Wendt Daniel, Eggebrecht Holger, Kahlert Philipp, Heine Torsten, Kottenberg Eva, Massoudy Parwis, Kamler Markus, Peters Jürgen, Erbel Raimund, Jakob Heinz, Thielmann Matthias
Klinik für Thorax- und Kardiovaskuläre Chirurgie, Westdeutsches Herzzentrum Essen, Universitätsklinikum der Universität Duisburg-Essen, Essen, Germany.
Herz. 2009 Aug;34(5):388-97. doi: 10.1007/s00059-009-3265-y.
Transapical transcatheter aortic valve implantation has emerged as an alternative to conventional aortic valve replacement in high-risk patients with degenerative aortic valve stenosis. The aim of this study was to assess a potential learning curve with the former technique based on the own experience with this novel procedure.
40 consecutive high-risk patients (82 +/- 5 years, logistic EuroSCORE 42% +/- 16%) with symptomatic aortic valve stenosis underwent transapical aortic valve implantation (balloon expandable Sapien bioprosthesis, Edwards Lifesciences, Irvine, CA, USA) in the hybrid operating room between October 2007 and May 2009 at the West German Heart Center Essen. To assess a potential learning curve, patients were allocated and compared according to the implantation date (initial n = 20: 10/2007 to 10/2008; second n = 20: 11/2008 to 05/2009).
All but one transapical aortic valve implantations were successful (procedural success rate 97.5%) and no prosthesis migration/embolization or coronary artery obstruction was observed. Comparing the groups, procedural time, fluoroscopy time, and contrast media volume decreased significantly (139 +/- 30 min vs. 112 +/- 41 min; 6.8 +/- 1.9 min vs. 5.5 +/- 1.5 min; 226 +/- 75 ml vs. 169 +/- 23 ml; p <or= 0,05). Predicted 30-day mortality for patients operated upon within the 1st period was 51% +/- 14% (logistic EuroSCORE) and 20% +/- 11% (STS Score [Society of Thoracic Surgeons]) compared to 32% +/- 12% and 13% +/- 7% in the 2nd period, while observed 30-day mortality decreased from 25% to 10%.
This study reflects the authors' experience with transapical aortic valve implantation in patients presenting with a high surgical risk for conventional aortic valve replacement. Within this patient cohort improved clinical outcome, and lower morbidity and mortality demonstrate a learning curve. Improved results were achieved by (1) patient selection with regard to specific procedure-related risk factors, (2) careful preoperative patient preparation, (3) an optimum interventional and surgical approach, and (4) continuous application of this new procedure.
经心尖经导管主动脉瓣植入术已成为传统主动脉瓣置换术之外，用于治疗高危退行性主动脉瓣狭窄患者的一种替代方法。本研究旨在基于这项新手术的自身经验，评估该技术潜在的学习曲线。
2007年10月至2009年5月期间，在德国埃森市西德心脏中心的杂交手术室，对40例连续的有症状主动脉瓣狭窄高危患者（82±5岁，逻辑欧洲心脏手术风险评估系统评分为42%±16%）进行了经心尖主动脉瓣植入术（使用球囊扩张型Sapien生物人工瓣膜，美国加利福尼亚州尔湾市爱德华兹生命科学公司生产）。为评估潜在的学习曲线，根据植入日期对患者进行分组并比较（第一组n = 20：2007年10月至2008年10月；第二组n = 20：2008年11月至2009年5月）。
除1例经心尖主动脉瓣植入术外均成功（手术成功率97.5%），未观察到人工瓣膜移位/栓塞或冠状动脉阻塞情况。比较两组，手术时间、透视时间和造影剂用量均显著减少（139±30分钟对112±41分钟；6.8±1.9分钟对5.5±1.5分钟；226±75毫升对169±23毫升；p≤0.05）。第一阶段接受手术患者的预测30天死亡率为51%±14%（逻辑欧洲心脏手术风险评估系统）和20%±11%（胸外科医师学会评分），而第二阶段分别为32%±12%和13%±7%，同时观察到的30天死亡率从25%降至10%。
本研究反映了作者在为传统主动脉瓣置换术手术风险高的患者进行经心尖主动脉瓣植入术方面的经验。在这一患者队列中，临床结局改善，发病率和死亡率降低，显示出存在学习曲线。通过（1）针对特定手术相关风险因素进行患者选择，（2）仔细的术前患者准备，（3）最佳的介入和手术方法，以及（4）持续应用这一新手术，取得了更好的结果。
