2~5个月的心脏功能变化并与健康对照组对比分析。结果(1)A、B两组术前心脏各腔室较对照组明显增大(P<0.05),LVEF、LVFS、RVEF、Sm、Em、St、Et较正常显著减低。(2)A组上述心功能指标术后1个月内开始明显改善(P<0.05)。B组术后1个月内上述心功能指标进一步降低,术后2~5个月右室的大部分收缩舒张功能指标开始升高。结论QTVI为风湿性心脏病瓣膜置换术术后心功能观察提供了一个新的无创评价手段。     

定量组织速度成像评价风湿性心脏病换瓣前后左右心室的功能

目的 采用定量组织速度成像(QTVI)测量风湿性心脏病患者换瓣手术前后心脏二、三尖瓣环各时相运动速度,分析心肌收缩舒张功能的变化,指导临床治疗.方法 45例风湿性心脏病患者分为A、B两组,A组25例,心功能Ⅰ～Ⅱ级,X线平片心胸比值＜0.65;B组20例心功能Ⅲ～Ⅳ级,X线平片心胸比值≥0.65.健康对照组25例.测量A、B组患者术前、术后1个月,2～5个月的心脏功能变化并与健康对照组对比分析.结果 (1)A、B两组术前心脏各腔室较对照组明显增大(P＜0.05),LVEF、LVFS、RVEF、Sm、Em、St、Et较正常显著减低.(2)A组上述心功能指标术后1个月内开始明显改善(P＜0.05).B组术后1个月内上述心功能指标进一步降低,术后2～5个月右室的大部分收缩舒张功能指标开始升高.结论 QTVI为风湿性心脏病瓣膜置换术术后心功能观察提供了一个新的无创评价手段.     

儿童心脏瓣膜置换手术技巧及效果

目的 总结1999年9月至2006年9月14例儿童心脏瓣膜置换术的经验。探讨儿童瓣膜置换的手术指征、辩膜选择、手术技术和术后抗凝治疗等问题。方法 全组14例中10例为先天性心脏瓣膜病变，3例风湿性病变，1例先天性室间隔缺损致心内膜炎、主动脉瓣膜菌栓。在中低温体外循环下手术，二尖瓣置换7例，主动脉瓣置换6例，二尖瓣置换＋主动脉瓣置换1例。均采用机械瓣。若合并其它先天性心脏畸形或三尖瓣关闭不全，同期矫治。术后常规应用华法林抗凝。结果 本组手术死亡1倒，12例心功能恢复至Ⅰ级，1例心功能Ⅱ级。发生1例感染性心内膜炎，治愈。均坚持采用华法林抗凝，无血栓栓塞及抗凝相关并发症发生，辩膜功能良好。结论 儿童心脏瓣膜置换术采用机械瓣效果较好；应用低强度的华法林进行抗凝治疗安全可靠。     

自体心包补片修补主动脉瓣环辅助主动脉瓣置换

背景：在主动脉置换过程中常遇到瓣环钙化、瓣周囊肿等特殊情况,这时一般应用特殊技术辅助主动脉瓣置换。 目的：观察自体心包补片修补主动脉瓣环辅助主动脉瓣置换治疗钙化性主动脉瓣狭窄并瓣环钙化的临床可行性。 方法：回顾性分析2009年1月至 2012年1月郑州大学第一附属医院42例钙化性主动脉瓣狭窄并瓣环钙化患者的临床资料,并通过统计学软件处理自体心包补片修补主动脉瓣环技术辅助主动脉瓣置换前后的主动脉瓣有效瓣口面积指数、最大跨瓣压差、血流峰值速度、左室射血分数等数据,分析自体心包补片修补主动脉瓣环技术辅助主动脉瓣置换的应用效果。 结果与结论：无置换中死亡病例,置换中主动脉阻断时间为52-88(63.0±18.1) min,体外循环时间为78-122(102.6±25.1) min,置换后1例患者出现急性肾功能衰竭,经床旁血透治疗后治愈。余患者无严重置换并发症。置换后住院天数为7-20(13.6±5.5) d。置换后多普勒超声心动图示：瓣膜功能良好,均未发现主动脉瓣周漏。置换后6个月的主动脉瓣有效瓣口面积指数、最大跨瓣压差、血流峰值速度、左室射血分数均有显著改善,与置换前比较差异均有显著性意义(P < 0.05)。证实对置换适应证合适的特殊换瓣患者,自体心包补片修补主动脉瓣环辅助主动脉瓣置换可取得满意的外科治疗效果,且操作安全简单,是一项可行的技术。     

