主动脉瓣环的构象性脉动变化：经导管主动脉瓣置换术的 CT 对人工瓣膜尺寸测量的影响。
Conformational pulsatile changes of the aortic annulus: impact on prosthesis sizing by computed tomography for transcatheter aortic valve replacement.
机构信息
Heart and Vascular Center, Medical University of South Carolina, Charleston, South Carolina 29401, USA.
出版信息
JACC Cardiovasc Interv. 2012 Sep;5(9):984-94. doi: 10.1016/j.jcin.2012.05.014.
OBJECTIVES
This study sought to investigate pulsatile changes of the aortic annulus and their impact on prosthesis selection by computed tomography (CT).
BACKGROUND
Precise noninvasive prosthesis sizing is a prerequisite for transcatheter aortic valve replacement.
METHODS
A total of 110 patients with severe aortic stenosis (mean age: 82.9 ± 8 years, mean aortic valve area: 0.69 ± 0.18 cm(2)) underwent electrocardiogram-gated CT. Aortic annulus dimensions were planimetrically quantified as area-derived diameter (D(A) = 2 ×✓(CSA/π), where CSA is the cross-sectional area) and perimeter-derived diameter (D(P) = P/π, where P is the length of the perimeter) in 5% increments of the RR interval. Hypothetical prosthesis sizing was based on D(A) and D(P) (23-mm prosthesis for <22 mm; 26 mm: 22 to 25 mm; 29 mm: >25 mm) and compared between maximum and traditional cardiac CT reconstruction phases at 35% and 75% of RR. Agreement for prosthesis selection was calculated by κ statistics.
RESULTS
D(A) and D(P) were increased and eccentricity was reduced during systole, with D(A-MAX) and D(P-MAX) most often observed at 20% of RR. D(P) was consistently larger than D(A). Average net differences were 2.0 ± 0.6 mm and 1.7 ± 0.5 mm by D(A-MIN) versus D(A-MAX) and D(P-MIN) versus D(P-MAX). Agreement for prosthesis sizing was found in 93 of 110 patients (κ = 0.75) by D(A-75%) and in 80 of 110 patients (κ = 0.53) by D(A-MAX) compared with D(A-35%); and in 94 of 110 patients (κ = 0.73) by D(P-75%) and in 93 of 110 patients (κ = 0.73) by D(P-MAX) compared with D(P-35%). With sizing by D(A-75%) or D(P-75%), nominal prosthesis diameter was smaller than D(A-MAX) or D(P-MAX) in 15 and 6 patients respectively.
CONCLUSIONS
Aortic annulus morphology exhibits conformational pulsatile changes throughout the cardiac cycle due to deformation and stretch. These changes affect prosthesis selection. Prosthesis selection by diastolic perimeter- or area-derived dimensions harbors the risk of undersizing.
目的
本研究旨在通过计算机断层扫描（CT）探讨主动脉瓣环的搏动变化及其对假体选择的影响。
背景
精确的无创假体尺寸是经导管主动脉瓣置换术的前提。
方法
共对 110 例严重主动脉瓣狭窄患者（平均年龄：82.9±8 岁，平均主动脉瓣口面积：0.69±0.18cm²）进行了心电图门控 CT 检查。主动脉瓣环尺寸通过面积衍生直径（D(A) = 2 ×✓(CSA/π)，其中 CSA 为横截面积）和周长衍生直径（D(P) = P/π，其中 P 为周长）以 RR 间隔的 5%递增进行平面量化。基于 D(A)和 D(P)（<22mm 用 23mm 假体；22 至 25mm 用 26mm；>25mm 用 29mm）进行假设假体尺寸选择，并在 35%和 75%RR 时比较最大和传统心脏 CT 重建相位之间的差异。通过 κ 统计计算假体选择的一致性。
结果
在收缩期，D(A)和 D(P)增加，偏心度降低，D(A-MAX)和 D(P-MAX)最常在 RR 的 20%时观察到。D(P)始终大于 D(A)。通过 D(A-MIN)与 D(A-MAX)和 D(P-MIN)与 D(P-MAX)相比，平均净差异分别为 2.0±0.6mm 和 1.7±0.5mm。通过 D(A-75%)和 D(A-MAX)，在 110 例患者中有 93 例（κ=0.75）和 80 例患者（κ=0.53）符合假体尺寸选择的一致性；通过 D(P-75%)和 D(P-MAX)，在 110 例患者中有 94 例（κ=0.73）和 93 例患者（κ=0.73）符合一致性。使用 D(A-75%)或 D(P-75%)进行尺寸选择时，15 例和 6 例患者的名义假体直径小于 D(A-MAX)或 D(P-MAX)。
结论
由于变形和拉伸，主动脉瓣环形态在整个心动周期中表现出搏动性变化。这些变化会影响假体的选择。基于舒张周长或面积衍生尺寸的假体选择有尺寸过小的风险。
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