主动脉瓣狭窄患者经导管主动脉瓣置换术后短期超声心动图和血N末端B型利钠肽原浓度变化特点分析
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摘要
目的:探讨主动脉瓣狭窄患者经导管主动脉瓣置换(TAVR)术后6个月内心功能、主动脉瓣跨瓣压差及血流速度特点,以明确TAVR术后心功能、主动瓣跨瓣压差的变化规律,为临床治疗提供指导信息。方法:2013-12至2015-12连续入选常规外科换瓣手术禁忌或美国胸外科医师学会(STS)评分高危、在我院成功行TAVR治疗的49例重度主动脉瓣狭窄患者。在TAVR治疗前后、术后1个月及6个月时,所有患者接受超声心动图检查和血N末端B型利钠肽原(NT-pro BNP)检测,记录左心室射血分数、主动脉瓣平均跨瓣压差、最大跨瓣压差、最大跨瓣血流速度和血NT-pro BNP浓度。TAVR术前左心室射血分数<50%的患者分入心功能不全组,左心室射血分数≥50%的患者分入心功能正常组,观察两组患者TAVR术后心功能和NT-pro BNP浓度变化。结果:49例患者中,心功能不全组15例(30.6%),心功能正常组34例(69.4%)。TAVR治疗后7 d内,所有患者的左心室射血分数[(56.0±14.6)%vs(52.5±13.8)%]、主动脉瓣平均跨瓣压差[(11±5)mmH g(1 mmH g=0.133 kP a)vs(58±18)mmH g]、最大跨瓣压差([21.7±9.5)mmH g vs(93.0±28.6)mmH g]、最大跨瓣血流速度([2.3±0.5)m/s vs(4.8±0.7)m/s]、血NT-proB NP浓度[1 831(1 098~3 363)pg/ml vs 3 842(1 763~8 664)pg/ml]、主动脉瓣瓣口面积[(1.57±0.43)cm2 vs(0.58±0.23)cm2]较术前均有明显改善,差异均有统计学意义(P均<0.05)。术后6个月内,患者的左心室射血分数仍持续上升,尤以心功能不全组为著;主动脉瓣平均跨瓣压差、最大跨瓣血流速度、NT-proB NP浓度较术后持续下降,纽约心脏协会心功能分级持续改善,差异均有统计学意义(P均<0.05)。结论:TAVR是外科手术禁忌或STS评分高危的重度主动脉瓣狭窄患者的一种有效治疗方式,在6个月内可明显且持续改善患者的心功能,左心功能不全患者改善尤为明显。
Objective: To explore the cardiac function and outcomes in patients of aortic stenosis(AS) after transcatheter aortic valve replacement(TAVR) within 6 months in order to provide the guidance for clinical treatment.Methods: A total of 49 consecutive severe AS patients with surgical contradiction or STS high risk score and received successful TAVR in our hospital from 2013-12 to 2015-12 were studied. Echocardiography and blood levels of NT-pro BNP were examined at pre-and 1 month, 6 months after TAVR. Left ventricular ejection fraction(LVEF), aortic valve mean gradient(MG), peak gradient(PG) and peak velocity(PV) were recorded. Based on pre-operative LVEF, the patients were divided into 2 groups: Cardiac dysfunction group, LVEF<50%, n =15(30.6%) and Normal cardiac function group, LVEF≥50%, n=34(69.4%). Post-operative cardiac function and blood levels of NT-pro BNP were compared between 2 groups.Results: In all 49 patients, the following parameters were significantly improved within 7 days after TAVR: LVEF(56.0±14.6) % vs(52.5±13.8)%, MG(11±5) mm Hg vs(58±18) mm Hg, PG(21.7±9.5) mm Hg vs(93.0±28.6) mm Hg, PV(2.3±0.5) m/s vs(4.8±0.7) m/s, blood NT-pro BNP level [1831(1098-3363)] pg/ml vs [3842(1763-8664)] pg/ml and aortic valve area(1.57±0.43) cm2 vs(0.58±0.23) cm2 all P<0.05. Within 6 months after TAVR, LVEF was continuously increasing especially in Cardiac dysfunction group; MG, PV and NT-pro BNP level were continuously decreasing, NYHA grade was continuously improving, all P<0.05.Conclusion: TAVR was an effective treatment in AS patients with surgical contradiction or STS high risk score; it may continuously improve cardiac function, especially in patients with left heart dysfunction.
