经皮自膨胀式肺动脉瓣植入术的长期随访
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摘要
目的评估经皮肺动脉瓣植入术(percutaneous pulmonary valve implantation,PPVI)的长期疗效及国产自膨胀式瓣膜(Venus-P)的耐久性。方法选取2013年5月至2015年11月于复旦大学附属中山医院接受PPVI并完成1年以上随访的14名患者,其中男3例,女11例,平均年龄(35.8±7.8)岁,均为法洛四联症外科根治术重度肺动脉瓣反流患者。对14名患者的生存率、术后围手术期及远期并发症发生率、PPVI的远期疗效及Venus-P的远期功能进行评估。结果 14名患者平均随访(2.3±0.8)年(1.0~3.5年),术后死亡患者1例(6.7%)。无心衰恶化、感染性心内膜炎、恶性心律失常等并发症,无患者再次手术。所有瓣膜位置固定,无瓣膜脱落、移位、支架断裂,无轻度及以上瓣周漏和瓣膜反流。术后6个月心脏磁共振测得右心室舒张末容积相比术前明显下降[(40.711±19.58)m L/m2vs.(83.03±20.0)m L/m2,P<0.05];术后1年随访超声心动图测得跨瓣压差为(20.85±4.45)mm Hg(1 mm Hg=0.133 k Pa);术后1年时NYHA心功能较术前提升1~2个等级(Ⅰ~Ⅲ级4人,Ⅰ~Ⅱ级10人),6分钟步行实验距离显著提高[(475.00±55.06)m vs.(594.23±194.51)m,P<0.05];术后QRS波宽度有缩短趋势,术后1个月及3个月有显著差异[(169.93±21.34)ms vs.(159.87±24.4)ms及(160.00±27.07)ms,P均<0.05]。结论使用国产自膨胀式瓣膜(Venus-P)介入治疗慢性肺动脉瓣反流具有较好的长期疗效和较低的并发症发生率,该瓣膜耐久性良好。
Objective To evaluate the long-term efficacy of percutaneous pulmonary valve implantation(PPVI) and the durability of the home-made self-expanding pulmonary valve(Venus-P). Methods From May,2013 to Nov.,2015,14 patients who underwent percutaneous pulmonary valve implantation at Zhongshan Hospital,Fudan University and received at least 1 year follow-up were enrolled,including 3 males and 11 females,with an average age of(35. 8 ± 7. 8) years. All patients with tetralogy of Fallot received radical resection and developed severe pulmonary regurgitation. The long-term mortality,the operation related complications,the short-term and long-term effect of PPVI,as well as the durability and effect of the self-expanding pulmonary valve were evaluated in the 14 patients. Results Over an average follow-up period of(2. 3 ± 0. 8) years(1. 0-3. 5 years),only 1 patient died(6. 7%). During the follow-up,no deterioration,infective endocarditis,malignant arrhythmia and other serious complications was observed,and nobody needed reoperation. There was no valve displacement,valve stent fracture,obvious circumferential leakage and pulmonary regurgitation. After PPVI,an acute improvement in pulmonary artery diastolic pressure was observed [(4. 93 ± 3. 37) mm Hg vs.(11. 47 ± 4.61) mm Hg,P < 0. 05]. Six month postoperatively,right ventricular end diastolic volume measured by cardiac nuclear magnetic resonance was significantly reduced [(139. 29 ± 18. 21) m L/m2 vs.(83. 03 ± 20. 0) m L/m2,P < 0. 05]. At 1 year follow up,the across valve pressure difference were(20. 85 ± 4. 45) mm Hg calculated by the echocardiography,and the NYHA cardiac function(Ⅰ-Ⅲ: 4 cases; Ⅰ-Ⅱ: 10 cases)was improved 1-2 degree and the distance of 6-minute walk test were significantly increased [(475. 00 ±55. 06) m vs.(594. 23 ± 194. 51) m,P < 0. 05]. Meanwhile,the QRS duration decreased was also observed. The changes of the QRS duration have statistical significance after 1 and 3 months of the PPVI when compared with the baseline [(169. 93 ± 21. 34) ms vs.(159. 87 ± 24. 4) ms or(160. 00 ± 27.0 ms,P < 0. 05]. Conclusions PPVI using home-made self-expanding pulmonary valve(Venus-P)for chronic pulmonary regurgitation has good long-term efficacy and low complication rate,and the valve is durable.
