背景:慢性重度主动脉瓣反流(AR)的长期预后较差,尤其是老年患者。考虑到他们的年龄,主动脉瓣置换术的手术方法可能并不总是此类患者的最佳替代治疗方式。因此,本研究的主要目的是提供经导管主动脉瓣置换术(TAVR)的中期和短期临床效果的初步总结,通过精确的多探测器计算机断层扫描(MDCT)测量指导严重和慢性AR患者,尤其是老年患者。
方法:本研究回顾性和前瞻性地纳入了2019年1月至2022年9月在阜外心血管病医院接受TAVR手术的重度AR患者,北京。基线信息,MDCT测量,解剖分类,围手术期,收集并分析1年随访结局.基于一种新颖的解剖分类和双重锚定理论,根据锚定区的水平将患者分为四类。1、2和3型患者(具有至少两个锚定区域)将接受带有经导管心脏瓣膜(THV)的TAVR,但4型患者(具有零个或一个锚定位置)将被视为不适合TAVR,而是将接受医疗护理(已接受TAVR的回顾性入组患者为例外).
结果:37例重度慢性AR患者的平均年龄为73.1±8.7岁,男性23例(62.2%)。美国胸外科医师协会评分为8.6±2.1%。MDCT解剖分型包括1型17例(45.9%),2型3例(8.1%),3型13例(35.1%),四型4例(10.8%)。VitaFlow阀(MicroPort,上海,中国)植入19例患者(51.3%),而维纳斯A阀(维纳斯医疗技术,杭州,中国)植入患者18例(48.6%)。立即TAVR手术和设备成功率分别为86.5%和67.6%,分别,而8例(21.6%)需要THV-in-THV植入,9例(24.3%)需要永久起搏器植入。单因素回归分析显示,影响TAVR装置失效的主要因素为:THV类型,和MDCT解剖分类(p<0.05)。与基线相比,左心室射血分数逐渐升高,而左心室舒张末期直径仍然很小,1年内N末端前激素B型利钠肽水平明显下降。
结论:根据我们的研究结果,具有自我膨胀THV的TAVR对于慢性重度AR患者是安全可行的,特别是对于那些符合具有完整双主动脉锚的适当MDCT解剖分类标准的人,并且在至少一年内具有显著的临床效果。
BACKGROUND: Chronic severe aortic regurgitation (AR) has a poor long-term prognosis, especially among old-age patients. Considering their advancing age, the surgical approach of aortic valve replacement may not always be the best alternative modality of treatment in such patients. Therefore, this study\'s primary goal was to provide an initial summary of the medium- and short-term clinical effectiveness of transcatheter aortic valve replacement (TAVR) guided by accurate multi-detector computed tomography (MDCT) measurements in patients with severe and chronic AR, especially in elderly patients.
METHODS: The study enrolled retrospectively and prospectively patients diagnosed with severe AR who eventually underwent TAVR procedure from January 2019 to September 2022 at Fuwai cardiovascular Hospital, Beijing. Baseline information, MDCT measurements, anatomical classification, perioperative, and 1-year follow-up outcomes were collected and analyzed. Based on a novel anatomical categorization and dual anchoring theory, patients were divided into four categories according to the level of anchoring area. Type 1, 2, and 3 patients (with at least two anchoring regions) will receive TAVR with a transcatheter heart valve (THV), but Type 4 patients (with zero or one anchoring location) will be deemed unsuitable for TAVR and will instead receive medical care (retrospectively enrolled patients who already underwent TAVR are an exception).
RESULTS: The mean age of the 37 patients with severe chronic AR was 73.1 ± 8.7 years, and 23 patients (62.2%) were male. The American Association of Thoracic Surgeons\' score was 8.6 ± 2.1%. The MDCT anatomical classification included 17 cases of type 1 (45.9%), 3 cases of type 2 (8.1%), 13 cases of type 3 (35.1%), and 4 cases of Type 4 (10.8%). The VitaFlow valve (MicroPort, Shanghai, China) was implanted in 19 patients (51.3%), while the Venus A valve (Venus MedTech, Hangzhou, China) was implanted in 18 patients (48.6%). Immediate TAVR procedural and device success rates were 86.5% and 67.6%, respectively, while eight cases (21.6%) required THV-in-THV implantation, and nine cases (24.3%) required permanent pacemaker implantation. Univariate regression analysis revealed that the major factors affecting TAVR device failure were sinotubular junction diameter, THV type, and MDCT anatomical classification (p < 0.05). Compared with the baseline, the left ventricular ejection fraction gradually increased, while the left ventricular end-diastolic diameter remained small, and the N-terminal-pro hormone B-type natriuretic peptide level significantly decreased within one year.
CONCLUSIONS: According to the results of our study, TAVR with a self-expanding THV is safe and feasible for patients with chronic severe AR, particularly for those who meet the criteria for the appropriate MDCT anatomical classification with intact dual aortic anchors, and it has a significant clinical effect for at least a year.