应用人工瓣膜标识评估人工瓣膜嵴遮挡冠状动脉开口

Evaluation of coronary artery ostium obstruction caused by the commissure of transcatheter heart valve with the markers on transcatheter heart valve

目的 分析经导管主动脉瓣置换术(transcatheter aortic valve replacement,TAVR)治疗后的患者主动脉根部计算机断层扫描造影(computed tomographic angiography,CTA)图像,观察人工瓣膜嵴与冠状动脉开口的位置关系,分析应用X线下人工瓣膜标识评估人工瓣膜嵴遮挡冠状动脉开口的可行性。方法 回顾性分析北部战区总医院2020年1月-2021年12月接受TAVR治疗且术后行主动脉根部心电门控CTA检查的25例主动脉瓣狭窄或关闭不全患者。观察患者人工瓣膜定位(无冠状动脉窦最低位,多数情况下为右前斜加足位)时的影像,记录瓣膜释放后入口端3个标识的位置关系,分为3个标识平均分布、中间标识靠近左侧标识、中间标识靠近右侧标识3种情况。分析患者术后CTA,量取人工瓣膜入口端标识与冠状动脉开口的夹角,以中位数(下四分位数,上四分位数)表示各组夹角数据。结果 经纳入排除标准筛选后共17例患者入选研究。左冠状动脉开口与人工瓣膜标识夹角在3个标识平均分布组(n=7)、中间标识靠近左侧标识组(n=6)和中间标识靠近右侧标识组(n=4)中分别为19.0(16.0,31.0)°、36.0(15.0,44.0)°和3.0(3.0,5.0)°,差异有统计学意义(P=0.033);右冠状动脉开口与人工瓣膜标识夹角在3个标识平均分布组、中间标识靠近左侧标识组和中间标识靠近右侧标识组中分别为43.0(25.0,51.0)°、47.0(41.0,57.0)°和13.0(7.5,21.0)°,差异有统计学意义(P=0.017)。人工瓣膜嵴遮挡左冠状动脉开口的程度差异有统计学意义(P=0.008),人工瓣膜嵴遮挡右冠状动脉开口的程度差异无统计学意义(P=0.062)。中间标识靠近右侧标识时,右冠状动脉开口均未出现中度以上的遮挡,左冠状动脉开口的无遮挡率为4/4(100.0%)。中间标识靠近左侧标识时,左冠状动脉开口中度以上的遮挡率为4/6(66.7%),右冠状动脉开口中度以上的遮挡率为6/6(100.0%)。结论 应用人工瓣膜标识可以准确评估人工瓣膜嵴遮挡冠状动脉开口的程度。其中,中间标识靠近右侧标识时,人工瓣膜嵴遮挡冠状动脉开口的可能性最小。

Objective To evaluate the coronary artery ostium obstruction caused by the commissure of transcatheter heart valve(THV) with the markers on THV under X-ray, which was identified by observing the position relationship between the commissure of THV and the coronary artery ostium from analyzing aortic root computed tomographic angiography(CTA) images after transcatheter aortic valve replacement(TAVR). Methods A retrospective analysis was performed on 25 patients undergoing TAVR who were checked with electrocardiographically gated CTA for the aortic root after the TAVR procedure between January 2020 and December 2021 in General Hospital of Northern Theater Command. The images of THV with the lowest position of non-coronary sinus and the right anterior oblique and caudal in most cases were observed when the THVs were deployed. The position relationships of the three markers on the THV after valve release were recorded, which were divided into three conditions, namely the three markers being averagely distributed, the middle marker being close to left, and the middle marker being close to right. Postoperative CTA images of the patients were analyzed. The angle between the commissure of THV and the coronary artery ostium was measured, and the angles in each group were presented as medium(lower quartile, upper quartile). Results A total of 17patients were finally included. The angles between the commissure of THV and the left coronary artery ostium were 19.0(16.0, 31.0)°, 36.0(15.0, 44.0)°, and 3.0(3.0, 5.0)° in the markers averagely distributed group(n=7), the middle marker close to left group(n=6), and the middle marker close to right group(n=4), respectively, which were significantly different(P=0.033). The angles between the commissure of THV and the right coronary artery ostium were 43.0(25.0, 51.0)°, 47.0(41.0, 57.0)°, and 13.0(7.5, 21.0)° in the markers averagely distributed group, the middle marker close to left group, and the middle marker close to right group, respectively, which were significantly different(P=0.017). There was significant difference in the obstruction degrees of left coronary artery ostium by the commissure of THV(P=0.008), and no significant difference in the obstruction degrees of right coronary artery ostium(P=0.062). When the middle marker was close to right, there was no more than moderately obstruction on the right coronary artery ostium and no any obstruction on the left coronary artery ostium. When the middle marker was close to left, the obstruction rate of the left coronary artery ostium with more than moderate degree was 4/6(66.7%) and it was 6/6(100.0%) for the right coronary artery ostium. Conclusions The degree of coronary artery ostium obstruction by the commissure of THV can be accurately evaluated by using markers on THV. Among them, when the middle marker is close to right, the commissures of THV are least likely to block the coronary artery ostium.