Objective To evaluate the long-term efficacy of percutaneous pulmonary valve implantation(PPVI) and the durability of the home-made self-expanding pulmonary valve(Venus-P). Methods From May,2013 to Nov.,2015,14 patients who underwent percutaneous pulmonary valve implantation at Zhongshan Hospital,Fudan University and received at least 1 year follow-up were enrolled,including 3 males and 11 females,with an average age of(35. 8 ± 7. 8) years. All patients with tetralogy of Fallot received radical resection and developed severe pulmonary regurgitation. The long-term mortality,the operation related complications,the short-term and long-term effect of PPVI,as well as the durability and effect of the self-expanding pulmonary valve were evaluated in the 14 patients. Results Over an average follow-up period of(2. 3 ± 0. 8) years(1. 0-3. 5 years),only 1 patient died(6. 7%). During the follow-up,no deterioration,infective endocarditis,malignant arrhythmia and other serious complications was observed,and nobody needed reoperation. There was no valve displacement,valve stent fracture,obvious circumferential leakage and pulmonary regurgitation. After PPVI,an acute improvement in pulmonary artery diastolic pressure was observed [(4. 93 ± 3. 37) mm Hg vs.(11. 47 ± 4.61) mm Hg,P < 0. 05]. Six month postoperatively,right ventricular end diastolic volume measured by cardiac nuclear magnetic resonance was significantly reduced [(139. 29 ± 18. 21) m L/m2 vs.(83. 03 ± 20. 0) m L/m2,P < 0. 05]. At 1 year follow up,the across valve pressure difference were(20. 85 ± 4. 45) mm Hg calculated by the echocardiography,and the NYHA cardiac function(Ⅰ-Ⅲ: 4 cases; Ⅰ-Ⅱ: 10 cases)was improved 1-2 degree and the distance of 6-minute walk test were significantly increased [(475. 00 ±55. 06) m vs.(594. 23 ± 194. 51) m,P < 0. 05]. Meanwhile,the QRS duration decreased was also observed. The changes of the QRS duration have statistical significance after 1 and 3 months of the PPVI when compared with the baseline [(169. 93 ± 21. 34) ms vs.(159. 87 ± 24. 4) ms or(160. 00 ± 27.0 ms,P < 0. 05]. Conclusions PPVI using home-made self-expanding pulmonary valve(Venus-P)for chronic pulmonary regurgitation has good long-term efficacy and low complication rate,and the valve is durable.
引文
[1]LURZ P,COATS L,KHAMBADKONE S,et al.Percutaneous pulm-onary valve implantation:impact of evolving technology and learning curve on clinical outcome[J].Circulation,2008,117(15):1964-1972.
[2]周达新,潘文志,管丽华,等.经皮肺动脉瓣置入二例报道[J].中国介入心脏病学杂志,2013,21(5):332-334.
[3]万俊义,陆敏杰,张戈军,等.经皮肺动脉瓣植入术后患者心功能的变化8例分析[J].中国循环杂志,2016,31(7):683-686.
[4]潘文志,张蕾,张晓春,等.经皮自膨胀肺动脉瓣植入的初步经验[J].中国医学前沿杂志:电子版,2016,8(7):65-68.
[5]HUSAIN J,PRAICHASILCHAI P,GILBERT Y,et al.Early European experience with the Venus P-valve:filling the gap in percutaneous pulmonary valve implantation[J].Eurointervention,2016,12(5):e643-e651.
[6]PROMPHAN W,PRACHASILCHAI P,SIRIPORNPITAK S,et al.Percutaneous pulmonary valve implantation with the Venus Pvalve:clinical experience and early results[J].Cardiol Young,2016,26(4):698-710.
