Experience of transcatheter aortic valve replacement for severe aortic stenosis in single center
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摘要: 目的 探讨重度主动脉瓣狭窄(AS)患者经导管主动脉瓣置换术(TAVR)的安全性及有效性。方法 回顾性连续收集2017年12月—2023年12月中山市人民医院进行TAVR的89例重度AS患者基线特征、影像学评估、围手术期及术后随访的结果，并进行经验性总结。结果 平均年龄74.0(69.5，80.0)岁，美国胸外科协会(STS)评分4.45%(3.19%，6.49%)；二叶式主动脉瓣为46例(51.69%)。所有患者接受全身麻醉，以股动脉作为血管入路，自膨式瓣膜与球扩式瓣膜分别为82例(92.13%)、7例(7.87%)。技术成功率为97.75%，器械成功率为94.38%。术后纽约心脏病协会(NYHA)心功能分级Ⅲ及Ⅳ级者比例下降(68.54% vs 3.37%，P < 0.001)，N末端脑钠肽前体明显下降，左心室舒张末期内径改善，主动脉瓣峰值跨瓣压差下降，主动脉瓣峰值跨瓣流速下降。围手术期并发症以瓣周漏最为常见为48例(53.93%)，轻、中、重度瓣周漏所占比例分别为34.83%、15.73%、3.37%。新发房室传导阻滞13例(14.44%)，新发完全性左束支传导阻滞19例(21.35%)，需植入永久起搏器者8例(8.99%)；发生心包填塞者6例(6.74%)；手术入路主要血管并发症3例(3.37%)；造影剂诱发急性肾损伤9例(10.11%)；急性缺血性脑卒中1例(1.12%)。术后平均随访时间为(23.55±18.08)个月，全因死亡为10例(11.24%)。其余患者生活质量均得到明显改善。结论 TAVR改善重度AS患者的生存率及生活质量，具有良好的安全性及有效性。
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关键词:
- 主动脉瓣狭窄 /
- 经导管主动脉瓣置换术 /
- 并发症
Abstract: Objective To investigate the safety and efficacy of transcatheter aortic valve replacement(TAVR) in patients with severe aortic stenosis(AS).Methods The baseline characteristics, imaging evaluation, perioperative and postoperative follow-up results of 89 patients with severe AS who underwent TAVR in Zhongshan People's Hospital from December 2017 to December 2023 were retrospectively collected, and summarized.Results The mean age was 74.0(69.5, 80.0) years, and the American Society for Thoracic Surgery(STS) score was 4.45%(3.19%, 6.49%). Bicuspid aortic valve disease was found in 46 cases(51.69%). All patients received general anesthesia and femoral artery was used as the vascular approach. The 82 patients(92.13%) had self-dilatation valve and 7 patients(7.87%) had spherical dilatation valve. The technical success rate was 97.75%, and the instrument success rate was 94.38%. The proportion of patients with New York Heart Association(NYHA) grade Ⅲ and Ⅳ decreased after surgery(68.54% vs 3.37%, P < 0.001), the N-terminal brain natriuretic peptide prebody decreased significantly, the left ventricular end-diastolic diameter improved, the peak trans-valve pressure decreased, and the peak trans-valve flow rate decreased. Perivalvular leakage was the most common complication in 48 cases(53.93%), and the proportion of mild, moderate and severe perivalvular leakage were 34.83%, 15.73% and 3.37%, respectively. There were 13 cases(14.44%) of new atrioventricular block, 19 cases(21.35%) of new complete left bundle branch block, and 8 cases(8.99%) of patients needed permanent pacemaker implantation. Pericardial tamponade