二叶式主动脉瓣狭窄患者主动脉根部形态学特点对经导管主动脉瓣置换术疗效的影响
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摘要
目的:探讨二叶式主动脉瓣狭窄患者主动脉根部形态学特点对经导管主动脉瓣置换术(TAVR)疗效的影响。方法:回顾性选取2014年1月至2016年12月在阜外医院、四川大学华西医院及浙江大学附属第二医院行TAVR的二叶式主动脉瓣狭窄患者49例。分析患者主动脉根部形态学特点、手术有效性及安全性,并进行随访。结果:二叶式主动脉瓣无嵴与带嵴类型占比相当(55.1%vs 44.9%),瓣叶钙化程度重[钙化体积HU850=(604.1±318.7) mm~3],平均瓣环周长大于平均瓣环上水平周长[(78.8±7.4) mm vs (67.1±6.7) mm,P<0.001],平均左心室流出道(LVOT)周长大于平均瓣环周长[(81.6±10.5) mm vs (78.8±7.4) mm,P=0.003]。置入瓣中瓣患者12例(24.5%),瓣膜置入过深患者14例(34.1%)。置入瓣中瓣患者比无瓣中瓣患者瓣环平均内经[(26.8±2.4) mm vs(23.9±2.0) mm,P<0.001]、周长[(85.7±7.0) mm vs (76.6±6.1) mm,P<0.001]及LVOT平均内径[(28.4±2.7) mm vs (24.3±3.1) mm,P<0.001]、周长[(91.3±9.1) mm vs (78.4±8.9) mm,P<0.001]更大,LVOT周长/瓣环上水平周长比值虽差异无统计学意义[(125.5±12.3)%vs (119.4±15.7)%,P=0.067],但趋近阈值。瓣膜置入过深患者比无置入过深患者LVOT周长/瓣环周长比值更大[(108.0±7.4)%vs (101.2±6.7)%,P=0.005]。结论:二叶式主动脉瓣患者的瓣环和LVOT平均内径及LVOT周长/瓣环周长比值对于TAVR中瓣中瓣的置入及瓣膜置入深度具有一定影响。
Objectives:To explore the association between morphology of aortic root and the procedural feasibility and clinical outcomes of Trans-catheter aortic valve replacement(TAVR) in patients with bicuspid aortic valve(BAV) stenosis. Methods: This multi-center study included 49 patients with native BAV stenosis, who underwent TAVR using a selfexpanding prosthesis(the Venus A-valve) between 2014 to 2016 in China. The correlation between imaging data of aortic root and the procedural end-points was analyzed.Results: Patients were(73.4±5.9) years old(26 male patients), there were 22 Raphe-type(44.9%) cases and 47 non-raphe type. All cases had heavy valve calcium burden(HU850=[604.1±318.7] mm~3). There was an increasing trend from the mean perimeter of supra annular level to annulus level and left ventricular outflow tract(LVOT) level(mean perimeter of annulus level was bigger than mean perimeter of supra annular level([78.8±7.4] mm vs [67.1±6.7] mm, P <0.001), mean perimeter of LVOT level was bigger than mean perimeter of annulus level([81.6±10.5] mm vs [78.8±7.4] mm, P =0.003). Trans-catheter valve in Trans-catheter valve(TV-in-TV)(12/49 cases) and device deep implantation(14/41 cases) were frequently observed after procedure. The patients received TV-in-TV had larger mean diameter([26.8±2.4] mm vs [23.9±2.0] mm, P<0.001) and larger perimeter([85.7±7.0] mm vs [76.6±6.1] mm, P<0.001) at annulus level than non-TV-in-TV patients. The patients received TV-in-TV also had larger mean diameter([28.4±2.7] mm vs [24.3±3.1] mm, P<0.001) and perimeter([91.3±9.1] mm vs [78.4±8.9] mm, P<0.001) at LVOT level than nonTV-in-TV patients. The bigger mismatch rate of LVOT/annulus perimeter was related with higher rate of deep device implantation([108.0±7.4]% vs [101.2±6.7]%, P =0.005). The mismatch rate of LVOT/supra annular perimeter also showed a trend to increase in the rate of TV-in-TV([125.5±12.3]% vs [119.4±15.7]%, P =0.067) and deep device implantation([128.0±14.0]% vs [119.2±16.3]%, P=0.098). Conclusions: Supra annular, annulus and LVOT perimeters and the mismatch rate are important determinants for predicting TV-in-TV and deep device implantation in this patient cohort.