[7]CAO Q,KENNY D,ZHOU D,et al.Early clinical experience with a novel self-expanding percutaneous stent-valve in the native right ventricular outflow tract[J].Catheter Cardiovasc Interv,2014,84(7):1131-1137.
[8]周达新,潘文志,葛均波.经皮肺动脉瓣置入术中国专家建议[J].中国医学前沿杂志:电子版,2016,8(10):20-24.
[9]BONHOEFFER P,BOUDJEMLINE Y,SALIBA Z,et al.Percutaneous replacement of pulmonary valve in a right-ventricle to pulmonary-artery prosthetic conduit with valve dysfunction[J].Lancet,2000,356(9239):1403-1405.
[10]MCELHINNEY DB,HELLENBRAND WE,ZAHN EM,et al.Short-and medium-term outcomes after transcatheter pulmonary valve placement in the expanded multicenter US melody valve trial[J].Circulation,2010,122(5):507-516.
[11]MCELHINNEY DB,CHEATHAM JP,JONES TK,et al.Stent fracture,valve dysfunction,and right ventricular outflow tract reintervention after trans-catheter pulmonary valve implantation:patient-related and procedural risk factors in the US Melody Valve Trial[J].Circ Cardiovasc Interv,2011,4(6):602-614.
[12]VEZMAR M,CHATURVEDI R,LEE KJ,et al.Percutaneous pulmonary valve implantation in the young:2-year follow-up[J].JACC Cardiovasc Interv,2010,3(4):439-448.
[13]BORIK S,CREAN A,HORLICK E,et al.Percutaneous pulmonary valve implantation:5 years of follow-up.does age influence outcomes?[J].Circ Cardiovasc Interv,2015,8(2):e001745.
[14]CHEATHAM JP,HELLENBRAND WE,ZAHN EM,et al.Clinical and hemodynamic outcomes up to 7 years after transcatheter pulmonary valve replacement in the US melody valve investigational device exemption trial[J].Circulation,2015,131(22):1960-1970.
[15]NORDMEYER J,KHAMBADKONE S,COATS L,et al.Risk stratification,systematic classification,and anticipatory management strategies for stent fracture after percutaneous pulmonary valve implantation[J].Circulation,2007,115(11):1392-1397.
[16]NORDMEYER J,LURZ P,KHAMBADKONE S,et al.Prestenting with a bare metal stent before percutaneous pulmonary valve implantation:acute and 1-year outcomes[J].Heart,2011,97(2):118-123.
[17]MCELHINNEY DB,BERGERSEN L,MARSHALL AC.In situ fracture of stents implanted for relief of pul-monary arterial stenosis in patients with congeni-tally malformed hearts[J].Cardiol Young,2008,18(4):405-414.
[18]MCELHINNEY DB,BENSON LN,EICKEN A,et al.Infective endocarditis after transcatheter pulmo-nary valve replacement using the Melody valve:combined results of 3prospective North American and European studies[J].Circ Cardiovasc Interv,2013,6(3):292-300.
[19]EICKEN A,EWERT P,HAGER A,et al.Percutaneous pulmonary valve implantation:two-centre expe-rience with more than 100 patients[J].Eur Heart J,2011,32(10):1260-1265.
[20]SECCHI F,RESTA EC,CANNAPM,et al.Four-year cardiac magnetic resonance(CMR)follow-up of patients treated with percutaneous pulmonary valve stent implantation[J].Eur Radiol,2015,25(12):3606-3613.
[2]周达新,潘文志,管丽华,等.经皮肺动脉瓣置入二例报道[J].中国介入心脏病学杂志,2013,21(5):332-334.
[3]万俊义,陆敏杰,张戈军,等.经皮肺动脉瓣植入术后患者心功能的变化8例分析[J].中国循环杂志,2016,31(7):683-686.
[4]潘文志,张蕾,张晓春,等.经皮自膨胀肺动脉瓣植入的初步经验[J].中国医学前沿杂志:电子版,2016,8(7):65-68.
