Intraluminal stenting versus external ligation of Ahmed glaucoma valve in prevention of postoperative hypotony

AIM:To compare intraluminal stenting and external ligation of Ahmed glaucoma valves(AGV)for refractory glaucoma management and postoperative hypotony prevention.METHODS:This randomized prospective blind study included 30 eyes of 25 patients(age range:44-56y)with refractory glaucoma.This study was conducted from September 2018 to January 2020.The study included two groups,AGV with intraluminal stenting group(n=15 eyes)and AGV with external ligation group(n=15 eyes).Follow-up period was one year postoperatively.The primary outcome was intraocular pressure(IOP)and its association with the number of postoperative glaucoma medications.IOP≤21 mm Hg without medications indicated complete success while IOP≤21 mm Hg with medications indicated qualified success;and IOP<6 mm Hg was defined as hypotony.RESULTS:After a year of follow-up,IOP was significantly reduced in the intraluminal stenting group than in the external ligation group(11.67±0.89 vs 14.2±4.0 mm Hg,respectively,P=0.024).Postoperative hypotony was more common in the external ligation group(2 cases,13.33%)than in the intraluminal stenting group(1 case,6.67%).CONCLUSION:Application of intraluminal stenting or external ligation during AGV surgery usually prevents postoperative hypotony(transient and persistent)that occurs in conventional AGV surgery.

Finite element analysis of a percutaneous aortic valve stent design

Aim: This paper discusses the design and Finite Element Analysis (FEA) of a Percutaneous Aor-tic Valve Stent. The aim of this study was to model a percutaneous aortic valve stent and subject it to finite element analysis. The design process was carried out to meet the functional and surgical requirements. Methods and Results: Analysis was done with different materials with loads ranging from 50 kgf/mm&amp;amp;#178;to 73 kgf/mm&amp;amp;#178;. These forces were selected because these val-ues are far greater than the normal human blood pressure which ranges from 10kPa to 16kPa. It was also to understand the mechanical behavior of different stent materials under such high pressures. A stent model was generated and its physical, mechanical and behavioral properties were studied. Finite element analysis and simulation of the model enhanced the designer to optimize the geometry suitable for perform-ance during and after implantation. The design objective for the stent is to have long term du-rability, low thrombogenicity, resistance to mi-gration and paravalvular leak. Conclusion: The analysis performed in this paper may aid in understanding the stent’s tolerable pressures ranges in comparison with the physiological pressures exerted by the heart and cardiac blood flow during abnormal cardiovascular conditions.

Transcatheter versus surgical aortic valve replacement in severe, symptomatic aortic stenosis

Aortic stenosis （AS） is the most common type of valvular heart disease in the elderly. Surgical aortic valve replacement （SAVR） has been the standard practice for treating severe, symptomatic AS, but recently new treatment options have emerged, Transcatheter aortic valve replacement （TAVR） is now an established treatment option in patients at high surgical risk. In this review, we focus on recent developments and compare the two treatment methods in specific populations in terms of efficacy and safety （e.g., in patients with history of prior thoracic surgery, type of anesthesia employed, access site used or need for permanent pacing）. The impact of comorbidities （pulmonary hypertension, arterial hypertension and obesity paradox）, the cost-effectiveness of TAVR vs. SAVR and advances in transcatheter valve technology as well as issues that merit further investigation are further discussed. Moreover, outcomes and complications of TAVR in patients of different risk category （extremely high, high, intermediate and low risk） are analyzed. We strongly believe that during the following years, TAVR may evolve as the treatment of choice in a broader group of patients with symptomatic AS and beyond those with intermediate and high-risk features.

