Zierer Andreas, Wimmer-Greinecker Gerhard, Martens Sven, Moritz Anton, Doss Mirko
Division of Cardiothoracic Surgery, Hospital of the Johann Wolfgang Goethe University, Frankfurt, Main, Germany.
J Thorac Cardiovasc Surg. 2008 Oct;136(4):948-53. doi: 10.1016/j.jtcvs.2008.06.028.
Percutaneous aortic valve implantation has been performed clinically in high-risk patients with severe aortic stenosis. Transfemoral retrograde valve delivery is limited by concomitant peripheral vascular disease and the size of the delivery system. We report on the alternative transapical approach that allows accurate antegrade placement of a catheter-deliverable aortic valve.
Over a 2-year period, 26 consecutive patients (84.3 +/- 6.5 years) were treated at our center. Transapical aortic valve implantation was performed with 23-mm and 26-mm pericardial valves (Cribier-Edwards; Edwards Lifesciences, Irvine, Calif) mounted on a stainless steel stent. A limited anterolateral incision, in the fifth intercostal space, was used to access the apex of the heart. The valve was crimped, placed into a 24F sheath, and introduced into the left ventricle through purse-string sutures. Fluoroscopy and transesophageal echocardiography were used to guide the catheter across the native valve and to direct deployment of the stent at the level of the annulus. During deployment, the heart was unloaded with extracorporeal support or with rapid ventricular pacing. The average logistic EuroSCORE-predicted risk for mortality was 36.5% +/- 5.8%.
All valves were successfully deployed at the target. On echocardiography, all valves showed good hemodynamic function with only minor paravalvular leakages. The mean transaortic valve gradient was 6 +/- 2 mm Hg. Thirty-day mortality was 15% (n = 4). One patient died of perforation of the right ventricle and 1 of dissection of the aortic root. There were 2 cases of conversion to open surgery. In 2 patients, the left main stem was partially obstructed by the native valve and required stent angioplasty.
Initial results of the transapical approach are encouraging. Long-term studies and randomized protocols will be required to further evaluate this procedure.
经皮主动脉瓣植入术已在患有严重主动脉瓣狭窄的高危患者中临床应用。经股逆行瓣膜输送受到合并的外周血管疾病和输送系统尺寸的限制。我们报告了一种替代的经心尖方法，该方法允许将导管可输送的主动脉瓣准确地顺行放置。
在两年期间，我们中心连续治疗了26例患者（84.3±6.5岁）。使用安装在不锈钢支架上的23毫米和26毫米心包瓣膜（Cribier-Edwards；爱德华兹生命科学公司，加利福尼亚州尔湾）进行经心尖主动脉瓣植入术。在第五肋间间隙做一个有限的前外侧切口，以进入心尖。将瓣膜压接后，放入24F鞘管中，并通过荷包缝合线引入左心室。使用荧光透视和经食管超声心动图引导导管穿过天然瓣膜，并在瓣环水平引导支架展开。在展开过程中，通过体外支持或快速心室起搏使心脏卸载。逻辑欧洲心脏手术风险评估系统预测的平均死亡风险为36.5%±5.8%。
所有瓣膜均成功放置在目标位置。超声心动图显示，所有瓣膜均具有良好的血流动力学功能，仅有轻微的瓣周漏。平均跨主动脉瓣压差为6±2毫米汞柱。30天死亡率为15%（n = 4）。1例患者死于右心室穿孔，1例死于主动脉根部夹层。有2例转为开胸手术。2例患者的左主干被天然瓣膜部分阻塞，需要进行支架血管成形术。
经心尖方法的初步结果令人鼓舞。需要进行长期研究和随机试验方案以进一步评估该手术。