Prevalence of pannus formation after aortic valve replacement: clinical aspects and surgical management

Pannus formation after aortic valve replacement is not common, but obstruction due to chronic pannus is one of the most serious complications of valve replacement. The causes of pannus formation are still unknown and effective preventive methods have not been fully elucidated. We reviewed our clinical experience of all patients who underwent reoperation for prosthetic aortic valve obstruction due to pannus formation between 1973 and 2004. We compared the initial 18-year period of surgery, when the Björk–Shiley tilting-disk valve was used, and the subsequent 13-year period of surgery, when the St. Jude Medical valve was used. Seven of a total of 390 patients (1.8%) required reoperation for prosthetic aortic valve obstruction due to pannus formation. All seven patients were women; four patients underwent resection of the pannus and three patients needed replacement of the valve. The frequency of pannus formation in the early group was 2.4% (6/253), whereas it was 0.73% (1/137) in the late group (P < 0.05). Pannus was localized at the minor orifice of the Björk–Shiley valve in the early group and turbulent transvalvular blood flow was considered to be one of the important factors triggering its growth. We also consider that small bileaflet valves have the possibility of promoting pannus formation and that the implantation of a larger prosthesis can contribute to reducing the occurrence of pannus.     

经心尖主动脉瓣置换术治疗高危单纯无钙化主动脉瓣关闭不全的手术配合

目的探讨国产J-Valve?支架瓣膜行经心尖主动脉瓣置换(TAVR)术治疗高危单纯无钙化主动脉瓣关闭不全的手术配合方法。 方法收集2017年3月至2018年3月在首都医科大学附属北京安贞医院高危单纯无钙化主动脉瓣关闭不全患者资料,共15例。所有患者均使用国产J-Valve?系统为患者行TAVR术。经过细致的术前评估(包括术前访视、熟悉仪器设备、介入耗材设备等)、术中流畅的手术配合[包括严格遵循无菌原则、术中患者体温保护、X线防护、激活全血凝固时间(ACT)的监测以及支架瓣膜的装配等]和术中安全管理(包括防止输送器移位和动脉置管的护理等)。观测患者术中是否使用心肺转流、发生心室快速起搏、中转行常规体外循环下TAVR术,是否有冠状动脉阻塞、植入瓣膜是否有移位,有无瓣膜内狭窄及瓣周漏等情况发生,观测术后即刻平均主动脉瓣跨瓣压差;患者在ICU是否顺利脱离呼吸机拔除气管插管,术中平均出血量、患者在ICU时间和呼吸机辅助通气时间、射血分数以及是否存在瓣周漏等;了解患者心功能分级、活动耐量以及是否存在胸闷、心绞痛等症状。 结果本研究中所有患者均成功完成TAVR术,未使用心肺转流、未发生心室快速起搏,无中转行常规体外循环下TAVR术,未发生冠状动脉阻塞或植入瓣膜移位,未见瓣膜内狭窄及瓣周漏等情况。术后即刻平均主动脉跨瓣压差为[5.8(4.9,12.9)] mmHg(1 mmHg＝0.133 kPa)。所有患者在ICU均顺利脱离呼吸机拔除气管插管,术中平均出血量为[200.0 (100.0, 500.0)]mL,患者在ICU时间为(1.2±0.4) d,呼吸机辅助通气时间为[19.0 (8.5, 23.5)] h,平均射血分数为(56.2±15.6)%,仅有2例患者存在微量瓣周漏。末次随访中,10例患者心功能Ⅰ级,4例为Ⅱ级,1例为Ⅲ级;患者的活动耐量都较术前明显改善;患者术后胸闷、心绞痛等症状较术前明显改善。 结论手术室护士正确掌握TAVR术的手术配合方法,术前做好患者的心理护理以及各项术前准备,手术过程中与外科医师密切配合,是患者手术成功的保证。     

6-Month aortic valve implantation of an off-the-shelf tissue-engineered valve in sheep

