经导管主动脉瓣置换术治疗重度主动脉瓣狭窄的效果

Effects of transcatheter aortic valve replacement in patients with severe aortic valve stenosis

目的探讨经导管主动脉瓣置换术(TAVR)治疗重度主动脉瓣狭窄的效果.方法回顾性分析2010年1月1日至2016年10月30日在复旦大学附属中山医院接受TAVR(置入自膨胀式主动脉瓣瓣膜)的130例重度主动脉瓣狭窄患者的临床资料.根据术前多层螺旋CT重建图像,将重度主动脉瓣狭窄患者分为钙化性主动脉瓣狭窄组(112例)和无钙化主动脉瓣狭窄组(18例),对两组患者的临床基线特征、影像学检查结果、手术过程和临床预后进行比较.结果(1)与钙化性主动脉瓣狭窄组患者比较,无钙化主动脉瓣狭窄组患者的年龄较小,合并风湿性心脏病的比例较大,二叶式主动脉瓣畸形的比例较小(P<0.01或0.05).TAVR术前多层螺旋CT显示,除窦管交界直径最小值外(P=0.017),两组患者的主动脉瓣瓣环及主动脉根部参数差异均无统计学意义(P均>0.05).(2)与钙化性主动脉瓣狭窄组患者比较,无钙化主动脉瓣狭窄组患者快速心室起搏下置入瓣膜和瓣膜型号>术前多层螺旋CT预测的比例均较高,瓣膜释放后行球囊后扩张的比例较低(P<0.01或0.05).(3)钙化性主动脉瓣狭窄组患者术后左心室射血分数高于术前(P<0.001),无钙化主动脉瓣狭窄组患者手术前后的左心室射血分数差异无统计学意义(P=0.552);与术前比较,两组患者术后的平均主动脉瓣跨瓣压差和主动脉瓣收缩期最大流速均变小,主动脉瓣瓣口面积均变大,中重度主动脉瓣反流比例均变小(P均<0.01).TAVR术后,两组患者之间的左心室射血分数、平均主动脉瓣跨瓣压差、主动脉瓣收缩期最大流速、主动脉瓣瓣口面积和中重度主动脉瓣反流比例差异均无统计学意义(P均>0.05).(4)钙化性主动脉瓣狭窄组与无钙化主动脉瓣狭窄组患者的器械置入成功率和术后30d内心血管相关死亡事件发生率差异均无统计学意义[分别为105/112比17/18,P=0.909;3/112比1/18,P=0.453].结论TAVR是一种安全、有效的治疗重度主动脉瓣狭窄方法.

ObjectiveTo investigate the effects of transcatheter aortic valve replacement(TAVR)in patients with severe aortic valve stenosis.MethodsThe clinical data of 130 patients with severe aortic valve stenosis,who underwent TAVR in our hospital with self-expanding valve between January 1,2010 and October 30,2016,were analyzed retrospectively.The patients were divided into calcific aortic valve stenosis(CAS)group(112 cases)and non-calcific aortic valve stenosis(NCAS)group(18 cases)according to 3D volume-rendering reconstruction under multiple detector computed tomography before TAVR.The baseline clinical features,imageology results,procedural details,and clinical prognosis were compared between the 2 groups.Results(1)Compared with CAS group,the patients in NCAS group were younger,had higher proportion of rheumatic heart disease,and less proportion of bicuspid aortic valve morphology(P<0.01 or 0.05).Except for minimum value of sinotubular junction(P=0.017),there were no significant differences in multiple detector computed tomography measurements of aortic valve annulus and aortic root structure between the 2 groups(all P>0.05).(2)Compared with CAS group,the proportions of valve release under rapid pacing and oversized valve release were larger than pre-procedural evaluation,and the proportion of post-dilation was lower in NCAS group(P<0.01 or 0.05).(3)Post-procedural transthoracic echocardiography revealed that left ventricular ejection fraction was higher than baseline level in CAS group(P<0.001),while which was similar in NCAS group(P=0.552).Compared with before TAVR,mean pressure gradient and maximum transvalvular velocity were significantly reduced,aortic valve orifice area was significantly increased,and proportion of moderate to severe aortic regurgitation was significantly reduced after the procedure in both groups(all P<0.01).There were no significant differences in left ventricular ejection fraction,mean pressure gradient,maximum transvalvular velocity,aortic valve orifice area,and proportion of moderate to severe aortic regurgitation after TAVR between the 2 groups(all P>0.05).(4)There were no significant differences in successful rate of device placement and cardiovascular related death within 30 days after TAVR between the 2 groups(105/112 vs.17/18,P=0.909;3/112 vs.1/18,P=0.453,respectively).ConclusionTAVR is safe and effective for patients with severe aortic valve stenosis.