Although surgical aortic valve replacement is the standard therapy for severe aortic stenosis(AS),about one third of patients are considered inoperable due to unacceptable surgical risk.Under medical treatment alone t...Although surgical aortic valve replacement is the standard therapy for severe aortic stenosis(AS),about one third of patients are considered inoperable due to unacceptable surgical risk.Under medical treatment alone these patients have a very poor prognosis with a mortality rate of 50%at 2 years.Transcatheter aortic valve implantation(TAVI)has been used in these patients,and has shown robust results in the only randomized clinical trial of severe AS treatment performed so far.In this review,we will focus on the two commercially available systems:Edwards SAPIEN valve and CoreValve Revalving system.Both systems have demonstrated success rates of over 90%with 30-d mortality rates below 10%in the most recent transfemoral TAVI studies.Moreover,long-term studies have shown that the valves have good haemodynamic performance.Some studies are currently exploring the non-inferiority of TAVI procedures vs conventional surgery in high-risk patients,and long-term clinical results of the percutaneous valves.In this article we review the current status of TAVI including selection of patients,a comparison of available prostheses,results and complications of the procedure,clinical outcomes,and future perspectives.展开更多
Right ventricular outflow tract(RVOT)obstruction is present in a variety of congenital heart disease states including tetralogy of Fallot,pulmonary atresia/stenosis and other conotruncal abnormalities etc.After surgic...Right ventricular outflow tract(RVOT)obstruction is present in a variety of congenital heart disease states including tetralogy of Fallot,pulmonary atresia/stenosis and other conotruncal abnormalities etc.After surgical repair,these patients develop RVOT residual abnormalities of pulmonic stenosis and/or insufficiency of their native outflow tract or right ventricle to pulmonary artery conduit.There are also sequelae of other surgeries like the Ross operation for aortic valve disease that lead to right ventricle to pulmonary artery conduit dysfunction.Surgical pulmonic valve replacement(SPVR)has been the mainstay for these patients and is considered standard of care.Transcatheter pulmonic valve implantation(TPVI)was first reported in 2000 and has made strides as a comparable alternative to SPVR,being approved in the United States in 2010.We provide a comprehensive review in this space–indications for TPVI,detailed procedural facets and up-to-date review of the literature regarding outcomes of TPVI.TPVI has been shown to have favorable medium-term outcomes free of reinterventions especially after the adoption of the practice of pre-stenting the RVOT.Procedural mortality and complications are uncommon.With more experience,recognition of risk of dreaded outcomes like coronary compression has improved.Also,conduit rupture is increasingly being managed with transcatheter tools.Questions over endocarditis risk still prevail in the TPVI population.Head-to-head comparisons to SPVR are still limited but available data suggests equivalence.We also discuss newer valve technologies that have limited data currently and may have more applicability for treatment of native dysfunctional RVOT substrates.展开更多
Background:Due to the wide variety of morphology,size,and dynamics,selecting an optimal valve size and location poses great difficulty in percutaneous pulmonary valve implantation(PPVI).This study aimed to report our ...Background:Due to the wide variety of morphology,size,and dynamics,selecting an optimal valve size and location poses great difficulty in percutaneous pulmonary valve implantation(PPVI).This study aimed to report our experience with in vitro bench testing using patient-specific three-dimensional(3D)-printed models for planning PPVI with the Venus P-valve.Methods:Patient-specific 3D soft models were generated using PolyJet printing with a compliant synthetic material in 15 patients scheduled to undergo PPVI between July 2018 and July 2020 in Central China Fuwai Hospital of Zhengzhou University.Results:3D model bench testing altered treatment strategy in all patients(100%).One patient was referred for surgery because testing revealed that even the largest Venus P-valve would