主动脉瓣狭窄患者经导管主动脉瓣置换术尺寸策略和手术结局分析

Analysis of size strategy and surgical outcome of transcatheter aortic valve replacement in patients with aortic valve stenosis

目的:旨在分享近几年接受接受经导管主动脉瓣置换术(transcatheter aortic valve replacement,TAVR)的症状性严重主动脉瓣狭窄(aortic stenosis,AS)患者的尺寸策略和手术结局。方法:2017年10月到2021年10月,在北京安贞医院接受TAVR术的132例严重AS患者进行回顾性评估,包括主动脉根部的解剖结构和形态及手术策略。“缩小尺寸”策略是在患者有复杂形态时实施的,例如二叶式主动脉瓣(bicuspid aortic valve,BiAV)、小叶水平严重钙化、小叶明显增厚和融合。将采用缩小尺寸策略的患者与采用瓣环尺寸策略的患者临床结果进行比较。结果:在132例患者中,41例(31.1%)为BiAV形态。根据TAVR手术策略,38例患者选择瓣环尺寸策略,94例患者选择缩小尺寸策略。缩小尺寸组BiAV患者比例更高(P=0.046)。主动脉根部的钙体积为449.9(243.2,782.2)mm^(3),主要分布在小叶水平上。TAVR术后1个月,主动脉瓣口面积(aortic orifice area,AVA)从(0.7±0.2)cm^(2)改善到(1.4±0.4)cm^(2),主动脉瓣跨瓣压差也明显降低,两组AVA、主动脉瓣跨瓣压差和中重度瓣周反流患者的百分比是相似的(P>0.05)。与瓣环尺寸策略组相比,采用缩小尺寸策略的患者装置成功率相似(74.5%vs.71.1%,P=0.687)。结论:中国TAVR患者具有更普遍的BiAV形态和严重的主动脉根钙负荷,更适合缩小尺寸策略。而缩小尺寸策略提供了与瓣环尺寸策略相比非劣势的装置成功率和假体血液动力学性能。

Objective:To share the size strategy and surgical outcomes of symptomatic severe aortic stenosis(AS)patients who have undergone transcatheter aortic valve replacement(TAVR)in our hospital in recent years.Methods:From October 2017 to October 2021,132 patients with severe AS undergoing TAVR in Beijinng Anzhen Hospital were retrospectively evaluated,including the anatomical structure and morphology of the aortic root and surgical strategies.The"downsizing"strategy is implemented when the patient has complex morphology,such as bicuspid aortic valve(BiAV),severe calcification at the lobular level,significant lobular thickening,and fusion.Clinical outcomes were compared between patients with a reduced size strategy and those with a valve-ring size strategy.Results:A total of 132 patients,41(31.1%)had BiAV form.According to the TAVR surgical strategy,38 patients chose the flap ring size strategy and 94 patients chose the reduced size strategy.The reduced size group had a higher proportion of BiAV patients(P=0.046).The calcium volume(Hounsfield Unit-850)of the aortic root was 449.9(243.2,782.2)mm^(3),mainly distributed at the lobular level.One month after TAVR,the aortic orifice area(AVA)improved from(0.7±0.2)-(1.4±0.4)cm^(2),and the aortic cross-valve differential pressure was also significantly decreased,and the percentages of AVA,aortic cross-valve differential pressure and moderate-to-severe perivalvular regurgitant patients were similar in the 2 groups(P>0.05).Compared with the flap ring size strategy group,the device success rate was similar in patients with reduced size strategy(74.5%vs.71.1%,P=0.687).Conclusions:Chinese TAVR patients have more common BiAV morphology and severe aortic root calcium load,which is more suitable for reduced size strategy.The reduced size strategy provides a non-inferior device success rate and prosthesis hemodynamic performance compared to the flap ring size strategy.