经导管主动脉瓣置换术对中高危老年重度主动脉瓣狭窄患者心肌损伤及心室功能的影响

Impact of TAVR on myocardial injury and ventricular function in elderly patients with intermediate-high risk severe aortic stenosis

目的探讨经导管主动脉瓣置换术(transcatheter aortic valve replacement,TAVR)对中高危老年重度主动脉瓣狭窄患者心肌损伤、心室功能及终点事件的影响。方法收集郑州市第七人民医院急诊科2019年1月至2022年6月行手术治疗的中高危老年重度主动脉瓣狭窄患者196例临床资料,根据手术方式分为TAVR组(104例)、外科主动脉瓣置换术(surgical aortic valve replacement,SAVR)组(92例),比较2组心肌损伤(天冬氨酸转氨酶、乳酸脱氢酶、心肌肌钙蛋白T、肌酸激酶同工酶)、心室功能(左心室舒张末期内径、左心室射血分数、平均主动脉瓣跨瓣压差,主动脉瓣峰值流速、左心室质量指数)、终点事件。结果TAVR组患者术后3 d、术后1周天冬氨酸转氨酶[(130.45±15.21)U/L vs(136.23±16.42)U/L,(86.52±10.24)U/L vs(91.32±11.16)U/L,P<0.05]、乳酸脱氢酶[(356.32±20.45)U/L vs(372.24±23.12)U/L,(223.12±22.25)U/L vs(240.36±24.12)U/L,P<0.05]、心肌肌钙蛋白T[(0.96±0.17)μg/L vs(1.01±0.16)μg/L,(0.64±0.16)μg/L vs(0.69±0.15)μg/L,P<0.05]、肌酸激酶同工酶明显低于同期SAVR组[(65.36±7.12)KU/L vs(68.15±7.35)KU/L,(36.14±5.15)KU/L vs(37.86±5.24)KU/L,P<0.05]。TAVR组术后1、6个月左心室舒张末期内径[(58.02±6.42)mm vs(55.13±6.24)mm,(46.32±6.12)mm vs(43.72±6.30)mm,P<0.05]、左心室射血分数[(53.35±5.15)%vs(51.10±5.23)%,(64.02±5.21)%vs 61.82±5.13)%,P<0.05]、平均主动脉瓣跨瓣压差[(15.04±2.41)mm Hg(1 mm Hg=0.133 kPa)vs(13.92±2.35)mm Hg,(18.35±3.12)mm Hg vs(16.15±2.43)mm Hg,P<0.05]、左心室质量指数明显高于同期SAVR组[(141.21±16.54)g/m^(2)vs(132.41±15.64)g/m^(2),(130.42±15.23)g/m^(2)vs(124.15±14.62)g/m^(2),P<0.05],术后1、6个月主动脉瓣峰值流速明显低于同期SAVR组[(2.21±0.45)m/s vs(2.36±0.48)m/s,(2.04±0.42)m/s vs(2.21±0.45)m/s,P<0.05]。随访12个月,TAVR组新发心房颤动明显低于SAVR组(7.69%vs 21.74%,χ^(2)=7.866,P=0.005),新发传导阻滞(23.08%vs 9.78%,χ^(2)=6.162,P=0.013)、瓣周漏明显高于SAVR组(14.42%vs 4.35%,χ^(2)=5.661,P=0.017)。结论TAVR术能够缓解中高危老年重度主动脉瓣狭窄患者心肌损伤程度,改善心室功能,但应注意预防新发传导阻滞、瓣周漏的风险。

Objective To investigate the effects of transcatheter aortic valve replacement(TAVR)on myocardial injury,ventricular function and end-point events in the elderly patients with intermediate-high risk severe aortic stenosis(AS).Methods Clinical data of 196 elderly patients with intermediate-high risk severe AS admitted to our department from January 2019 to June 2022 were collected,and according to surgical methods,they were divided into TAVR group(104 cases)and surgical aortic valve replacement(SAVR)group(92 cases).Myocardial injury(AST,LDH,cTnT,CK-MB),ventricular function(LVEDD,LVEF,MPG,V_(max),LVMI),and incidence of end-point events were compared between the two groups.Results In 3 d and 1 week postoperatively,the TAVR group had significantly lower AST[(130.45±15.21)U/L vs(136.23±16.42)U/L,(86.52±10.24)U/L vs(91.32±11.16)U/L,P<0.05],LHD[(356.32±20.45)U/L vs(372.24±23.12)U/L,(223.12±22.25)U/L vs(240.36±24.12)U/L,P<0.05],cTnT[(0.96±0.17)μg/L vs(1.01±0.16)μg/L,(0.64±0.16)μg/L vs(0.69±0.15)μg/L,P<0.05]and CK-MB[(65.36±7.12)KU/L vs(68.15±7.35)KU/L,(36.14±5.15)KU/L vs(37.86±5.24)KU/L,P<0.05]levels than the SAVR group.In 1 and 6 months after operation,the values of LVEDD[(58.02±6.42)mm vs(55.13±6.24)mm,(46.32±6.12)mm vs(43.72±6.30)mm,P<0.05],LVEF[(53.35±5.15)%vs(51.10±5.23)%,(64.02±5.21)%vs 61.82±5.13)%,P<0.05],MPG[(15.04±2.41)mm Hg vs(13.92±2.35)mm Hg,(18.35±3.12)mm Hg vs(16.15±2.43)mm Hg,P<0.05]and LVMI[(141.21±16.54)g/m^(2) vs(132.41±15.64)g/m^(2),(130.42±15.23)g/m^(2) vs(124.15±14.62)g/m^(2),P<0.05]were obviously higher,while the V_(max)value was notably lower in the TAVR group than the SAVR group[(2.21±0.45)m/s vs(2.36±0.48)m/s,(2.04±0.42)m/s vs(2.21±0.45)m/s,P<0.05].In the follow-up of 12 months,the incidence of new-onset atrial fibrillation(7.69%vs 21.74%,χ^(2)=7.866,P=0.005)was remarkably lower,and the incidences of new-onset conduction block(23.08%vs 9.78%,χ^(2)=6.162,P=0.013)and perivalvular leakage(14.42%vs 4.35%,χ^(2)=5.661,P=0.017)were statistically higher in the TAVR group than the SAVR group.Conclusion TAVR can alleviate myocardial injury and improve ventricular function in elderly patients with intermediate-high risk severe AS.But,attention should be paid to preventing the risk of new-onset conduction block and perivalvular leakage.