not anchor properly.In the remaining 14 patients,valve size and/or implantation location was altered to avoid valve migration and/or compression coronary artery.In four patients,it was decided to change the point anchoring because of inverted cone-shaped right ventricular outflow tract(RVOT)(n=2)or risk of compression coronary artery(n=2).Concerning sizing,we found that an oversize of 2-5 mm suffices.Anchoring of the valve was dictated by the flaring of the in-and outflow portion in the pulmonary artery.PPVI was successful in all 14 patients(absence of valve migration,no coronary compression,and none-to-mild residual pulmonary regurgitation[PR]).The diameter of the Venus P-valve in the 3D simulation group was significantly smaller than that of the conventional planning group(36[2]vs.32[4],Z=-3.77,P<0.001).Conclusions:In vitro testing indicated no need to oversize the Venus P-valve to the degree recommended by the balloon-sizing technique,as 2-5 mm sufficed.展开更多
To investigate the mechanism and correlated factors of systolic anterior motion （SAM） phenomenon after aortic valve replacement, 48 patients with severe aortic valvular stenosis were studied. Tested by echo-Doppler ...To investigate the mechanism and correlated factors of systolic anterior motion （SAM） phenomenon after aortic valve replacement, 48 patients with severe aortic valvular stenosis were studied. Tested by echo-Doppler one week after aortic valve replacement, the patients were divided into two groups： SAM group and non-SAM group. The data of the left ventricular end-diastolic diameters, the left ventricular end-systolic diameters, the left ventricular outflow diameters, the thickness of the interventricular septum, the posterior wall of left ventricle, the blood velocities of left ventricular outflow and intra-cavitary gradients were recorded and compared. The results showed that no patients died during or after the operation. The blood velocities of left ventricular outflow was increased significantly in 9 patients （〉2.5 m/s）, and 6 of them developed SAM phenomenon. There was significant difference in all indexes （P〈0.05 or P〈0.01） except the posterior wall of left ventricle （P〉0.05） between two groups. These indicated that the present of SAM phenomenon after aortic valve replacement may be directly related to the increase of blood velocities of left ventricular outflow and intra-cavitary gradients. It is also suggested that smaller left ventricular diastolic diameters, left ventricular systolic diameters, left ventricular outflow diameters and hypertrophy of interventricular septum may be the anatomy basis of SAM phenomenon.展开更多
Background: Pulmonary hypertension development in pure severe aortic stenosis is a situation that affects mortality and morbidity. Material and Methods: Data from files of 31 patients with systolic pulmonary artery pr...Background: Pulmonary hypertension development in pure severe aortic stenosis is a situation that affects mortality and morbidity. Material and Methods: Data from files of 31 patients with systolic pulmonary artery pressure over 50 mm Hg and with pure severe aortic stenosis, and underwent aortic valve replacement in our clinic were examined retrospectively. Results: Preoperative effort capacities of the patients were evaluated as follows according to NYHA;4 patients class 1-2, 16 patients class 3, and 11 patients class 4. Twenty-five metal, and 6 biologic aortic valves were used. Postoperative hospital mortality was recorded as 12% with 4 patients. Patients were reevaluated on the postoperative 2nd and 12th months. Pulmonary arterial pressure of the patients was measured using echocardiography. Preoperative average pulmonary artery systolic pressure was measured as 55 ± 3 mmHg. The average pressure was measured as 41 ± 3 mmHg on the 2nd, and as 37.8 ± 4 mmHg on the 12th month. The effort capacity evaluation in the postoperative 2nd month was as follows: 11 patients class 1-2, 12 patients class 3, and 4 patients class 4. The effort capacity evaluation conducted in the 12th month was: 14 patients were class 1-2, 10 patients were class 3, and 2 patients were class 4. During the follow-up 1 year, survival rate of the patients was determined as 83.8% average, 5 year survival rate was determined as 61.5%. Conclusion: We believe that AVR may be performed in severe aortic stenosis cases with high pulmonary pressure with acceptable ortality, leading to a better quality and longer life.展开更多