Objectives:To explore the association between morphology of aortic root and the procedural feasibility and clinical outcomes of Trans-catheter aortic valve replacement(TAVR) in patients with bicuspid aortic valve(BAV) stenosis. Methods: This multi-center study included 49 patients with native BAV stenosis, who underwent TAVR using a selfexpanding prosthesis(the Venus A-valve) between 2014 to 2016 in China. The correlation between imaging data of aortic root and the procedural end-points was analyzed.Results: Patients were(73.4±5.9) years old(26 male patients), there were 22 Raphe-type(44.9%) cases and 47 non-raphe type. All cases had heavy valve calcium burden(HU850=[604.1±318.7] mm~3). There was an increasing trend from the mean perimeter of supra annular level to annulus level and left ventricular outflow tract(LVOT) level(mean perimeter of annulus level was bigger than mean perimeter of supra annular level([78.8±7.4] mm vs [67.1±6.7] mm, P <0.001), mean perimeter of LVOT level was bigger than mean perimeter of annulus level([81.6±10.5] mm vs [78.8±7.4] mm, P =0.003). Trans-catheter valve in Trans-catheter valve(TV-in-TV)(12/49 cases) and device deep implantation(14/41 cases) were frequently observed after procedure. The patients received TV-in-TV had larger mean diameter([26.8±2.4] mm vs [23.9±2.0] mm, P<0.001) and larger perimeter([85.7±7.0] mm vs [76.6±6.1] mm, P<0.001) at annulus level than non-TV-in-TV patients. The patients received TV-in-TV also had larger mean diameter([28.4±2.7] mm vs [24.3±3.1] mm, P<0.001) and perimeter([91.3±9.1] mm vs [78.4±8.9] mm, P<0.001) at LVOT level than nonTV-in-TV patients. The bigger mismatch rate of LVOT/annulus perimeter was related with higher rate of deep device implantation([108.0±7.4]% vs [101.2±6.7]%, P =0.005). The mismatch rate of LVOT/supra annular perimeter also showed a trend to increase in the rate of TV-in-TV([125.5±12.3]% vs [119.4±15.7]%, P =0.067) and deep device implantation([128.0±14.0]% vs [119.2±16.3]%, P=0.098). Conclusions: Supra annular, annulus and LVOT perimeters and the mismatch rate are important determinants for predicting TV-in-TV and deep device implantation in this patient cohort.
引文
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[5]宋光远,王墨扬,王媛,等.Venus-A主动脉瓣膜介入治疗重度主动脉瓣狭窄的效果[J].中华心血管病杂志,2017,45(10):843-847.DOI:10.3760/cma.j.issn.0253-3758.2017.10.006.
[6]王墨扬,许亮,裴汉军,等.15例拟行经导管主动脉瓣置换术患者主动脉根部影像学与临床应用-单中心早期经验[J].中国循环杂志,2014,29(9):714-717.DOI:10.3969/j.issn.1000-3614.2014.09.0015.
[7]Jilaihawi H,Chen M,Webb J,et al.A Bicuspid aortic valve imaging classification for the TAVR era[J].JACC Cardiovascular imaging,2016,9(10):1145-1158.DOI:10.1016/j.jcmg.2015.12.022.
[8]Kappetein AP,Head SJ,Genereux P,et al.Updated standardized endpoint definitions for transcatheter aortic valve implantation:the valve academic research consortium-2 consensus document[J].Eur heart J,2012,8(7):782-795.DOI:10.4244/EIJV8I7A121.
[9]Mack MJ,Brennan JM,Brindis R,et al.Outcomes following transcatheter aortic valve replacement in the United States[J].JAMA,2013,310(9):2069-2077.DOI:10.1001/jama.2013.282043.
[10]Yoon SH,Lefèvre T,Ahn JM,et al.Transcatheter aortic valve replacement with early-and new-generation devices in bicuspid aortic valve stenosis[J].J Am Coll Cardiol,2016,68(11):1195-1205.DOI:10.1016/j.jacc.2016.06.041.
[2]Smith CR,Leon MB,Mack MJ,et al.Transcatheter versus surgical aortic-valve replacement in high-risk patients[J].N Engl J Med,2011,364(23):2187-2198.DOI:10.1056/NEJMoa1103510.
[3]Hayashida K,Bouvier E,Lefevre T,et al.Transcatheter aortic valve implantation for patients with severe bicuspid aortic valve stenosis[J].Circ Cardiovasc Interv,2013,6(3):284-291.DOI:10.1161/CIRCINTERVENTIONS.112.000084.
[4]Zhao ZG,Jilaihawi H,Feng Y,et al.Transcatheter aortic valve implantation in bicuspid anatomy[J].Nat Rev Cardiol,2015,12(2):123-128.DOI:10.1038/nrcardio.2014.161.
[5]宋光远,王墨扬,王媛,等.Venus-A主动脉瓣膜介入治疗重度主动脉瓣狭窄的效果[J].中华心血管病杂志,2017,45(10):843-847.DOI:10.3760/cma.j.issn.0253-3758.2017.10.006.
[6]王墨扬,许亮,裴汉军,等.15例拟行经导管主动脉瓣置换术患者主动脉根部影像学与临床应用-单中心早期经验[J].中国循环杂志,2014,29(9):714-717.DOI:10.3969/j.issn.1000-3614.2014.09.0015.
[7]Jilaihawi H,Chen M,Webb J,et al.A Bicuspid aortic valve imaging classification for the TAVR era[J].JACC Cardiovascular imaging,2016,9(10):1145-1158.DOI:10.1016/j.jcmg.2015.12.022.
[8]Kappetein AP,Head SJ,Genereux P,et al.Updated standardized endpoint definitions for transcatheter aortic valve implantation:the valve academic research consortium-2 consensus document[J].Eur heart J,2012,8(7):782-795.DOI:10.4244/EIJV8I7A121.
[9]Mack MJ,Brennan JM,Brindis R,et al.Outcomes following transcatheter aortic valve replacement in the United States[J].JAMA,2013,310(9):2069-2077.DOI:10.1001/jama.2013.282043.
[10]Yoon SH,Lefèvre T,Ahn JM,et al.Transcatheter aortic valve replacement with early-and new-generation devices in bicuspid aortic valve stenosis[J].J Am Coll Cardiol,2016,68(11):1195-1205.DOI:10.1016/j.jacc.2016.06.041.