冠脉高风险患者TAVR术中预植保护性导丝2例并文献复习

目的探讨冠状动脉(冠脉)高风险患者经导管主动脉瓣置换术(TAVR)术中预植保护性导丝的临床价值。方法收集我院心脏外科2021年2例TAVR术中预植保护性导丝的冠脉高风险患者的临床资料,对其围手术期临床资料进行回顾性分析。结果2例患者均顺利完成了TAVR,其中1例患者左冠脉植入冠脉支架1枚,另1例患者仅行术中冠脉导丝、支架预保护,术后撤出导丝及支架。2例患者术后造影见人工介入瓣膜开放良好,轻度反流,冠脉通畅;术后心衰症状均不同程度地减轻或消失。术后3个月随访,2例患者的超声心动图均提示主动脉瓣人工生物瓣膜功能正常,少量瓣周反流;冠脉CTA均未见冠脉明显异常。结论保护性导丝预植入技术预防TAVR术中冠脉闭塞安全、有效。

应用Xcor瓣膜系统行经心尖的经导管主动脉瓣置换术1例

1资料与方法1.1患者资料患者,男性,65岁。因“反复胸闷气短4年,加重1个月”入院。患者分别于13年前和4年前行冠状动脉造影术和支架植入术。查体:体温36.2℃,心率84次/min,律齐,呼吸19次/min,血压142/74 mmHg;神志清,口唇未见发绀。实验室检查示:血红蛋白136 g/L,血小板计数146×10~9/L,肌钙蛋白T 0.068μg/L,血肌酐88μmol/L,白蛋白36.6 g/L。心电图结果显示为窦性心律(心率84次/min,Ⅲ、a VF呈qr型,q>0.04 s;ST Ⅰ、Ⅱ、a VL、Ⅲ、V4~V6下移0.05~0.1 mV)。心脏彩色超声提示:主动脉瓣明显增厚钙化伴重度狭窄,合并中度反流,射血分数为54%。CT血管造影(CT angiography,CTA)提示:主动脉瓣为四叶式,瓣环径24.3 mm,左室流出道宽度为25.3 mm,窦管交界28.1 mm。

New antireflux plastic stent for patients with distal malignant biliary obstruction

BACKGROUND Endoscopic biliary stenting is a well-established palliative treatment for patients with unresectable distal malignant biliary obstruction(MBO). However, the main problem with stent placement is the relatively short duration of stent patency.Although self-expanding metal stents(SEMSs) have a longer patency period than plastic stents(PSs), the higher costs limit the wide use of SEMSs. A PS with an antireflux valve is an attractive idea to prolong stent patency, but no ideal design for an antireflux PS(ARPS) has been proposed. We developed a new ARPS with a "duckbilled" valve attached to the duodenal end of the stent.AIM To compare the patency of ARPSs with that of traditional PSs(TPSs) in patients with unresectable distal MBO.METHODS We conducted a single-center, prospective, randomized, controlled, double-blind study. This study was conducted at the West China Hospital of Sichuan University. Consecutive patients with extrahepatic MBO were enrolled prospectively. Eligible patients were randomly assigned to receive either an ARPS or a TPS. Patients were followed by clinic visits or telephone interviews every 1-2 mo until stent exchange, death, or the final study follow-up in October 2018. The primary outcome was the duration of stent patency. Secondary outcomes included the rate of technical success, the rate of clinical success,adverse events, and patient survival.RESULTS Between February 2016 and December 2017, 38 patients were randomly assigned to two groups, with 19 patients in each group, to receive ARPSs or TPSs. Stent insertion was technically successful in all patients. There were no significant differences between the two groups in the rates of clinical success or the rates of early or late adverse events(P = 0.660, 1.000, and 1.000, respectively). The median duration of stent patency in the ARPS group was 285 d [interquartile range(IQR),170], which was significantly longer than that in the TPS group(median, 130 d;IQR, 90, P = 0.005). No significant difference in patient survival was noted between the two groups(P = 0.900).CONCLUSION The new ARPS is safe and effective for the palliation of unresectable distal MBO,and has a significantly longer stent patency than a TPS.