[5]HUSAIN J,PRAICHASILCHAI P,GILBERT Y,et al.Early European experience with the Venus P-valve:filling the gap in percutaneous pulmonary valve implantation[J].Eurointervention,2016,12(5):e643-e651.
[6]PROMPHAN W,PRACHASILCHAI P,SIRIPORNPITAK S,et al.Percutaneous pulmonary valve implantation with the Venus Pvalve:clinical experience and early results[J].Cardiol Young,2016,26(4):698-710.
[7]CAO Q,KENNY D,ZHOU D,et al.Early clinical experience with a novel self-expanding percutaneous stent-valve in the native right ventricular outflow tract[J].Catheter Cardiovasc Interv,2014,84(7):1131-1137.
[8]周达新,潘文志,葛均波.经皮肺动脉瓣置入术中国专家建议[J].中国医学前沿杂志:电子版,2016,8(10):20-24.
[9]BONHOEFFER P,BOUDJEMLINE Y,SALIBA Z,et al.Percutaneous replacement of pulmonary valve in a right-ventricle to pulmonary-artery prosthetic conduit with valve dysfunction[J].Lancet,2000,356(9239):1403-1405.
[10]MCELHINNEY DB,HELLENBRAND WE,ZAHN EM,et al.Short-and medium-term outcomes after transcatheter pulmonary valve placement in the expanded multicenter US melody valve trial[J].Circulation,2010,122(5):507-516.
[11]MCELHINNEY DB,CHEATHAM JP,JONES TK,et al.Stent fracture,valve dysfunction,and right ventricular outflow tract reintervention after trans-catheter pulmonary valve implantation:patient-related and procedural risk factors in the US Melody Valve Trial[J].Circ Cardiovasc Interv,2011,4(6):602-614.
[12]VEZMAR M,CHATURVEDI R,LEE KJ,et al.Percutaneous pulmonary valve implantation in the young:2-year follow-up[J].JACC Cardiovasc Interv,2010,3(4):439-448.
[13]BORIK S,CREAN A,HORLICK E,et al.Percutaneous pulmonary valve implantation:5 years of follow-up.does age influence outcomes?[J].Circ Cardiovasc Interv,2015,8(2):e001745.
[14]CHEATHAM JP,HELLENBRAND WE,ZAHN EM,et al.Clinical and hemodynamic outcomes up to 7 years after transcatheter pulmonary valve replacement in the US melody valve investigational device exemption trial[J].Circulation,2015,131(22):1960-1970.
[15]NORDMEYER J,KHAMBADKONE S,COATS L,et al.Risk stratification,systematic classification,and anticipatory management strategies for stent fracture after percutaneous pulmonary valve implantation[J].Circulation,2007,115(11):1392-1397.
[16]NORDMEYER J,LURZ P,KHAMBADKONE S,et al.Prestenting with a bare metal stent before percutaneous pulmonary valve implantation:acute and 1-year outcomes[J].Heart,2011,97(2):118-123.
[17]MCELHINNEY DB,BERGERSEN L,MARSHALL AC.In situ fracture of stents implanted for relief of pul-monary arterial stenosis in patients with congeni-tally malformed hearts[J].Cardiol Young,2008,18(4):405-414.
[18]MCELHINNEY DB,BENSON LN,EICKEN A,et al.Infective endocarditis after transcatheter pulmo-nary valve replacement using the Melody valve:combined results of 3prospective North American and European studies[J].Circ Cardiovasc Interv,2013,6(3):292-300.
[19]EICKEN A,EWERT P,HAGER A,et al.Percutaneous pulmonary valve implantation:two-centre expe-rience with more than 100 patients[J].Eur Heart J,2011,32(10):1260-1265.
[20]SECCHI F,RESTA EC,CANNAPM,et al.Four-year cardiac magnetic resonance(CMR)follow-up of patients treated with percutaneous pulmonary valve stent implantation[J].Eur Radiol,2015,25(12):3606-3613.