目的:评估使用自膨式瓣膜的二叶主动脉瓣患者新发传导障碍的预测因素,并确定可修改的技术因素。背景:新发传导紊乱(NOCDs),包括完全性左束支传导阻滞和高度房室传导阻滞,仍然是经导管主动脉瓣置换术(TAVR)后最常见的并发症。方法:从2016年2月至2020年9月,在中国5个中心共纳入209例连续接受自扩张TAVR的患者。本研究中的最佳截止值是通过接收器操作员特征曲线分析得出的。在术前计算机断层扫描中测量了环形和冠状膜隔膜(MS)的长度。MSID是通过从环形MS或冠状MS长度中减去术后计算机断层扫描的植入深度来计算的。结果:42例(20.1%)患者发生完全性左束支传导阻滞,21例(10.0%)患者发生高度房室传导阻滞,61例(29.2%)患者发生NOCDs。冠状MS<4.9mm(OR:3.08,95%CI:1.63-5.82,p=0.001)或环状MS<3.7mm(OR:2.18,95%CI:1.04-4.56,p=0.038)和左心室流出道周长<66.8mm(OR:4.959595%CI:1.59-15.45,p=0.006)是NOCD的有力预测因子。多变量模型包括年龄>73岁(OR:2.26,95%CI:1.17-4.36,p=0.015),Δ冠状MSID<1.8mm(OR:7.87,95%CI:2.84-21.77,p<0.001)和左心室流出道假体尺寸增大率>3.2%(OR:3.42,95%CI:1.74-6.72,p<0.001)显示NOCD的最佳预测价值,c统计量=0.768(95%CI:0.699-0.837,p<0.001)。NOCD的发病率要低得多(7.5vs.55.2%,p<0.001)与具有这两个危险因素的患者相比,无Δ冠状MSID<1.8mm且左心室流出道假体尺寸过大比例>3.2%的患者。结论:可以根据MS长度和假体尺寸过大比例评估二叶主动脉瓣狭窄患者的NOCD风险。MS长度指导下的植入深度和减少尺寸过大的比例可能是严重钙化的双叶伴短小MS患者的可行策略。
Objective: To evaluate the predictors of new-onset conduction disturbances in bicuspid aortic valve patients using self-expanding valve and identify modifiable technical factors. Background: New-onset conduction disturbances (NOCDs), including complete left bundle branch block and high-grade atrioventricular block, remain the most common complication after transcatheter aortic valve replacement (TAVR). Methods: A total of 209 consecutive bicuspid patients who underwent self-expanding TAVR in 5 centers in
China were enrolled from February 2016 to September 2020. The optimal cut-offs in this study were generated from receiver operator characteristic curve analyses. The infra-annular and coronal membranous septum (MS) length was measured in preoperative computed tomography. MSID was calculated by subtracting implantation depth measure on postoperative computed tomography from infra-annular MS or coronal MS length. Results: Forty-two (20.1%) patients developed complete left bundle branch block and 21 (10.0%) patients developed high-grade atrioventricular block after TAVR, while 61 (29.2%) patients developed NOCDs. Coronal MS <4.9 mm (OR: 3.08, 95% CI: 1.63-5.82, p = 0.001) or infra-annular MS <3.7 mm (OR: 2.18, 95% CI: 1.04-4.56, p = 0.038) and left ventricular outflow tract perimeter <66.8 mm (OR: 4.95 95% CI: 1.59-15.45, p = 0.006) were powerful predictors of NOCDs. The multivariate model including age >73 years (OR: 2.26, 95% CI: 1.17-4.36, p = 0.015), Δcoronal MSID <1.8 mm (OR: 7.87, 95% CI: 2.84-21.77, p < 0.001) and prosthesis oversizing ratio on left ventricular outflow tract >3.2% (OR: 3.42, 95% CI: 1.74-6.72, p < 0.001) showed best predictive value of NOCDs, with c-statistic = 0.768 (95% CI: 0.699-0.837, p < 0.001). The incidence of NOCDs was much lower (7.5 vs. 55.2%, p < 0.001) in patients without Δcoronal MSID <1.8 mm and prosthesis oversizing ratio on left ventricular outflow tract >3.2% compared with patients who had these two risk factors. Conclusion: The risk of NOCDs in bicuspid aortic stenosis patients could be evaluated based on MS length and prosthesis oversizing ratio. Implantation depth guided by MS length and reducing the oversizing ratio might be a feasible strategy for heavily calcified bicuspid patients with short MS.