Department of Cardiac Surgery, University Heart Center Dresden, Dresden, Germany.
Ann Thorac Surg. 2013 Jan;95(1):111-7. doi: 10.1016/j.athoracsur.2012.08.004. Epub 2012 Oct 11.
The transcatheter valve-in-valve concept has been described for patients requiring redo valve surgery. We report our experience with transapical mitral valve-in-valve implantation.
Since 2008, 301 patients were treated with transapical transcatheter valve implantation. Seven of these patients presented with a deteriorated mitral valve bioprosthesis and underwent transapical mitral valve-in-valve implantation. Median age was 79 years. Preoperatively, all patients presented in New York Heart Association functional class III. For risk estimation, The Society of Thoracic Surgeons and European System for Cardiac Operative Risk scores were used and predicted high mortality (mean ± standard error of mean: Society of Thoracic Surgeons mortality, 12.3% ± 2.1%; European System for Cardiac Operative Risk mortality, 58.0% ± 7.0%). Mean follow-up time was 93 ± 29 days, with a total of 21.6 patient-months.
Preoperatively, all patients who had deteriorated bioprostheses presented with severe regurgitation and increased transvalvular pressure gradients (maximal pressure gradient, 23.9 ± 0.9 mm Hg; mean pressure gradient, 11.3 ± 1.0 mm Hg). One patient was identified with mitral valve stenosis (effective orifice area, 0.25 cm(2)). All patients underwent successful transapical mitral valve-in-valve implantation. Sizes of previously implanted bioprostheses were 27, 29, and 31 mm; Edwards SAPIEN valves at sizes 26 and 29 mm were implanted. Postoperatively, echocardiography revealed excellent hemodynamics with no remaining mitral regurgitation in 5 patients and minimal regurgitation in 2 patients. Transvalvular pressure gradients decreased significantly (maximal pressure gradient, 13.8 ± 2.1 mm Hg; mean pressure gradient 5.7 ± 0.8 mm Hg, p < 0.05). One patient had fatal pneumonia on postoperative day 34. No patient died during further follow-up, and all patients remained in New York Heart Association class I or II.
Our results demonstrate the feasibility of transapical mitral valve-in-valve implantation for treatment of a degenerated bioprosthesis (size range, 27 to 31 mm) using the Edwards SAPIEN valve in sizes 26 and 29 mm.
经导管瓣中瓣技术已被用于需要再次瓣膜手术的患者。我们报告经心尖二尖瓣瓣中瓣植入术的经验。
自 2008 年以来，301 例患者接受了经心尖经导管瓣膜植入术。其中 7 例患者因二尖瓣生物瓣退化而接受了经心尖二尖瓣瓣中瓣植入术。中位年龄为 79 岁。术前所有患者均为纽约心脏协会功能 III 级。为了风险评估，使用了胸外科医生协会和欧洲心脏手术风险系统评分，并预测死亡率较高（胸外科医生协会死亡率平均值±标准误差：12.3%±2.1%；欧洲心脏手术风险死亡率平均值±标准误差：58.0%±7.0%）。中位随访时间为 93±29 天，共 21.6 个患者月。
术前，所有生物瓣退化的患者均有严重反流和跨瓣压差增加（最大压差，23.9±0.9mmHg；平均压差，11.3±1.0mmHg）。1 例患者诊断为二尖瓣狭窄（有效瓣口面积，0.25cm²）。所有患者均成功接受了经心尖二尖瓣瓣中瓣植入术。先前植入的生物瓣大小为 27、29 和 31mm；植入 Edwards SAPIEN 瓣大小为 26 和 29mm。术后超声心动图显示，5 例患者血流动力学良好，无残余二尖瓣反流，2 例患者有轻微反流。跨瓣压差显著下降（最大压差，13.8±2.1mmHg；平均压差，5.7±0.8mmHg，p<0.05）。1 例患者术后第 34 天死于致命性肺炎。在进一步随访中无患者死亡，所有患者均保持在纽约心脏协会 I 级或 II 级。
我们的结果表明，对于退行性生物瓣（尺寸范围 27 至 31mm），使用 Edwards SAPIEN 瓣（尺寸 26 和 29mm），经心尖二尖瓣瓣中瓣植入术是可行的。
