背景:经导管主动脉瓣植入术(TAVI)现在是老年高危主动脉瓣疾病患者队列中公认的治疗选择。虽然最常通过经股动脉途径进行,TAVI的替代方法正在不断改进。而不是经典的迷你胸骨切开术,可以通过在第二肋间空间的右前小胸廓切开术实现经主动脉入路。与经典的经主动脉入路相比,我们描述了这种保留胸骨和肋骨的技术的经验。
方法:我们的回顾性研究包括在2017年1月至2020年4月期间在我们机构通过上胸骨小切口或肋间开胸手术治疗经主动脉TAVI的173例患者。主要终点是30天死亡率,次要终点定义为主要的术后并发症,包括入住重症监护病房和总体住院时间,根据阀门学术研究联盟3。
结果:82例患者接受TAo-TAVI上段胸骨小切开术,91例患者接受肋间入路。两组在年龄(平均年龄:82岁)和女性患者比例上具有可比性。肋间组的外周动脉疾病发生率较高(41%vs.22%,p=0.008)和冠状动脉疾病(71%vs.40%,p<0.001),有经皮冠状动脉介入治疗或冠状动脉旁路移植术史,导致显著更高的介入前风险评估(EuroScoreII8%在肋间与TAo组的4%,p=0.005)。在所有情况下,成功的装置植入和跨瓣梯度的降低均实现了,在肋间组中,轻度瓣周漏的发生率显着降低(12%vs.33%,p<0.001)。肋间组需要的输血明显减少(0vs.2个单位,p=0.001),并且倾向于需要较少的再次手术(7%与15%,p=0.084)。住院(9vs.12d,p=0.011)在肋间组中也较短。随访中的短期和长期生存率显示出两种方法之间具有可比性的结果(30天,6个月和2年死亡率:7%,23%和36%在肋间与9%,TAo组分别为26%和33%),急性肾损伤(AKI)和重新插管是死亡的独立危险因素。
结论:经肋间途径经主动脉TAVI可安全有效地治疗主动脉瓣狭窄。
BACKGROUND: Transcatheter aortic valve implantation (TAVI) is now a well-established therapeutic option in an elderly high-risk patient cohort with aortic valve disease. Although most commonly performed via a transfemoral route, alternative approaches for TAVI are constantly being improved. Instead of the classical mini-sternotomy, it is possible to achieve a transaortic access via a right anterior mini-thoracotomy in the second
intercostal space. We describe our experience with this sternum- and rib-sparing technique in comparison to the classical transaortic approach.
METHODS: Our retrospective study includes 173 patients who were treated in our institution between January 2017 and April 2020 with transaortic TAVI via either upper mini-sternotomy or intercostal thoracotomy. The primary endpoint was 30-day mortality, and secondary endpoints were defined as major postoperative complications that included admission to the intensive care unit and overall hospital stay, according to the Valve Academic Research Consortium 3.
RESULTS: Eighty-two patients were treated with TAo-TAVI by upper mini-sternotomy, while 91 patients received the intercostal approach. Both groups were comparable in age (mean age: 82 years) and in the proportion of female patients. The
intercostal group had a higher rate of peripheral artery disease (41% vs. 22%, p = 0.008) and coronary artery disease (71% vs. 40%, p < 0.001) with a history of percutaneous coronary intervention or coronary artery bypass grafting, resulting in significantly higher preinterventional risk evaluation (EuroScore II 8% in the intercostal vs. 4% in the TAo group, p = 0.005). Successful device implantation and a reduction of the transvalvular gradient were achieved in all cases with a significantly lower rate of trace to mild paravalvular leakage in the intercostal group (12% vs. 33%, p < 0.001). The
intercostal group required significantly fewer blood transfusions (0 vs. 2 units, p = 0.001) and tended to require less reoperation (7% vs. 15%, p = 0.084). Hospital stays (9 vs. 12 d, p = 0.011) were also shorter in the
intercostal group. Short- and long-term survival in the follow-up showed comparable results between the two approaches (30-day, 6-month- and 2-year mortality: 7%, 23% and 36% in the intercostal vs. 9%, 26% and 33% in the TAo group) with acute kidney injury (AKI) and reintubation being independent risk factors for mortality.
CONCLUSIONS: Transaortic TAVI via an
intercostal access offers a safe and effective treatment of aortic valve stenosis.