A single-center study of risk prevention of coronary artery occlusion after transcatheter aortic valve replacement
-
摘要: 目的 探讨经导管主动脉瓣置换术(transcatheter aortic valve replacement，TAVR)冠状动脉(冠脉)阻塞风险的有效预防策略。方法 收集2016年1月—2024年1月于河北医科大学第二医院行TAVR患者的围手术期资料，回顾性分析TAVR术后患者冠脉阻塞事件的发生情况。结果 共行TAVR 385例，其中经外周入路321例，经心尖入路64例；冠脉高风险72例，术中行冠脉保护26例(“烟囱”支架2例、冠脉开口支架开窗20例、冠脉保护性导丝或支架预置入4例)，应用冠脉风险较低的J-Valve瓣膜17例，其余病例经进一步风险评估初步排除冠脉风险，未予冠脉保护或行相应处理；术后冠脉阻塞发生1例(0.3%)。结论 冠脉阻塞是经导管主动脉瓣置换术后极为严重的并发症，虽整体发生水平不高，但致死性极强。对于冠脉高风险TAVR病例，预防重于补救，术前详尽研判、术中充分保护意义重大。围手术期内方法合理、策略得当可有效降低TAVR相关冠脉阻塞事件的发生，提高整体手术的成功率。
-
关键词:
- 冠状动脉阻塞 /
- 经导管主动脉瓣置换术 /
- 预防
Abstract: Objective To explore the effective prevention strategy of transcatheter aortic valve replacement(TAVR) and summarize the relevant experience.Methods The perioperative data of TAVR patients in the Second Hospital of Hebei Medical University from 2016 to 2024 were collected, and the occurrence of coronary artery occlusion events in patients after TAVR was retrospectively analyzed.Results A total of 385 cases of TAVR were treated, including 321 cases via peripheral approach and 64 cases via apical approach. There were 72 high-risk cases with coronary artery, 26 cases received coronary artery protection during the operation(2 cases with "chimney" stent, 20 cases with coronary opening stent window opening, and 4 cases with coronary protective guide wire or stent prepositioning), 17 cases received J-Valve valve with low coronary risk, and the remaining cases were preliminatively excluded by further risk assessment without coronary artery protection or corresponding treatment. Postoperative coronary artery obstruction occurred in 1 case, and the incidence of coronary artery obstruction was 0.3%.Conclusion Coronary artery occlusion is a very serious complication after transcatheter aortic valve replacement. Although the overall incidence is not high, it is extremely fatal. For high-risk coronary TAVR cases, prevention is more important than remedy, and detailed preoperative investigation and adequate protection during operation are of great significance. In the perioperative period, reasonable methods and proper strategies can effectively reduce the occurrence of TAVR-related coronary artery obstruction events and improve the overall success rate of surgery. -
-
表 1 基线情况
Table 1. General data
例(%), X±S 临床资料 数据 性别 男 255(66.2) 女 130(33.8) 年龄/岁 66.9±3.8 主动脉瓣病变 单纯主动脉瓣狭窄 119(30.9) 单纯主动脉瓣关闭不全 72(18.7) 主动脉瓣狭窄伴关闭不全 194(50.4) 主动脉瓣形态 二叶式主动脉瓣 155(40.3) 三叶式主动脉瓣 230(59.7) 冠脉高风险 72(18.7) 术前NYHA心功能分级 Ⅲ级 62(16.1) Ⅳ级 323(83.9) 
下载: 导出CSV
表 2 术中及术后情况
Table 2. Intraoperative and postoperative conditions
例(%) 临床资料 数据 手术入路 经心尖 64(16.6) 经外周 321(83.4) 冠脉风险干预 43(11.2) 冠脉保护 26(6.8) “烟囱”支架 2(0.5) 冠脉开口支架开窗 20(5.3) 冠脉保护性导丝或支架预置入 4(1.0) 应用J-Valve瓣膜 17(4.4) 术后冠脉阻塞 1(0.3)
下载: 导出CSV
表 3 干预有效性
Table 3. Effectiveness of intervention
例(%) 项目 干预有效性 冠脉保护 26(100.0) “烟囱”支架 2(100.0) 冠脉开口支架开窗 20(100.0) 冠脉保护性导丝或支架预置入 4(100.0) 应用J-Valve瓣膜 16(94.1)
下载: 导出CSV
-
