Cohen Mauricio G, Singh Vikas, Martinez Claudia A, O'Neill Brian P, Alfonso Carlos E, Martinezclark Pedro O, Heldman Alan W, O'Neill William W
Elaine and Sydney Sussman Cardiac Catheterization Laboratory, Cardiovascular Division, Depeartment of Medicine, University of Miami Hospital, Miller School of Medicine, Miami, Florida.
Catheter Cardiovasc Interv. 2013 Nov 15;82(6):987-93. doi: 10.1002/ccd.25036. Epub 2013 Jul 3.
To assess the feasibility and outcomes in patients undergoing transvenous transseptal (TS) transcatheter aortic valve replacement (TAVR).
TS approach for TAVR was abandoned in favor of retrograde transfemoral, transaortic, or transapical approaches. TS TAVR may still be warranted in patients for whom no other approach is feasible.
Observational consecutive case series at a single center, to evaluate technical outcomes in inoperable patients with aortic stenosis who had contraindications for other approaches and who underwent TAVR via a transvenous TS antegrade approach using the Edwards-Sapien (ES) valve.
Over a 4-month period, 9 patients underwent TS TAVR with 26 mm (n = 4) and 23 mm (n = 5) ES valves. Mean age was 84.5 ± 6.6 years and Society of Thoracic Surgeons predicted risk of mortality was 7.8 ± 2.8%. Specific contraindications for other access included iliofemoral arterial diameter <7 mm in 9 (100%), porcelain aorta in 6 (66%) patients, multiple (≥2) sternotomies in 2 (22%) patients, severe pulmonary disease in 3 (33%), extreme frailty in 1 (11%), spinal stenosis with impaired ability to rehabilitate postsurgery in 1 (11%) and apical left ventricular thrombus in 1 (11%) patient. Antegrade deployment of the ES prosthetic valve was technically feasible in 8 patients. Major bleeding occurred in 4 patients, two patients suffered acute kidney injury without need for dialysis and one patient required a permanent pacemaker. The median (25th, 75th percentiles) fluoroscopy time was 49 (34, 81) minutes and contrast volume was 150 (120, 225) ml. No patient had hemodynamically significant post-TAVR aortic insufficiency nor damage to the mitral valve. At 6 months follow-up, there were no cerebrovascular events or rehospitalizations and mean NYHA Class improved from 3.4 to 1.7.
The antegrade TS approach to TAVR is a technically feasible option for "no-access" patients. Prospective assessment of the safety and efficacy of this approach in the current era warrants further study.
评估经静脉房间隔穿刺（TS）行经导管主动脉瓣置换术（TAVR）患者的可行性及预后。
TAVR的TS入路已被放弃，转而采用逆行股动脉、经主动脉或经心尖入路。对于没有其他可行入路的患者，TS TAVR可能仍然是必要的。
在单一中心进行的观察性连续病例系列研究，以评估主动脉瓣狭窄且因其他入路存在禁忌证而无法手术的患者，通过经静脉TS顺行入路使用爱德华兹-赛沛（ES）瓣膜进行TAVR的技术预后。
在4个月期间，9例患者接受了TS TAVR，使用了26mm（n = 4）和23mm（n = 5）的ES瓣膜。平均年龄为84.5±6.6岁，胸外科医师协会预测的死亡风险为7.8±2.8%。其他入路的特定禁忌证包括：9例（100%）患者的髂股动脉直径<7mm，6例（66%）患者的瓷化主动脉，2例（22%）患者有多次（≥2次）胸骨切开术，3例（33%）患者有严重肺部疾病，1例（11%）患者极度虚弱，1例（11%）患者有脊柱狭窄且术后康复能力受损，1例（11%）患者有心尖部左心室血栓。ES人工瓣膜的顺行置入在8例患者中技术上可行。4例患者发生大出血，2例患者发生急性肾损伤但无需透析，1例患者需要永久起搏器。透视时间的中位数（第25、75百分位数）为49（34，81）分钟，造影剂用量为150（120，225）ml。没有患者在TAVR后出现血流动力学显著的主动脉瓣关闭不全，也没有二尖瓣受损。在6个月的随访中，没有发生脑血管事件或再次住院，纽约心脏协会（NYHA）心功能分级平均从3.4级改善到1.7级。
对于“无法进行其他入路”的患者，TAVR的顺行TS入路在技术上是可行的选择。在当前时代对该入路的安全性和有效性进行前瞻性评估值得进一步研究。
