超声心动图在经导管主动脉瓣置换术中的应用价值

Application value of echocardiography in transcatheter aortic valve replacement

目的探讨超声心动图在主动脉瓣膜病变患者经导管主动脉瓣置换术(TAVR)的术前评估、术中监测及术后随访中的应用价值。方法回顾性分析我院收治的32例行TAVR的主动脉瓣膜病变患者的临床资料,分为单纯主动脉狭窄患者13例(Ⅰ组),单纯主动脉瓣反流患者6例(Ⅱ组),主动脉瓣狭窄合并反流患者13例(Ⅲ组)。分析各组术前多层计算机断层扫描(MSCT)对主动脉根部结构测值、术前及术后1个月超声心动图参数的差异,以及术中情况、术后并发症发生情况。结果32例患者术中均经股动脉植入瓣膜,并应用经食管超声心动图(TEE)监测,其中2例于TEE引导下行房间隔穿刺逆行跨主动脉瓣,4例采用瓣中瓣手术。术前实时三维经食管超声心动图(RT-3D TEE)与MSCT测得的主动脉瓣环最大径、最小径、面积、周长,以及左、右冠状动脉开口高度比较,差异均无统计学意义。术后即刻TEE评估:少至中量瓣周漏4例,少量瓣周漏9例,微量瓣周漏5例,无瓣周漏14例。经胸超声心动图结果显示,与术前比较,Ⅰ组术后1个月主动脉瓣峰值流速(AV Vmax)、主动脉瓣平均跨瓣压差(AVPGmean)、室间隔厚度(IVST)、左室后壁厚度(PWT)均减小,左室射血分数(LVEF)增大,差异均有统计学意义(均P<0.05);Ⅱ组术后1个月主动脉瓣反流面积(AR area)、主动脉瓣缩流径(AR width)及左室舒张末期内径(LVEDD)均减小,差异均有统计学意义(均P<0.05);Ⅲ组术后1个月AV Vmax、AVPGmean、AR area、AR width、IVST、PWT、LVEDD均减小,LVEF增大,差异均有统计学意义(均P<0.05)。术后随访死亡1例,行永久起搏器植入4例。结论超声心动图在不同类型的主动脉瓣膜病变患者TAVR的术前评估、术中监测及术后随访中均具有重要作用,可为TAVR的疗效评估及预后判断提供依据。

Objective To investigate the application value of echocardiography in the preoperative evaluation,intraoperative monitoring,and postoperative follow-up of transcatheter aortic valve replacement(TAVR)in patients with aortic valve lesions.Methods The clinical data of 32 patients with aortic valve lesions underwent TAVR were retrospectively analyzed,including 13 patients with simple aortic stenosis(groupⅠ),6 patients with simple aortic regurgitation(groupⅡ),and 13 patients with aortic stenosis with regurgitation(groupⅢ).Preoperative multilayer computed tomography(MSCT)measurements of aortic root structures,intraoperative conditions,preoperative and 1-month postoperative echocardiographic parameters,and postoperative complications in each group were analyzed.Results Intraoperative valve implantation via the femoral artery was performed in 32 patients and monitored by transesophageal echocardiography(TEE),including retrograde transaortic valve by TEE-guided septal puncture in 2 cases and valve-in-valve in 4 cases.The differences between preoperative real-time three-dimensional(RT-3D TEE)and MSCT measurements of the maximum diameter,minimum diameter,area,circumference of the aortic annulus,as well as the height of the left and right coronary artery openings,were not statistically significant.Immediate postoperative evaluation of TEE:few-moderate perivalvular leaks in 4 cases,few perivalvular leaks in9 cases,microperivalvular leaks in 5 cases,and no perivalvular leaks in 14 cases.Compared with the preoperative results,the peak aortic valve velocity(AV Vmax),mean transvalvular pressure difference(AVPGmean),interventricular septal thickness(IVST),and posterior left ventricular wall thickness(PWT)decreased,and left ventricular ejection fraction(LVEF)increased in groupⅠ1 month after surgery,and the differences were statistically significant(all P<0.05).The aortic regurgitation area(AR area),aortic valve constriction diameter(AR width)and left ventricular end-diastolic diameter(LVEDD)decreased in groupⅡ1 month after surgery,and the differences were statistically significant(all P<0.05).The AV Vmax,AVPGmean,AR area,AR width,IVST,PWT,and LVEDD decreased,and LVEF increased in groupⅢ1 month after surgery,and the differences were statistically significant(all P<0.05).There was 1 case of postoperative follow-up death and 4 cases of permanent pacemaker implantation.Conclusion Echocardiography plays an important role in preoperative evaluation,intraoperative monitoring and postoperative follow-up of TAVR in patients with different types of aortic valve leisons,and can provide evidence for the assessment of the efficacy and prognosis of TAVR.