Background:Surgical left atrial appendage occlusion(SLAAO)may be associated with a lower risk of thromboembolism in patientswith atrial fibrillation undergoing cardiac surgery.However,evidence regarding the effectiven...Background:Surgical left atrial appendage occlusion(SLAAO)may be associated with a lower risk of thromboembolism in patientswith atrial fibrillation undergoing cardiac surgery.However,evidence regarding the effectiveness of SLAAO in patients undergoingmechanical heart valve replacement(MHVR)is lacking.Therefore,we aimed to evaluate the association between SLAAO and thecardiovascular outcomes in patients with atrial fibrillation undergoing MHVR.Methods:We retrospectively analyzed data for 497 patients with atrial fibrillation;27.6%of the patients underwent SLAAO,andthe remainder of the patients did not(No-SLAAO group).The primary outcome was a composite of ischemic stroke,systemicembolism,and all-cause mortality.Cumulative event-free survival rates were estimated using Kaplan-Meier curves,and weperformed multivariate Cox analyses to evaluate the association between SLAAO and outcomes.We used one-to-one propensityscore matching to balance patients’baseline characteristics,and analyzed 120 matching pairs.Results:Five patients died within 30 days postoperatively,and there were no significant differences between the two groupsregarding in-hospital complications(all P>0.05).After a median follow-up of 14 months,14 primary events occurred.Kaplan-Meier curves showed no difference in the cumulative incidence of freedom from the primary outcome(log-rank P=0.830),hemorrhagic events(log-rank P=0.870),and the secondary outcome(log-rank P=0.730),between the two groups.MultivariableCox proportional hazards regression analysis showed no association between SLAAO and any outcome(all P>0.05).Afterpropensity score matching,cardiopulmonary bypass time and aortic cross-clamp time,and the postoperative length of stay weresignificantly longer in the SLAAO group(all P<0.05);results were similar to the unadjusted analyses.Conclusions:Concomitant SLAAO and MHVR was associated with longer length of stay,and cardiopulmonary bypass time andaortic cross-clamp time,but was not associated with additional protective effects against thromboembolic events and mortalityduring the 14-month follow-up.展开更多
背景:退行性二尖瓣关闭不全的病例有逐渐增加的趋势,而单纯二尖瓣环扩张引起的二尖瓣关闭不全是退行性二尖瓣关闭不全的一种类型,国内尚无关于此类二尖瓣关闭不全的外科治疗的临床研究报告。目的:观察单纯瓣环置入修复单纯二尖瓣环扩张...背景:退行性二尖瓣关闭不全的病例有逐渐增加的趋势,而单纯二尖瓣环扩张引起的二尖瓣关闭不全是退行性二尖瓣关闭不全的一种类型,国内尚无关于此类二尖瓣关闭不全的外科治疗的临床研究报告。目的:观察单纯瓣环置入修复单纯二尖瓣环扩张引起的二尖瓣关闭不全早中期生物相容性的反应。方法:单纯二尖瓣瓣环扩张致二尖瓣关闭不全患者48例,均行二尖瓣人工瓣环置入修复,其中使用Carpentier-Edwards生理环23例、SJMTM刚性鞍形成形环25例。出院后随访,采用超声心动图观察心功能和二尖瓣反流程度等变化,并比较两种瓣环与宿主生物相容性有无差别。结果与结论:围术期无死亡,均治愈出院。48例均获随访,随访率100%,随访时间3个月至4年,无死亡病例。NYHA心功能分级Ⅰ级32例,Ⅱ级16例。与术前比较,随访期超声心动图显示左心房内径、左心室舒张末期内径、左心室收缩末期内径、肺动脉收缩压和反流速面积/左房面积均明显减少(P<0.01),左室射血分数明显增加(P<0.01)。跨瓣压差均<3 mm Hg。二尖瓣无明显返流36例,微量返流10例,轻度反流2例。未出现成形环断裂、成形环撕脱及溶血现象。Carpentier-Edwards生理环组和SJMTM刚性鞍形成形环组比较,上述各指标差异无显著性意义(P>0.05)。结果提示对于因单纯二尖瓣环扩张引起的退行性二尖瓣关闭不全,通过正确的置入技巧、选择合适的人工瓣环,应用人工瓣环置入有与宿主生物较好的生物相容性反应,置入后的瓣膜替代功能良好。展开更多
文摘Although surgical aortic valve replacement is the standard therapy for severe aortic stenosis(AS),about one third of patients are considered inoperable due to unacceptable surgical risk.Under medical treatment alone these patients have a very poor prognosis with a mortality rate of 50%at 2 years.Transcatheter aortic valve implantation(TAVI)has been used in these patients,and has shown robust results in the only randomized clinical trial of severe AS treatment performed so far.In this review,we will focus on the two commercially available systems:Edwards SAPIEN valve and CoreValve Revalving system.Both systems have demonstrated success rates of over 90%with 30-d mortality rates below 10%in the most recent transfemoral TAVI studies.Moreover,long-term studies have shown that the valves have good haemodynamic performance.Some studies are currently exploring the non-inferiority of TAVI procedures vs conventional surgery in high-risk patients,and long-term clinical results of the percutaneous valves.In this article we review the current status of TAVI including selection of patients,a comparison of available prostheses,results and complications of the procedure,clinical outcomes,and future perspectives.
