15例主动脉瓣周漏的介入治疗

Evaluation of the safety and efficacy of transcatheter intervention of paravalvular leakage （PVL） after aortic valve re- placement-- 15 cases report

目的评价经导管治疗主动脉瓣置换术后瓣周漏介入封堵术的效果。方法2011年9月至2014年11月，15例主动脉瓣置换术后瓣周漏患者行介入治疗，男14例，女1例；平均年龄（46．2±9．8）岁。既往行单纯主动脉瓣膜置换10例，主动脉瓣及二尖瓣置换3例，主动脉瓣膜置换＋室缺修补2例；其中感染眭心内膜炎11例；均置换机械瓣。术前心功能Ⅱ级4例，Ⅲ级6例，Ⅳ级5例；距初次手术（3．7±4．2）年；主动脉瓣反流量（9．3±3．0）ml。手术于导管室内进行，在局麻下通过穿刺股动脉置入封堵器的方法完成。评价该方法围手术期病死率、并发症以及术后残余分流等指标。术后随访1—38个月，平均13个月。结果手术成功率100％，选用3枚封堵器1例，2枚封堵器2例，余12例均用1枚封堵器；其中肌部室间隔缺损封堵器3枚，动脉导管未闭封堵器8枚，plug血管塞8枚。总体手术时间（73．8±34．8）min，其中DSA照射（15．4±22．1）min；住院（9．1±4．8）天。术后发生血红蛋白尿3例，需治疗输血3例，输血量平均（88．9±10．0）ml。随访无死亡病例。心功能有不同程度改善，主动脉瓣反流量减少至（1．5±1．6）ml（P〈0．05），除1例既往感染性心内膜炎患者出现新发瓣周漏外，余者生存良好，未出现严重并发症。结论主动脉瓣膜置换术后瓣周漏经导管采用先心病封堵器治疗具有操作简便安全、创伤小、住院时间短、术后恢复快，治疗费用低等优点，是近年来微创心脏外科治疗领域的全新技术之一。通过改进手术技巧、个性化选择封堵器、早期治疗溶血并发症等能够提高介入治疗成功率及长期效果。

Objective To evaluate the safety and efficacy of transcatheter intervention of paravalvular leakage （PVL） af- ter aortic valve replacement. Methods From September 2011 to Nov 2014, 15 patients of paravalvular leakage after aortic valve replacement underwent interventional therapy. There were 14 male and 1 female, with mean age was（46.2 ±9.8） years old. Previously, 10 patients underwent aortic valve replacement, 3 patients had aortic valve replacement and mitral valve re- placement, 2 patients underwent repair of ventricular septal defect concomitant with aortic valve replacement, 11 patients had a history of previous infective endocarditis. All the 15 patients used mechanical valve. There were 4 cases of NYHA heart func- tion wereⅡ, 6 cases were Ⅲ, s cases were Ⅳ. The period of time between transcatheter intervention and previous operation was （3.7 ± 4.2） years, with aortic regurgitation volume was （9.3 ± 3.0） ml. Transcatheter intervention was carried out in the catheterization laboratory with the patient under local anesthesia. By puncturing femoral artery and implantation of different con- genital heart disease devices, the aortic PVL were occluded interventionally. Follow-up evaluation included peri-operational mortality, complications and postoperative residual shunt. The average follow-up time was 13 months （1 -38 months）. Results The success rate of transcatheter intervention was 100%. 1 patients was implanted with 3 occluders, 2 patients were implan- ted with 2 occluders with the other 12 patients had one occluder each. In total, there were 3 muscular ventricular septal defectoccludem, 8 patent ductus arteriosus oecluders and 8 vascular plugs. The average operation time was（ 73.8± 34.8 ） min, and the DSA radiation time were（ 15.4 ±22.1 ） rain, with average hospitalization time of（9.1 ±4.8） days. The main post-opera- tive complications included 3 cases of hematuria（20% ） and 3 cases of blood transfusion （20%） , with blood transfusion volume （88.9 ±10.0 ） ml. During the follow-up, there was no death. Aortic regurgitation volume decreased to（ 1.5 ± 1.6） ml（ P 〈 0.05 ）. 1 patient with previous infective endocardtitis got new paravalvular leakage, and the remaining patients live well, with improved imart function and no serious complications. Conclusion The traditional treatment of paravalvular leakage after aor- tic valve replacement need thoracotomy, extracorporeal circulation, and open surgery. There was great trauma, high risk and many complications. Transcatheter intervention of aortic PVL has the advantages of simpler and safe approach, less trauma, shorter time of hospitalization, faster post-operative recovery and lower treatment cost. This method is one of the new technolo- gies in the field of minimally invasive cardiac surgery in recent years. By improving operation skills, choosing individualized oc- cluders and treatment of early hemolytic complications, the success rate and long-term effect of interventional therapy can get further improved.