Diseased aortic valves often require replacement, with over 30% of the current aortic valve surgeries performed in patients who will outlive a bioprosthetic valve. While many promising tissue-engineered valves have been created in the lab using the cell-seeded polymeric scaffold paradigm, none have been successfully tested long-term in the aortic position of a pre-clinical model. The high pressure gradients and dynamic flow across the aortic valve leaflets require engineering a tissue that has the strength and compliance to withstand high mechanical demand without compromising normal hemodynamics. A long-term preclinical evaluation of an off-the-shelf tissue-engineered aortic valve in the sheep model is presented here. The valves were made from a tube of decellularized cell-produced matrix mounted on a frame. The engineered matrix is primarily composed of collagen, with strength and organization comparable to native valve leaflets. In vitro testing showed excellent hemodynamic performance with low regurgitation, low systolic pressure gradient, and large orifice area. The implanted valves showed large-scale leaflet motion and maintained effective orifice area throughout the duration of the 6-month implant, with no calcification. After 24 weeks implantation (over 17 million cycles), the valves showed no change in tensile mechanical properties. In addition, histology and DNA quantitation showed repopulation of the engineered matrix with interstitial-like cells and endothelialization. New extracellular matrix deposition, including elastin, further demonstrates positive tissue remodeling in addition to recellularization and valve function. Long-term implantation in the sheep model resulted in functionality, matrix remodeling, and recellularization, unprecedented results for a tissue-engineered aortic valve.     

The membranous portion of the interventricular septum and its relationship with the aortic valve in humans

Summary Investigation of the membranous portion of the interventricular septum (MPIS) and its relationship with the aortic valve was performed in 32 human hearts of adult individuals (19 Caucasians and 11 non-Caucasians). With transillumination of the MPIS the specimens were photographed and 35 mm slides obtained. These were digitized into Apple Macintosh II using a Dage Model 68 video camera and a Data Translations DT 2255 frame grabber. The areas and the distances were traced manually, using the NIH Image program (Wayne Rasband, NIH, Research Services Branch, NIHM). The following forms of MPIS were found: oval (31.3%), triangular (28.1%), quadrangular (18.8%), circular (15.6%) and semilunar (6.2%); its surface area varied from 5.65 mm² to 142.63 mm² (mean 48.82±29.17 mm²). The superior border of the MPIS was in close relationship with the aortic valve, and its upper part was usually (41%) in direct continuity with the attachments of both right (RAC) and posterior (PAC) aortic cusps, or with PAC (34%) or RAC (6%) only. Rarely (19%) the MPIS lay below the attachments of both cusps. The distance between the MPIS superior border and the attachment of the RAC was not greater than 5.89 mm (mean 1.69 mm±1.9 mm). The distance between the superior border of the MPIS and the attachment of the PAC was not greater than 5.63 mm (mean 0.77±1.49 mm). Differences between sex, race and age groups were not statistically significant.

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La portion membraneuse du septum interventriculaire et ses rapports avec la valve aortique chez l'homme

Résumé L'étude de la portion membraneuse du septum interventriculaire (PMSIV) et de ses rapports avec la valve aortique a été réalisée sur 32 curs humains adultes (19 Caucasiens et 11 non-Caucasiens). Sous transillumination, la PMSIV est photographiée et les diapositives de 35 mm obtenues sont numérisées dans le Apple MacIntosh II, utilisant une caméra vidéo « Dage Model 68 » et un convertisseur d'images « DT 2255 frame grabber ». Les surfaces et les distances sont tracées manuellement, utilisant le « programme d'images NIH » (Wayne Rasband, NIH, Research Services Branch, NIHM). Les formes suivantes de la PMSIV ont été observées : ovale (31,3 %), triangulaire (28,1 %), quadrangulaire (18,8 %), circulaire (15,6 %) et semi-lunaire (6,2 %). Sa surface varie de 5,65 mm² à 142,63 mm² (moyenne 48,82±29). Le bord supérieur de la PMSIV contracte des rapports intimes avec la valve aortique; sa partie haute est habituellement en continuité directe avec les pieds d'insertion des valuvles aortiques : les deux valvules droite (VAD) et postérieure (VAP) dans 41 %; la VAP ou la VAD isolément, respectivement dans 34 et 6 % des cas. Rarement (19 %) la PMSIV se situe au-dessous des bords adhérents de ces valvules VAD et VAP. La distance entre le bord supérieur de la PMSIV et l'insertion de la VAD n'est pas supérieure à 5,89 mm (M : 1,69 mm±1,9 mm). La distance entre le bord supérieur de la PMSIV et l'insertion de la VAP n'est pas supérieure à 5,63 mm (M : 0,77±1,49 mm). Les différences entre sexes, races et âges ne sont pas statistiquement significatives.