文摘Right ventricular outflow tract(RVOT)obstruction is present in a variety of congenital heart disease states including tetralogy of Fallot,pulmonary atresia/stenosis and other conotruncal abnormalities etc.After surgical repair,these patients develop RVOT residual abnormalities of pulmonic stenosis and/or insufficiency of their native outflow tract or right ventricle to pulmonary artery conduit.There are also sequelae of other surgeries like the Ross operation for aortic valve disease that lead to right ventricle to pulmonary artery conduit dysfunction.Surgical pulmonic valve replacement(SPVR)has been the mainstay for these patients and is considered standard of care.Transcatheter pulmonic valve implantation(TPVI)was first reported in 2000 and has made strides as a comparable alternative to SPVR,being approved in the United States in 2010.We provide a comprehensive review in this space–indications for TPVI,detailed procedural facets and up-to-date review of the literature regarding outcomes of TPVI.TPVI has been shown to have favorable medium-term outcomes free of reinterventions especially after the adoption of the practice of pre-stenting the RVOT.Procedural mortality and complications are uncommon.With more experience,recognition of risk of dreaded outcomes like coronary compression has improved.Also,conduit rupture is increasingly being managed with transcatheter tools.Questions over endocarditis risk still prevail in the TPVI population.Head-to-head comparisons to SPVR are still limited but available data suggests equivalence.We also discuss newer valve technologies that have limited data currently and may have more applicability for treatment of native dysfunctional RVOT substrates.
基金Henan Province health science and technology innovation talents training project(No.YXKC 2020047)
文摘Background:Due to the wide variety of morphology,size,and dynamics,selecting an optimal valve size and location poses great difficulty in percutaneous pulmonary valve implantation(PPVI).This study aimed to report our experience with in vitro bench testing using patient-specific three-dimensional(3D)-printed models for planning PPVI with the Venus P-valve.Methods:Patient-specific 3D soft models were generated using PolyJet printing with a compliant synthetic material in 15 patients scheduled to undergo PPVI between July 2018 and July 2020 in Central China Fuwai Hospital of Zhengzhou University.Results:3D model bench testing altered treatment strategy in all patients(100%).One patient was referred for surgery because testing revealed that even the largest Venus P-valve would not anchor properly.In the remaining 14 patients,valve size and/or implantation location was altered to avoid valve migration and/or compression coronary artery.In four patients,it was decided to change the point anchoring because of inverted cone-shaped right ventricular outflow tract(RVOT)(n=2)or risk of compression coronary artery(n=2).Concerning sizing,we found that an oversize of 2-5 mm suffices.Anchoring of the valve was dictated by the flaring of the in-and outflow portion in the pulmonary artery.PPVI was successful in all 14 patients(absence of valve migration,no coronary compression,and none-to-mild residual pulmonary regurgitation[PR]).The diameter of the Venus P-valve in the 3D simulation group was significantly smaller than that of the conventional planning group(36[2]vs.32[4],Z=-3.77,P<0.001).Conclusions:In vitro testing indicated no need to oversize the Venus P-valve to the degree recommended by the balloon-sizing technique,as 2-5 mm sufficed.
文摘To investigate the mechanism and correlated factors of systolic anterior motion （SAM） phenomenon after aortic valve replacement, 48 patients with severe aortic valvular stenosis were studied. Tested by echo-Doppler one week after aortic valve replacement, the patients were divided into two groups： SAM group and non-SAM group. The data of the left ventricular end-diastolic diameters, the left ventricular end-systolic diameters, the left ventricular outflow diameters, the thickness of the interventricular septum, the posterior wall of left ventricle, the blood velocities of left ventricular outflow and intra-cavitary gradients were recorded and compared. The results showed that no patients died during or after the operation. The blood velocities of left ventricular outflow was increased significantly in 9 patients （〉2.5 m/s）, and 6 of them developed SAM phenomenon. There was significant difference in all indexes （P〈0.05 or P〈0.01） except the posterior wall of left ventricle （P〉0.05） between two groups. These indicated that the present of SAM phenomenon after aortic valve replacement may be directly related to the increase of blood velocities of left ventricular outflow and intra-cavitary gradients. It is also suggested that smaller left ventricular diastolic diameters, left ventricular systolic diameters, left ventricular outflow diameters and hypertrophy of interventricular septum may be the anatomy basis of SAM phenomenon.
文摘Background: Pulmonary hypertension development in pure severe aortic stenosis is a situation that affects mortality and morbidity. Material and Methods: Data from files of 31 patients with systolic pulmonary artery pressure over 50 mm Hg and with pure severe aortic stenosis, and underwent aortic valve replacement in our clinic were examined retrospectively. Results: Preoperative effort capacities of the patients were evaluated as follows according to NYHA;4 patients class 1-2, 16 patients class 3, and 11 patients class 4. Twenty-five metal, and 6 biologic aortic valves were used. Postoperative hospital mortality was recorded as 12% with 4 patients. Patients were reevaluated on the postoperative 2nd and 12th months. Pulmonary arterial pressure of the patients was measured using echocardiography. Preoperative average pulmonary artery systolic pressure was measured as 55 ± 3 mmHg. The average pressure was measured as 41 ± 3 mmHg on the 2nd, and as 37.8 ± 4 mmHg on the 12th month. The effort capacity evaluation in the postoperative 2nd month was as follows: 11 patients class 1-2, 12 patients class 3, and 4 patients class 4. The effort capacity evaluation conducted in the 12th month was: 14 patients were class 1-2, 10 patients were class 3, and 2 patients were class 4. During the follow-up 1 year, survival rate of the patients was determined as 83.8% average, 5 year survival rate was determined as 61.5%. Conclusion: We believe that AVR may be performed in severe aortic stenosis cases with high pulmonary pressure with acceptable ortality, leading to a better quality and longer life.