[1] Vahanian A, Beyersdorf F, Praz F, et al. ESC/EACTS Scientific Document Group. 2021 ESC/EACTS Guidelines for the management of valvular heart disease[J]. Eur Heart J, 2022, 43(7): 561-632. doi: 10.1093/eurheartj/ehab395
[2] 卢麒麟, 卫志轩, 冯策, 等. 主动脉瓣狭窄合并冠心病患者行单纯介入治疗与单纯外科治疗的疗效对比分析[J]. 临床心血管病杂志, 2023, 39(6): 428-431. doi: 10.13201/j.issn.1001-1439.2023.06.005
[3] Bowdish ME, D'Agostino RS, Thourani VH, et al. STS adult cardiac surgery database: 2021 update on outcomes, quality, and research[J]. Ann Thorac Surg, 2021, 111(6): 1770-1780. doi: 10.1016/j.athoracsur.2021.03.043
[4] Ribeiro HB, Webb JG, Makkar RR, et al. Predictive factors, management, and clinical outcomes of coronary obstruction following transcatheter aortic valve implantation: insights from a large multicenter registry[J]. J Am Coll Cardiol, 2013, 62(17): 1552-1562. doi: 10.1016/j.jacc.2013.07.040
[5] 张航, 安景辉, 石凤梧. "烟囱"支架技术在经导管主动脉瓣置换术中的应用[J]. 中国循证心血管医学杂志, 2023, 15(1): 127-128. https://www.cnki.com.cn/Article/CJFDTOTAL-PZXX202301024.htm
[6] 张航, 安景辉, 刘苏, 等. 冠脉高风险患者TAVR术中预植保护性导丝2例并文献复习[J]. 精准医学杂志, 2024, 39(1): 59-62. https://www.cnki.com.cn/Article/CJFDTOTAL-SPAN202401015.htm
[7] Khan JM, Babaliaros VC, Greenbaum AB, et al. Preventing coronary obstruction during transcatheter aortic valve replacement: results from the multicenter international BASILICA Registry[J]. JACC Cardiovasc Interv, 2021, 14(9): 941-948. doi: 10.1016/j.jcin.2021.02.035
[8] 牛冠男, 王墨扬, 赵庆豪, 等. 冠状动脉低开口患者行经导管主动脉瓣置换术的结果分析[J]. 中国循环杂志, 2022, 37(4): 356-361. https://www.cnki.com.cn/Article/CJFDTOTAL-ZGXH202204007.htm
[9] 中国医师协会心血管内科医师分会结构性心脏病专业委员会. 经导管主动脉瓣置换术中国专家共识(2020更新版)[J]. 中国介入心脏病学杂志, 2020, 28(6): 301-309. https://www.cnki.com.cn/Article/CJFDTOTAL-HXYX202109004.htm
[10] Blanke P, Weir-mccall JR, Achenbach S, et al. Computed tomography imaging in the context of transcatheter aortic valve implantation(TAVI)/transcatheter aortic valve replacement(TAVR): an expert consensus document of the society of cardiovascular computed tomography[J]. JACC Cardiovasc Imaging, 2019, 12(1): 1-24. doi: 10.1016/j.jcmg.2018.12.003
[11] Arai T, Lefèvre T, Hovasse T, et al. Incidence and predictors of coronary obstruction following transcatheter aortic valve implantation in the real world[J]. Catheter Cardiovasc Interv, 2017, 90(7): 1192-1197. doi: 10.1002/ccd.26982
[12] Yamamoto M, Shimura T, Kano S, et al. Impact of preparatory coronary protection in patients at high anatomical risk of acute coronary obstruction during transcatheter aortic valve implantation[J]. Int J Cardiol, 2016, 217: 58-63. doi: 10.1016/j.ijcard.2016.04.185
[13] 祝磊, 欧袁伟翔, 李茜, 等. 经导管主动脉瓣置换术并发冠状动脉阻塞的研究进展[J]. 华西医学, 2020, 35(9): 1039-1043. https://www.cnki.com.cn/Article/CJFDTOTAL-HXYX202009005.htm
[14] 石峻, 赵元, 郭应强, 等. 心尖入路经导管主动脉瓣植入手术操作规范[J]. 中国胸心血管外科临床杂志, 2023, 30(4): 491-500. https://www.cnki.com.cn/Article/CJFDTOTAL-ZXYX202304001.htm
[15] 印敏燕, 陆云涛, 魏来, 等. 经导管主动脉瓣置换术后冠状动脉阻塞的风险因素及预防研究进展[J]. 中国临床医学, 2024, 31(1): 154-160. https://www.cnki.com.cn/Article/CJFDTOTAL-LCYX202401024.htm
[16] 杜招娜, 芦秀燕, 邵一兵, 等. 经导管主动脉瓣植入术相关冠状动脉阻塞的研究进展[J]. 中国胸心血管外科临床杂志, 2023, 30(8): 1188-1192. https://www.cnki.com.cn/Article/CJFDTOTAL-ZXYX202308018.htm
-