球扩式介入主动脉瓣膜支架的抗迁移力学行为

目的 研究球扩式主动脉瓣膜支架植入后的抗迁移力学行为。方法 建立球扩式瓣膜支架介入主动脉瓣膜后的抗迁移力学模型,采用数值模拟方法研究不同瓣环椭圆率、摩擦因数、瓣膜支架材料及自体瓣叶钙化情况对瓣膜支架抗迁移力的影响规律。结果 当主动脉瓣环椭圆率为0.2、0.3、0.4、0.5时,对应的最大抗迁移力分别为12.37、10.94、8.50、4.75 N;当摩擦因数为0.1、0.2、0.3时,瓣膜支架的最大抗迁移力分别为8.98、11.00、13.10 N;L605钴铬合金制成的瓣膜支架的锚定性要优于316L不锈钢制成瓣膜支架的锚定性,其对应的最大抗迁移力分别为13.10、9.82 N;当自体瓣叶发生钙化时,最大抗迁移力为13.1 N,而未钙化时最大抗迁移力仅为5.51 N,相比而言降低了57.9%。结论 随着主动脉瓣瓣环椭圆率不断增大,瓣膜支架的锚定性逐渐降低;随着瓣膜支架与组织间的摩擦因数不断增大,最大抗迁移力也不断增大;L605钴铬合金制成的瓣膜支架比316L不锈钢制成瓣膜支架的锚定性能优异;瓣膜发生钙化情况下瓣膜支架的锚定性要优于未发生钙化时的锚定性。研究结果为抗迁移瓣膜支架的结构设计和临床选择提供重要的科学依据。

1例危重症患者一站式经导管主动脉瓣置换术联合冠状动脉支架植入术的护理

报告1例危重症患者行一站式经导管主动脉瓣置换术(TAVR)联合冠状动脉支架植入术的护理体会。患者基础疾病较多,年龄偏大,手术难度及风险增加。术中采用一站式微创手术,同时将冠状动脉支架植入术及TAVR联合进行,术中行气管插管,临时起搏器植入术。由于患者血压无法维持,在主动脉内球囊反搏(IABP)及体外膜肺氧合(ECMO)支持及辅助下进行。术后患者合并消化道出血等因素,增加术后护理难度。医护团队加强术前评估和心理护理,术后严密监测患者生命体征,做好各种仪器设备护理、伤口及并发症观察护理等。

Chimney支架技术联合All in One技术在经导管主动脉瓣置换术中应用的初步经验

目的:总结Chimney支架技术联合All in One技术在经导管主动脉瓣置换术(TAVR)中应用的初步经验。方法:收集2021年7月至2022年7月首都医科大学附属北京安贞医院心脏瓣膜病介入中心在TAVR术中联合应用Chimney支架技术和All in One技术的10例患者进行回顾性分析,总结临床资料、影像学资料、手术操作、住院和出院随访期间主要不良心脑血管事件的发生情况。结果:10例患者中男性4例,女性6例,平均年龄(76.2±3.9)岁,三叶式主动脉瓣7例,二叶式主动脉瓣3例,术前CT评估均有冠状动脉阻塞危险因素,并且术中球囊预扩张提示冠状动脉阻塞。所有患者均使用一枚药物洗脱支架完成Chimney支架技术,冠状动脉支架置入有8例位于左主干,2例位于右冠状动脉,支架平均直径(3.7±0.3)mm,平均长度(20.6±2.4)mm,在住院及平均随访(7.8±3.7)个月期间,无死亡、心肌梗死、脑卒中等主要不良心脑血管事件发生。结论:TAVR术中Chimney支架技术联合All in One技术安全可行。

心血管植介入体表面抗凝涂层近十年进展

心血管植介入体已被广泛用于治疗各种心血管疾病.然而,植介入体表面和血液之间的接触会导致血栓,进而显著增加了血栓疾病的发病率和死亡率.为降低血栓风险,在植介入体表面修饰抗凝涂层是预防血栓的常用方法.本文中作者综述了近十年中不同心血管植介入体表面的抗凝涂层技术,重点回顾了应用于四种典型的心血管植介入体(包括人工心脏瓣膜、血管支架、心室辅助装置和导管)的抗凝涂层的进展.最后,总结了每种植介入体表面的理想设计,并展望了心血管植介入体表面抗凝涂层技术的未来,对推进心血管植介入体的设计开发和应用具有重要意义.