     

右胸骨旁微创小切口体外循环停跳下二尖瓣置换术20例

目的 探讨右胸骨旁微创小切口体外循环停跳下二尖瓣置换术治疗二尖瓣病变的可行性,评价其临床应用价值。方法 回顾性分析2016年9月—2017年5月蚌埠医学院第一附属医院心脏外科采用右胸骨旁微创小切口体外循环停跳下行二尖瓣置换术20例患者的临床资料,其中男6例、女14例,年龄39~72(55±3.8)岁。均通过右胸骨旁第四肋间6~10 cm横切口进胸,股动脉插管、右房房腔管引流建立体外循环,经胸直视下阻断升主动脉,心脏停跳后经左房入路行二尖瓣置换。结果 无围术期死亡,体外循环时间118～205(150.3±37.2)min,主动脉阻断时间98～189(133.5±27.4)min,术后机械通气时间(11.1±10.4)h,ICU停留时间(1.3±0.5)d,住院时间(7.3±1.7)d。患者术后平均随访(2.1±1.7)月,瓣膜位置均良好、启闭功能正常,无瓣周漏发生及严重心脑血管并发症出现。结论 作为向全胸腔镜下二尖瓣置换过渡的一种微创术式,右胸骨旁微创小切口体外循环停跳下二尖瓣置换术安全、可靠,早期临床效果确切。     

A European update on transcatheter aortic valve implantation (TAVI) in the COVID era

Minimally invasive approaches for aortic valve replacement are now at the forefront of pathological aortic valve treatment. New trials show comparability of these devices to existing therapies, not only in high-risk surgical cohorts but also in low-risk and intermediate-risk cohorts. This review provides vital clinical and anatomical background to aortic valvular disease treatment guidelines, while also providing an update on transcatheter aortic valve implantation (TAVI) devices in Europe, their interventional trials and associated complications.     

Incidental in vivo detection of an isolated hemangioma of the aortic valve in a man with a history of renal transplantation

Hemangiomas of the cardiac valves are exceptional. To our knowledge, only ten cases of valve hemangiomas, six in the mitral and four in the tricuspid valve, have been reported in the English literature. We describe an incidentally detected aortic valve hemangioma of a 62-year-old man with chronic, degenerative aortic valve stenosis, who underwent renal transplantation 7 years before. We believe that this is the first report of a hemangioma in this localization and the first one in association with solid organ transplantation. The review of the literature of the adult cases of valve hemangioma, including this report, revealed that the average age was 47.2 years (range, 24 to 68 years). No clear sex predominance has been noted. Patients can be asymptomatic or experience sudden death. Symptomatic patients have complaints of palpitations, dyspnea, or syncopal episodes. Histologically, these valve tumors are classified as capillary, cavernous, and mixed. Mean tumor size is 1.1 cm (range, 0.6 to 2 cm). In 50% of cases the hemangioma is an incidental finding at autopsy or in a removed valve. Valve aortic hemangioma, despite its rarity, should be considered in the differential diagnosis of vascular lesions of this cardiac valve.     

Minimally immunogenic decellularized porcine valve provides in situ recellularization as a stentless bioprosthetic valve

Currently used bioprosthetic valves have several limitations such as calcification and functional deterioration, and revitalization through cellular ingrowth is impossible. To overcome these obstacles, we have developed a minimally immunogenic tissue-engineered valve that consists of an unfixed, decellularized porcine valve scaffold capable of being spontaneously revitalized in vivo after implantation. Porcine aortic root tissue was decellularized using detergents such as sodium lauryl sulfate and Triton X-100. The porcine valve was treated very gently and plenty of time was allowed for constituents to diffuse in and out of the matrix. In a preliminary study, a piece of decellularized porcine valve tissue was implanted into the rat subdermal space for 14 and 60 days and the structural integrity and calcification were evaluated. As an in vivo valve replacement model, the decellularized porcine valve was implanted in the pulmonary valve position in dogs and functional and histological evaluation was performed after 1, 2, and 6 months. Histological examination showed that the newly developed detergent treatment effectively removed cellular debris from the porcine aortic tissue. Decellularized porcine valve tissue implanted subdermally in rats showed minimal inflammatory cell infiltration and calcification. In the valve replacement model, spontaneous reendothelialization and repopulation of the medial cells were observed within 2 months, and good valve function without regurgitation was observed by echocardiography up to 6 months. The minimally immunogenic decellularized porcine valve proved effective in mitigating postimplant calcification and provided a suitable matrix for revitalizing prostheses through in situ recellularization, cellular ingrowth, and tissue remodeling.     

