主动脉瓣疾病合并冠心病患者行经导管主动脉瓣置换术联合经皮冠状动脉介入治疗效果分析

Efficacy of transcatheter aortic valve replacement plus percutaneous coronary intervention on aortic valve disease complicated with coronary artery disease

目的分析主动脉瓣疾病合并冠心病患者的临床资料,探讨其行经导管主动脉瓣置换术(TAVR)联合经皮冠状动脉介入治疗(PCI)的效果及安全性。方法2018年11月—2022年6月河南省胸科医院诊治症状性主动脉瓣疾病合并冠心病患者44例,术前记录性别、年龄、EuroSCOREⅡ评分,行经胸超声心动图检查,记录主动脉瓣狭窄或关闭不全情况、主动脉瓣最大跨瓣压差、主动脉瓣最大流速、主动脉瓣反流面积,冠状动脉CT血管造影或冠状动脉造影检查评估冠状动脉病变部位及程度,选择行同期或分期TAVR联合PCI。出院前及术后3、12个月行经胸超声心动图、心电图检查,记录瓣周漏、血管并发症、新发急性心肌梗死、房室传导阻滞、急性肾损伤、消化道出血、脑卒中等并发症发生情况及生存情况。结果44例患者EuroSCOREⅡ评分(6.18±1.99)分。44例患者术前主动脉瓣最大跨瓣压差(77.32±38.40)mmHg,主动脉瓣最大流速(4.16±1.32)m/s,主动脉瓣反流面积(6.16±3.81)cm^(2);以主动脉瓣狭窄为主32例(单纯主动脉瓣狭窄2例,主动脉瓣狭窄并关闭不全30例),以主动脉瓣关闭不全为主12例(单纯主动脉瓣关闭不全6例,主动脉瓣关闭不全并狭窄6例)。44例患者中冠状动脉单支病变37例,其中左主干病变1例,左前降支病变19例,左回旋支病变7例,右冠状动脉病变10例;≥2支病变7例。44例患者中3例复杂病变行分期手术(均先行PCI,再行TAVR),41例行同期TAVR联合PCI;PCI时处理单支病变37例,处理≥2支病变7例。44例患者均顺利完成手术;术中大出血1例,循环崩溃1例,体外膜肺氧合1例;术中无死亡,术后即刻无中度及以上瓣周漏;住院期间因多器官功能衰竭死亡2例。42例患者术后发生Ⅲ度房室传导阻滞1例,消化道出血1例;出院前行经胸超声心动图检查示主动脉瓣最大跨瓣压差(15.93±10.28)mmHg,主动脉瓣最大流速(1.91±0.56)m/s,均无反流,无中度及以上瓣周漏;术后随访(17.2±7.3)个月,随访期间无血管并发症、新发急性心肌梗死、急性肾损伤、脑卒中及死亡。结论主动脉瓣疾病合并冠心病患者行TAVR联合PCI近中期效果良好,并发症少,分期或同期手术需根据患者情况个体化选择。

Objective To analyze the clinical data of patients with aortic valve disease complicated with coronary artery disease,and to investigate the efficacy and safety of transcatheter aortic valve replacement(TAVR)combined with percutaneous coronary intervention(PCI).Methods Forty-four patients with aortic valve disease complicated with coronary artery disease were treated in Henan Chest Hospital from November 2018to June 2022.The gender,age and EuroSCOREⅡwere recorded before surgery.Transthoracic echocardiography was performed to record aortic stenosis or insufficiency,transvalvular pressure gradient,maximum aortic flow velocity,and aortic regurgitation area.Coronary CT angiography or coronary angiography was performed to record the location and extent of coronary artery lesions in order to choose simultaneous or staged PCI+TAVR.Transthoracic echocardiographic and electrocardiographic results were reviewed to record the complications such as perivalvular leakage,vascular complications,newly-onset acute myocardial infarction,atrioventricular block,acute kidney injury,gastrointestinal bleeding and stroke before discharge,and 3and 12months after surgery.Results In 44patients,the EuroSCOREII score was 6.18±1.99,the maximum transvalvular pressure gradient was(77.32±38.40)mmHg,the maximum aortic flow velocity was(4.16±1.32)m/s,and the aortic regurgitation area before surgery was(6.16±3.81)cm^(2).There were 32patients with main aortic stenosis(pure aortic stenosis in 2patients,aortic stenosis and insufficiency in 30patients)and 12patients with main aortic insufficiency(pure aortic insufficiency in 6patients,aortic stenosis and insufficiency in 6patients).The single artery lesions in 37patients included left main artery lesion in 1patient,left anterior descending lesions in 19patients,left circumflex artery lesions in7patients,and right coronary artery lesions in 10patients.Seven patients were found≥2lesions.Among 44patients,3patients with complex lesions underwent staged surgery(PCI followed by TAVR),41patients underwent simultaneous TAVR combined with PCI.PCI was performed in 37patients with single-vessel lesion and 7 with≥2lesions.All surgeries were successfully completed.Intraoperative massive hemorrhage developed in 1patient,hemodynamic collapse developed in 1patient and extracorporeal membrane oxygenation was applied in 1patient.There was no intraoperative death,and no moderate or above perivalvular leakage immediately after surgery.Two patients died of multiple organ failure in hospital.In the other 42patients,atrioventricular block degreeⅢoccurred in 1patient and gastrointestinal hemorrhage occurred in 1 patient.Transthoracic echocardiography was done again in 42 patients before discharge,showing the maximum transvalvular pressure gradient of(15.93±10.28)mmHg,the maximum velocity of(1.91±0.56)m/s,no reflux,and no moderate or above perivalvular leakage.The follow-up lasted for(17.2±7.3)months,showing no vascular complications,newly-onset acute myocardial infarction,acute kidney injury,stroke or death.Conclusion TAVR combined with PCI has a good short-term and medium-term efficacy in the treatment of aortic valve disease complicated with coronary artery disease,with few complications,and staged or simultaneous surgery is selected according to the individual condition of patients.