Percutaneous aortic valve replacement using a W-model valved stent： a preliminary feasibility study in sheep

Background Percutaneous aortic valve replacement is a promising strategy in the treatment of patients with aortic valve stenosis. And many kinds of valved stents have been implanted in selected patients worldwide. However, the clinical experience is still limited. We developed a W-model valved stent and evaluated the feasibility and safety of percutaneous implantation of the device in the native aortic valve position.Methods A self expanding nitinol stent with W-model, containing porcine pericardium valves in its proximal part, was implanted in six sheep by means of a 14 French catheter through the right common iliac artery under guidance of fluoroscopy. During stent deployment the original aortic valve was pushed against the aortic wall by the self expanding force of the stent while the new valve was expanded. These sheep were followed up shortly after procedure with supra-aortic angiogram and left ventriculography. Additionally, one sheep was sacrificed after the procedure for anatomic evaluation.Results It was possible to replace the aortic valve in the beating heart in four sheep. The procedure failed in two sheep due to coronary orifice occlusion in one case and severe aortic valve regurgitation in the other case. One sheep was killed one hour after percutaneous aortic valve replacement for anatomic evaluation. There were no signs of damage of the aortic JntJma, or of obstruction of the coronary orifice,Conclusions Percutaneous aortic valve replacement with a W-model valved stent in the beating heart is possible. Further studies are mandatory to assess safety and efficacy of this kind of valved stent in larger sample size and by longer follow-up period.

用于经导管二尖瓣置换术的支架有限元评估

目的:提出一种经导管二尖瓣置换术支架设计,评估支架与瓣叶植入后在体内相互作用产生的变形情况并分析其力学行为。方法:应用有限元方法,建立支架瓣叶组合模型,在瓣叶上施加压强载荷模拟其在人体内闭合的过程,分析其变形情况和应力应变结果以及受此影响的疲劳寿命。结果:本支架受瓣叶牵拉产生的最大顶端位移为0.24 mm,周期性应变的疲劳寿命约为2.05×108次。结论:变形程度可接受但不可忽视,瓣叶的周期性牵拉对支架的影响可使其在人体内正常工作5~9年。

Percutaneous valve stent insertion to correct the pulmonary regurgitation： an animal feasibility study

Background Pulmonary regurgitation leads to progressive right ventricular dysfunction, susceptibility to arrhythmias,and sudden cardiac death. Percutaneous valve replacement has been developed in recent years, providing patients with an alternative option. Percutaneous pulmonary valve replacement has been recently introduced into clinical practice. The goal of this study was to evaluate the feasibility of percutaneous valve stent insertion to correct the pulmonary regurgitation in sheep using a cup-shaped valve stent.Methods Pulmonary regurgitation was created by percutaneous cylindrical stent insertion in native pulmonary annulus of 8 sheep. One month after the initial procedure, the sheep with previous cylindrical stent implanted underwent the same implantation procedure of pulmonary valve stent. The valve stent consisted of a cup-shaped stent and pericardial valves.Hemodynamic assessments of the bioprosthetic pulmonary valve were obtained by echocardiography at immediately post-implant and at 2 months follow up.Results Successful transcatheter cylindrical stent insertion was performed in 7 sheep but failed in 1 sheep because the cylindrical stent was released to right ventricle outflow tract. After one month the 7 sheep with pulmonary regurgitation underwent valve stent implantation successfully. Echocardiography confirmed the stents were in desired position during the follow-up. No evidence of pulmonary valve insufficiency occurred in any animals. Echocardiography showed all heart function markers were normal.Conclusions Percutaneous cylindrical stent insertion to induce significant pulmonary regurgitation in sheep was feasible, simple and reproducible. Percutaneous pulmonary valve stent implantation can reduce pulmonary regurgitation in a sheep model. Further development of animal model and clinical trials are warranted.