Patient–prosthesis mismatch may be irrelevant after aortic valve replacement with the 19-mm Perimount pericardial bioprosthesis in patients aged 65 years or older

The prevalence of patient–prosthesis mismatch (PPM) and its influence on clinical midterm results were examined in elderly patients whose activity was supposed to be less than that of younger patients. We evaluated valve function and the effects of PPM on the midterm results of the 19-mm Carpentier–Edwards Perimount (CEP) pericardial aortic valve in patients aged 65 years or older. Between August 1996 and May 2005, 51 patients underwent aortic valve replacement with the 19-mm CEP valve. The mean follow-up was 2.4 ± 1.8 years, involving a total of 134.4 patient-years. The mean age and body surface area at operation were 74.0 ± 5.0 years and 1.41 ± 0.14 m². There were two (3.9%) operative deaths. Three patients (5.9%) underwent enlargement of their small aortic annuli. The actuarial survival rate at 8 years, including operative mortality, averaged 90.2% ± 4.7%. The freedom from thromboembolism, reoperation, and valve-related mortality averaged 75.0% ± 21.7%, 97.8% ± 2.2%, and 95.3% ± 3.2%, respectively, at 8 years. High preoperative peak and mean transvalvular pressure gradients were significantly improved after the operation (peak, 93 ± 35 versus 28 ± 12 mmHg; mean, 58 ± 19 versus 17 ± 7 mmHg, respectively; P < 0.01). The mean left ventricular mass index was reduced from 192 ± 44 to 142 ± 46 g/m² at late follow-up (P < 0.01). The prevalence of PPM was low (17.6%) when an indexed effective orifice area of less than 0.85 cm²/m² was taken as the definition of PPM. The clinical results, postoperative pressure gradients, and reduction in left ventricular mass index were not different between the PPM and no-PPM groups. The 19-mm CEP valve produced satisfactory midterm clinical outcomes in patients aged 65 years or older whose activity was supposed to be less than that of younger patients, regardless of the presence or absence of PPM. Moderate PPM was rare and it did not adversely impact on the midterm results. The application of annulus enlargement could be limited to the small number of patients for whom the 19-mm CEP valves are not able to be inserted.     

Infective endocarditis in patients who have undergone transcatheter aortic valve implantation: a review

BackgroundTranscatheter aortic valve implantation (TAVI) has been approved for the treatment of severe aortic stenosis since 2008 and recent trials have shown that TAVI is at least non-inferior to surgical aortic valve replacement (SAVR) with regards to short-term efficacy and safety in patients across all surgical risk profiles. Prosthetic valve endocarditis of the transcatheter heart valve is a feared complication; data on the risk of infective endocarditis (IE) subsequent to TAVI are now gradually emerging.ObjectivesWe set forth to conduct a review of the incidence, diagnosis, microbial aetiologies, prevention, outcome and management of TAVI-IE.SourcesFrom the MEDLINE database we included a total of 12 observational studies and five studies of long-term results from randomized controlled trials.ContentThe incidence of TAVI-IE was reported to be between 0.7% and 3.0% per person-year. The most common microbes were reported to be enterococci, Staphylococcus aureus, streptococci and coagulase-negative staphylococci. International guidelines on prevention strategies of IE recommend good sanitary conditions including cutaneous care, good oral hygiene and good care of dialysis catheters. Antibiotic prophylaxis is recommended by guidelines prior to dental procedures in patients with TAVI; however, evidence is sparse. The majority of the patients included in this review with TAVI-IE had an indication for surgical intervention due to IE (50.0% or more); however, only a small subset of the patients underwent surgery (16.4% or less). The in-hospital mortality was around 25%, i.e. of the same order of magnitude as in prosthetic valve IE in general, but varied substantially between studies (from 11% to 64%).ImplicationsThe US Food and Drug Administration's approval of TAVI in patients at low surgical risk may change the characteristics of patients with TAVI, which may influence the incidence, management, and outcome of patients with TAVI-IE.     

Spectral analysis and acoustic transmission of mitral and aortic valve closure sounds in dogs

A surgical protocol was designed to implant, in seven dogs, a programmable sequential atrioventricular pacemaker after destruction of the bundle of His to produce a chronic heart block. The heart rate and P-R interval were then varied independently and their influence on the spectra and acoustic transmission of the mitral M1 and aortic A2 valve closure sounds was studied. Results indicate that the major effects of varying the P-R interval are a strong change in the intensity of M1 and modifications of its acoustic transmission across the heart/thorax acoustic system. No similar influence is observed on the intensity and acoustic transmission of A2. Varying the heart rate has a small effect of the intensity of M1 but none on the intensity of A2. In addition, changes in either the P-R interval or the heart rate do not seem to modify the spectral profile of the intracardiac and thoracic M1 and A2 components.