基金Supported by the grants from the Ministry of Science and Technology of China and the Prevention and Control Project of Major Chronic Non-infection Disease during the 13th 5-year plan period(No:2016YFC1302000)the Beijing Municipal Science and Technology Commission(D171100002917001).
文摘Background:Surgical left atrial appendage occlusion(SLAAO)may be associated with a lower risk of thromboembolism in patientswith atrial fibrillation undergoing cardiac surgery.However,evidence regarding the effectiveness of SLAAO in patients undergoingmechanical heart valve replacement(MHVR)is lacking.Therefore,we aimed to evaluate the association between SLAAO and thecardiovascular outcomes in patients with atrial fibrillation undergoing MHVR.Methods:We retrospectively analyzed data for 497 patients with atrial fibrillation;27.6%of the patients underwent SLAAO,andthe remainder of the patients did not(No-SLAAO group).The primary outcome was a composite of ischemic stroke,systemicembolism,and all-cause mortality.Cumulative event-free survival rates were estimated using Kaplan-Meier curves,and weperformed multivariate Cox analyses to evaluate the association between SLAAO and outcomes.We used one-to-one propensityscore matching to balance patients’baseline characteristics,and analyzed 120 matching pairs.Results:Five patients died within 30 days postoperatively,and there were no significant differences between the two groupsregarding in-hospital complications(all P>0.05).After a median follow-up of 14 months,14 primary events occurred.Kaplan-Meier curves showed no difference in the cumulative incidence of freedom from the primary outcome(log-rank P=0.830),hemorrhagic events(log-rank P=0.870),and the secondary outcome(log-rank P=0.730),between the two groups.MultivariableCox proportional hazards regression analysis showed no association between SLAAO and any outcome(all P>0.05).Afterpropensity score matching,cardiopulmonary bypass time and aortic cross-clamp time,and the postoperative length of stay weresignificantly longer in the SLAAO group(all P<0.05);results were similar to the unadjusted analyses.Conclusions:Concomitant SLAAO and MHVR was associated with longer length of stay,and cardiopulmonary bypass time andaortic cross-clamp time,but was not associated with additional protective effects against thromboembolic events and mortalityduring the 14-month follow-up.
文摘背景:退行性二尖瓣关闭不全的病例有逐渐增加的趋势,而单纯二尖瓣环扩张引起的二尖瓣关闭不全是退行性二尖瓣关闭不全的一种类型,国内尚无关于此类二尖瓣关闭不全的外科治疗的临床研究报告。目的:观察单纯瓣环置入修复单纯二尖瓣环扩张引起的二尖瓣关闭不全早中期生物相容性的反应。方法:单纯二尖瓣瓣环扩张致二尖瓣关闭不全患者48例,均行二尖瓣人工瓣环置入修复,其中使用Carpentier-Edwards生理环23例、SJMTM刚性鞍形成形环25例。出院后随访,采用超声心动图观察心功能和二尖瓣反流程度等变化,并比较两种瓣环与宿主生物相容性有无差别。结果与结论:围术期无死亡,均治愈出院。48例均获随访,随访率100%,随访时间3个月至4年,无死亡病例。NYHA心功能分级Ⅰ级32例,Ⅱ级16例。与术前比较,随访期超声心动图显示左心房内径、左心室舒张末期内径、左心室收缩末期内径、肺动脉收缩压和反流速面积/左房面积均明显减少(P<0.01),左室射血分数明显增加(P<0.01)。跨瓣压差均<3 mm Hg。二尖瓣无明显返流36例,微量返流10例,轻度反流2例。未出现成形环断裂、成形环撕脱及溶血现象。Carpentier-Edwards生理环组和SJMTM刚性鞍形成形环组比较,上述各指标差异无显著性意义(P>0.05)。结果提示对于因单纯二尖瓣环扩张引起的退行性二尖瓣关闭不全,通过正确的置入技巧、选择合适的人工瓣环,应用人工瓣环置入有与宿主生物较好的生物相容性反应,置入后的瓣膜替代功能良好。