奶嘴形主动脉瓣支架经导管植入动物实验研究

目的探讨经导管植入奶嘴形带瓣膜主动脉瓣支架置换动物主动脉瓣的可行性。方法选择健康实验山羊3只,全麻下分离腹主动脉,经腹主动脉穿刺送入加硬导丝至左心室建立轨道。透视下沿加硬导丝将预载有奶嘴形支架的20 F输送鞘管的头端送至左心室内,缓慢后撤外鞘,定位准确后释放整个支架,手术后即刻观察实验效果。结果3只实验羊经导管主动脉瓣植入术均获得成功,术后即刻DSA及解剖学评价表明人工主动脉瓣膜植入位置理想,代替原瓣膜工作。结论新型奶嘴形主动脉瓣支架经导管植入可行,操作简单,效果理想。

Balloon-expanding stent and delivery system for transcatheter aortic valve implantation:An animal study

Objective: To evaluate the feasibility and satefy of transcatheter aortic valve implantation in animals by using a new balloon-expanding valved stent. Methods: The balloon-expandable stent is made from cobalt-based alloy material and designed with a tubular, slotted structure. Fresh bovine pericardium was treated, sutured and fixed on the balloon-expandable stent. Ten healthy sheep (five males and five females), weighing an average of (25.16 ± 1.83) kg, were selected to undergo transcatheter implantation of the valve stents. The function of the valve stent was evaluated by angiography, echocardiography, and histology six months after the procedure. Results: Of the ten experimental sheep, two sheep died during the operation because the higher position of the artificial valve affected the opening of the coronary artery. We successfully implanted the aortic valve stent in other eight sheep;however, one sheep died of heart failure two weeks after the operation due to the lower position of the valve stent. The valve stents were implanted in the desired position in seven sheep. Ascending aortic angiographic and autoptic findings immediately after the operation confirmed the satisfactory location and function of the valved stent. Echocardiography, angiography, and histology at six post-operative months confirmed the satisfactory location and function of the valve stent. Conclusion: We successfully implanted our new valve stent as a replacement of native aortic valve via the transcatheter route with satisfactory outcome. Copyright ? 2015, Chinese Medical Association Production. Production and hosting by Elsevier B.V. on behalf of KeAi Communications Co., Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1例主动脉瓣置换联合胸主动脉腔内修复及肾动脉支架植入术后病人的护理

总结1例经颈动脉主动脉瓣置换术联合胸主动脉腔内修复术及肾动脉支架植入术的观察和护理。术前护理包括生命体征监测、病情动态观察、心理护理、术前准备等;术后护理包括生命体征监测、病情动态观察和术后并发症的观察等护理。经过术后7 d的积极治疗和护理,病人术后一般状态良好,生命体征平稳,术后未出现并发症,术后顺利出院。

1例急性心肌梗死合并三尖瓣修补术患者的抗栓治疗及药学监护

目的 探讨急性心梗经皮冠状动脉介入治疗(PCI)支架术后合并三尖瓣修补术患者的抗栓治疗方案。方法 评估患者出血和栓塞风险,查阅相关资料、利用药学专业知识,参与整个治疗过程,为患者制定个体化用药方案。结果 通过实施药学监护,对患者进行用药教育,取得较好的治疗效果。结论 临床药师开展抗栓药物方面的药学监护,可提高患者安全用药水平,为临床合理用药提供参考。