occurred in 6 cases(6.74%). There were 3 cases(3.37%) of major vascular complications of surgical approach. Contrast media-induced acute kidney injury was in 9 cases(10.11%); Acute ischemic stroke occurred in 1 case(1.12%). The mean follow-up time was(23.55±18.08) months, and 10 cases(11.24%) died of all causes. The quality of life of other patients was significantly improved.Conclusion TAVR is safe and effective in improving the survival rate and quality of life in patients with severe aortic stenosis.-
Key words:
- aortic stenosis /
- transcatheter aortic valve replacement /
- complications
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表 1 TAVR患者临床基线资料
Table 1. General data
例(%), X±S, M(P25, P75) 项目 数据 男性 54(60.67) 年龄/岁 74.0(69.5，80.0) BMI/(kg/m2) 23.15±3.64 NYHA心功能分级Ⅲ及Ⅳ 61(68.54) 吸烟 32(35.96) 高血压 60(67.42) 冠心病 55(61.80) 糖尿病 18(20.22) 慢性肾功能不全 17(19.10) 肺部疾病 5(5.62) 短暂脑缺血或卒中 4(4.49) 外周动脉疾病 24(26.97) 既往心房颤动 12(13.48) 既往完全性LBBB 5(5.62) 既往完全性右束支传导阻滞 17(19.10) STS评分 低危(< 4%) 34(38.20) 中危(4%~8%) 39(43.82) 高危(>8%) 16(17.98) 
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表 2 TAVR患者影像学资料
Table 2. Imaging data of TAVR patients
例(%), X±S 项目 数据 瓣叶类型 二叶式主动脉瓣 46(51.69) 三叶式主动脉瓣 40(44.94) 外科生物瓣衰败 3(3.37) 主动脉瓣环平均直径/mm 23.94±3.02 主动脉瓣环周长/mm 75.85±9.27 主动脉瓣环面积/mm2 448.01±109.90 STJ高度/mm 22.29±4.37 STJ平均直径/mm 31.17±5.00 心脏角度/° 50.83±10.04 主动脉瓣钙化积分 轻度钙化(< 400 mm3) 43(48.32) 中度钙化(400~600 mm3) 17(19.10) 重度钙化(>600 mm3) 29(32.58) STJ：窦管结合部。
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表 3 TAVR患者围术期数据及术后并发症
Table 3. Perioperative data and postoperative complications
例(%), X±S, M(P25, P75) 项目 数值 入路途径：股动脉 89(100.00) 全身麻醉 89(100.00) 一站式PCI+TAVR 8(8.99) 冠脉保护策略 5(5.62) 主动脉瓣支架类型 球扩式 7(7.87) 自膨式 82(92.13) 人工瓣膜后扩张 37(41.57) 瓣膜移位 3(3.37) 瓣中瓣策略 2(2.25) 心包填塞 6(6.74) 新发完全性LBBB 19(21.35) 新发AVB 13(14.44) 置入PPM 8(8.99) 术后新发心房颤动 9(10.11) 急性缺血性脑卒中 1(1.12) 手术入路及主要血管并发症 3(3.37) CIAKI 9(10.11) 瓣周漏 48(53.93) 轻度 31(34.83) 中度 14(15.73) 重度 3(3.37) 技术成功率 87(97.75) 器械成功率 84(94.38) 平均住院天数/d 22.24±11.05 手术时间/h 2.08±0.79 术后监护室住院时间/h 52.00(46.00，107.25)
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表 4 TAVR患者手术前后指标变化
Table 4. Changes of indexes before and after operation
例(%), X±S, M(P25, P75) 指标 术前 术后 P NYHAⅢ及Ⅳ级 61(68.54) 3(3.37) < 0.001 NT-proBNP/(ng/L) 2 941.0(949.5，10 086.0) 1 726.0(741.0，3 138.8) < 0.001 左房内径/mm 39.90±6.23 39.10±7.13 0.465 LVEDD/mm 49.98±10.43 47.53±9.31 < 0.001 左室射血分数/% 58.43±13.75 59.03±11.98 0.662 峰值跨瓣压差/mmHg 86.88±33.69 20.82±11.65 < 0.001 峰值跨瓣流速/(m/s) 4.55±0.93 2.19±0.63 < 0.001
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