快速起搏下释放自膨胀式人工主动脉瓣的安全性及有效性——单中心经验

Safety and efficacy of releasing self-expandable heart valve under rapid pacing:single center experience

目的评估快速起搏下释放自膨胀式人工主动脉瓣的安全性及有效性。方法回顾性分析2015年9月至2016年9月在复旦大学附属中山医院接受经导管主动脉瓣置换术(transcatheter aortic valve replacement,TAVR)治疗的30例重度主动脉瓣狭窄患者临床及手术资料,根据术中是否在快速起搏下释放人工瓣膜,将30例TAVR患者分为起搏释放组(8例)和标准释放组(22例),并对两组患者瓣膜释放结果及其相关手术并发症进行对比分析。结果 30例TAVR患者中,无死亡、急性肾衰竭及不可逆缺血性脑损伤等严重靶器官不良事件发生,无主动脉夹层、心脏穿孔等严重并发症发生。起搏释放组瓣膜释放成功比例为8/8,标准释放组为20/22。标准释放组有2例患者术中出现体循环崩溃予以心肺复苏,同时快速释放瓣膜,最终瓣膜释放成功;另有2例患者瓣膜释放失败,其中1例在释放过程中出现瓣膜移位,1例在瓣膜释放后堵塞右冠状动脉开口,此2例患者均在复合手术室行紧急心外科手术治疗,最终手术成功。起搏释放组无术中并发症发生。行TAVR后标准释放组出现并发症9例,包括血清肌酸激酶/肌酸激酶同工酶一过性升高2例,脑血管事件发生3例,瓣周漏1例,Ⅲ度房室传导阻滞3例(其中1例术后转为Ⅱ度房室传导阻滞)。起搏释放组术后有1例出现左前分支传导阻滞,1例出现Ⅰ度房室传导阻滞,无Ⅲ度房室传导阻滞发生。起搏释放组平均瓣膜深度小于标准释放组[(1.77±0.81)mm比(4.51±2.66)mm,P=0.009],差异有统计学意义。两组患者术后瓣口面积、主动脉瓣跨瓣压差等比较,差异均无统计学意义(均P>0.05)。结论快速起搏下释放自膨胀式人工主动脉瓣安全有效,不增加术后并发症发生率,瓣膜位置或更稳定。

Objective To explore the safety and efficacy of releasing self-expandable valve under rapid pacing during transcatheter aortic valve replacement （TAVR） safety and effect. Methods A total of 30 TAVR cases from Zhongshan Hospital, Fudan University between September 2015 and September 2016 were enrolled. Patients with self-expandable valve released under rapid pacing were divided into pacing release group and the standard release group. The clinical and surgical data of the two groups were analyzed and compared. Results Eight patients were included into the pacing release group and 22 patients in the standard release group. No patient died within the study.The device success rate was 8/8 in the pacing release group, and 20/22 in the standard release group. During the operation, 2 cases from the standard release group had valves deployed successfully under cardiopulmonary resuscitation but another 2 cases failed and required emergent cardiac surgery in the hybrid operation room. After TAVR, 9 cases of the standard release group presented complications including transient serum CK/CK-MB increase, cerebrovascular events, obvious perivalvular leak and complete atrioventricular block. Two cases of the pacing release group developed branch conduction blockade and atrioventricular block. The valve depth of the pacing release group was less than that of the standard release group [ （1.77±0.81） mm vs. （4.51±2.66） mm, P=0.009]. There were no significant differences between the two groups in postoperative valve area, aortic transvalvular pressure difference and LVEF. Conclusions It is safe and effective to perform transcatheter aortic valve replacement under rapid pacing. The incidence of postoperative complications was not increased with better position of the implanted valve.