Fusari Melissa, Alamanni Francesco, Bona Veronica, Muratori Manuela, Salvi Luca, Parolari Alessandro, Biglioli Paolo
Department of Cardiovascular Surgery, Centro Cardiologico Monzino IRCCS, Milan, Italy.
J Cardiovasc Med (Hagerstown). 2009 May;10(5):383-93. doi: 10.2459/jcm.0b013e328329acf2.
Aortic stenosis is the most common valvular heart disease in the Western world and the proportion of patients unsuitable for conventional surgery is increasing as a result of aging and comorbidities. We report our early experience with transcatheter aortic valve implantation in high-risk patients with severe symptomatic aortic stenosis.
Transcatheter Edwards-SAPIEN valve implantation was attempted in 22 patients (80 +/- 5 years) in whom surgical risk was deemed excessive because of older age, poor left ventricular function, comorbidities, or all. A retrograde transarterial approach was used in 15 cases. In seven cases, valve implantation was performed by transapical approach because of aortic or iliac artery tortuosity, or both, and stenosis. All procedures were performed without cardiopulmonary bypass. Rapid ventricular pacing was used to reduce cardiac output while delivering balloon-expandable prosthesis.
One patient died because of aortic dissection during early catheterization maneuvers. In the remaining patients, procedural success was achieved in all cases. Successful valve replacement was associated with an increase in transthoracic echocardiographic valve area from 0.65 +/- 0.14 to 2.2 +/- 0.4 cm2 and significant improvement in clinical condition. During the course of this experience, we encountered three (13.6%) cases of vascular complications related to transcatheter aortic valve implantation procedures.
The present study confirms the excellent hemodynamic performances of the transcatheter-implanted aortic prosthesis, with both transarterial and transapical approaches, in inoperable candidates with end-stage aortic stenosis. With progressive improvement in patient selection, techniques, equipment, and operator endovascular skills, vascular complications can decline further.
在西方世界，主动脉瓣狭窄是最常见的心脏瓣膜疾病，由于老龄化和合并症，不适合传统手术的患者比例正在增加。我们报告了我们在有严重症状的高危主动脉瓣狭窄患者中进行经导管主动脉瓣植入术的早期经验。
对22例患者（80±5岁）尝试进行经导管Edwards-SAPIEN瓣膜植入术，这些患者因年龄较大、左心室功能差、合并症或以上所有因素而被认为手术风险过高。15例采用逆行经动脉途径。7例因主动脉或髂动脉迂曲或两者兼有及狭窄，采用经心尖途径进行瓣膜植入。所有手术均在无体外循环的情况下进行。在输送球囊扩张式假体时，采用快速心室起搏以降低心输出量。
1例患者在早期导管操作过程中因主动脉夹层死亡。其余患者均手术成功。成功的瓣膜置换与经胸超声心动图测得的瓣膜面积从0.65±0.14 cm²增加到2.2±0.4 cm²以及临床状况的显著改善相关。在这一过程中，我们遇到了3例（13.6%）与经导管主动脉瓣植入手术相关的血管并发症。
本研究证实了经导管植入的主动脉假体在经动脉和经心尖途径下，对于终末期主动脉狭窄的不可手术患者具有出色的血流动力学性能。随着患者选择、技术、设备和术者血管内操作技能的不断进步，血管并发症可能会进一步减少。