Objective: To explore the cardiac function and outcomes in patients of aortic stenosis(AS) after transcatheter aortic valve replacement(TAVR) within 6 months in order to provide the guidance for clinical treatment.Methods: A total of 49 consecutive severe AS patients with surgical contradiction or STS high risk score and received successful TAVR in our hospital from 2013-12 to 2015-12 were studied. Echocardiography and blood levels of NT-pro BNP were examined at pre-and 1 month, 6 months after TAVR. Left ventricular ejection fraction(LVEF), aortic valve mean gradient(MG), peak gradient(PG) and peak velocity(PV) were recorded. Based on pre-operative LVEF, the patients were divided into 2 groups: Cardiac dysfunction group, LVEF<50%, n =15(30.6%) and Normal cardiac function group, LVEF≥50%, n=34(69.4%). Post-operative cardiac function and blood levels of NT-pro BNP were compared between 2 groups.Results: In all 49 patients, the following parameters were significantly improved within 7 days after TAVR: LVEF(56.0±14.6) % vs(52.5±13.8)%, MG(11±5) mm Hg vs(58±18) mm Hg, PG(21.7±9.5) mm Hg vs(93.0±28.6) mm Hg, PV(2.3±0.5) m/s vs(4.8±0.7) m/s, blood NT-pro BNP level [1831(1098-3363)] pg/ml vs [3842(1763-8664)] pg/ml and aortic valve area(1.57±0.43) cm2 vs(0.58±0.23) cm2 all P<0.05. Within 6 months after TAVR, LVEF was continuously increasing especially in Cardiac dysfunction group; MG, PV and NT-pro BNP level were continuously decreasing, NYHA grade was continuously improving, all P<0.05.Conclusion: TAVR was an effective treatment in AS patients with surgical contradiction or STS high risk score; it may continuously improve cardiac function, especially in patients with left heart dysfunction.
引文
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[6]Ponikowski P,Voors AA,Anker SD,et al.2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure:The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology(ESC).Developed with the special contribution of the Heart Failure Association(HFA)of the ESC.Eur J Heart Fail,2016,18:891-975.
[7]Otto CM,Kumbhani DJ,Alexander KP,et al.2017 ACC expert consensus decision pathway for transcatheter aortic valve replacement in the management of adults with aortic stenosis:a report of the American College of Cardiology task force on clinical expert consensus documents.J Am Coll Cardiol,2017 Jan 4.PMID:28063810.
[8]Burwash IG,Thomas DD,Sadahiro M,et al.Dependence of Gorlin formula and continuity equation valve areas on transvalvular volume flow rate in valvular aortic stenosis.Circulation,1994,89:827-835.
[9]Bergler-Klein J,Gyongyosi M,Maurer G.The role of biomarkers in valvular heart disease:focus on natriuretic peptides.Can J Cardiol,2014,30:1027-1034.
[10]Leon MB,Smith CR,Mack MJ,et al.Transcatheter or surgical aorticvalve replacement in intermediate-risk patients.N Engl J Med,2016,374:1609-1620.
[11]Smith CR,Leon MB,Mack MJ,et al.Transcatheter versus surgical aortic-valve replacement in high-risk patients.N Engl J Med,2011,364:2187-2198.
[12]Kodali S,Thourani VH,White J,et al.Early clinical and echocardiographic outcomes after SAPIEN 3 transcatheter aortic valve replacement in inoperable,high-risk and intermediate-risk patients with aortic stenosis.Eur Heart J,2016,37:2252-2262.
[2]Leon MB,Smith CR,Mack M,et al.Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery.N Engl J Med,2010,363:1597-1607.
[3]Smith CR,Leon MB,Mack MJ,et al.Transcatheter versus surgical aortic-valve replacement in high-risk patients.N Engl J Med,2011,364:2187-2198.
[4]Adams DH,Popma JJ,Reardon MJ,et al.Transcatheter aortic-valve replacement with a self-expanding prosthesis.N Engl J Med,2014,370:1790-1798.
[5]Nishimura RA,Otto CM,Bonow RO,et al.2014 AHA/ACC guideline for the management of patients with valvular heart disease:executive summary:a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol,2014,63:2438-2488.
[6]Ponikowski P,Voors AA,Anker SD,et al.2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure:The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology(ESC).Developed with the special contribution of the Heart Failure Association(HFA)of the ESC.Eur J Heart Fail,2016,18:891-975.
[7]Otto CM,Kumbhani DJ,Alexander KP,et al.2017 ACC expert consensus decision pathway for transcatheter aortic valve replacement in the management of adults with aortic stenosis:a report of the American College of Cardiology task force on clinical expert consensus documents.J Am Coll Cardiol,2017 Jan 4.PMID:28063810.
[8]Burwash IG,Thomas DD,Sadahiro M,et al.Dependence of Gorlin formula and continuity equation valve areas on transvalvular volume flow rate in valvular aortic stenosis.Circulation,1994,89:827-835.
[9]Bergler-Klein J,Gyongyosi M,Maurer G.The role of biomarkers in valvular heart disease:focus on natriuretic peptides.Can J Cardiol,2014,30:1027-1034.
[10]Leon MB,Smith CR,Mack MJ,et al.Transcatheter or surgical aorticvalve replacement in intermediate-risk patients.N Engl J Med,2016,374:1609-1620.
[11]Smith CR,Leon MB,Mack MJ,et al.Transcatheter versus surgical aortic-valve replacement in high-risk patients.N Engl J Med,2011,364:2187-2198.
[12]Kodali S,Thourani VH,White J,et al.Early clinical and echocardiographic outcomes after SAPIEN 3 transcatheter aortic valve replacement in inoperable,high-risk and intermediate-risk patients with aortic stenosis.Eur Heart J,2016,37:2252-2262.