小切口开胸经导管肺动脉瓣置换术实验研究

目的探讨小切口开胸经导管植入自膨胀式带瓣膜支架置换动物肺动脉瓣的可行性和有效性。方法使用国产自主研发的酒杯状镍钛合金自膨胀支架,将新鲜的猪心包经脱细胞、防钙化等处理后裁剪成人工瓣膜,缝合在自膨胀支架上,制成自膨胀式带瓣膜肺动脉瓣支架。选择健康山羊8只,非体外循环下右侧小切口开胸暴露右室前壁,穿刺右心室前壁送入加硬钢丝建立右心室-肺动脉轨道,X线引导下沿加硬导丝通过18 F输送鞘管将自膨胀式带瓣膜支架送至羊肺动脉瓣原位,释放支架置换动物原肺动脉瓣,术后即刻和术后6个月,通过DSA和心脏彩色多普勒超声(彩超)检测人工瓣膜的功能。结果8只羊手术均获成功,无明显手术并发症。术后即刻DSA显示带瓣膜支架植入位置理想,人工瓣膜无明显反流。术后6个月,心脏超声和DSA证实支架在位,人工瓣膜启闭正常,无明显返流,代替原瓣膜工作。结论非体外循环下小切口开胸经导管植入国产自膨胀式带瓣膜支架置换肺动脉瓣方法可行,有效。

带瓣膜主动脉瓣支架的研制及经导管植入动物实验

目的:研制可经导管植入的带瓣膜主动脉瓣支架,探索经导管植入该瓣膜支架的可行性。方法:采用0.2mm镍钛记忆合金丝编织内径为15～19mm的网状支架。取牛心包,经固定处理后,按仿形类比设计的方法修剪成瓣叶,并缝合在支架的远端,制成带瓣膜主动脉瓣支架。所有瓣膜支架行体外冲水实验、释放实验、体外管道内释放及静态实验。小香猪7只,采用经导管逆行的方法行升主动脉内置入瓣膜支架的动物实验。结果:研制的带瓣膜主动脉瓣支架,经体外试验证明瓣膜关闭良好,反向均为中心水流,并明确该瓣膜支架能经导管顺利释放,释放后能迅速完全扩张,在管道内固定牢靠。采用12F～16F的输送导管,6只实验动物经髂总动脉植入,所有瓣膜支架均能顺利跨过主动脉弓达升主动脉,并顺利释放,除1例瓣膜支架释放后未完全扩张、移位外,其余均迅速完全扩张、固定良好。24h后处死动物解剖,见支架固定,支架内未见血栓。结论:该带瓣膜主动脉瓣支架启闭功能、自膨功能良好,压缩后的体积符合经导管植入的要求,可采用逆行的方法经髂总动脉植入于升主动脉内,释放后能迅速扩张,固定牢靠。

带瓣膜主动脉瓣支架的研制及体外经导管植入实验

目的:评价一种新的带瓣膜主动脉瓣支架经导管植入的可行性及其对冠脉血流的影响。方法:用超弹性镍钛记忆合金丝编织成圆柱状网状支架,腰部凹陷,并将网孔扩大,下段内置瓣膜环,将新鲜的猪心包经脱细胞处理后给予0.6%戊二醛浸泡36h,缝合在瓣膜环上,制成带瓣膜主动脉瓣支架。支架近端连接丝线,收入鞘管,取离体猪心脏标本,经升主动脉将带瓣膜支架送至左室,直视下送至主动脉瓣位置,释放支架,注水观察瓣膜功能及冠脉水流量。结果:制备的带瓣膜主动脉瓣支架可牢固地置于原主动脉瓣位置,释放后可回收,人工瓣膜启闭功能好,冠脉流量及二尖瓣前叶活动未受影响。结论:带瓣膜主动脉瓣支架设计合理,可经导管释放并回收,瓣膜功能良好,不影响冠脉开口,可用于动物体内植入实验研究。