Department of Cardiac Surgery, University Heart Center Dresden, Dresden, Germany.
Department of Cardiac Surgery, University Heart Center Dresden, Dresden, Germany.
J Thorac Cardiovasc Surg. 2014 Jan;147(1):210-9. doi: 10.1016/j.jtcvs.2013.09.021. Epub 2013 Oct 30.
Transcatheter heart valve (THV) procedures are constantly evolving. We report our experience with valve-in-valve, valve-in-ring, and direct-view valve-in-native-ring implantation in the mitral position.
Fourteen patients undergoing THV implantation in the mitral position were included. Clinical and postoperative data, including echocardiography and further follow-up, were analyzed.
Ten valve-in-valve and 2 valve-in-ring procedures were successfully performed using the transapical access route. For the third valve-in-ring procedure we used an antegrade left-atrial access via right anterolateral minithoracotomy. In 1 patient surgical mitral valve replacement was planned. Intraoperatively, the annulus appeared severely calcified and regular implantation of a bioprosthesis was not possible. As a last resort, a 29-mm Sapien XT valve (Edwards Lifesciences Inc, Irvine, Calif) was implanted under direct view. The initial result was satisfactory, but on the first postoperative day relevant paravalvular regurgitation occurred. Subsequently, the valve was fixed to an atrial cuff by 1 running suture. In this series 27-, 29-, and 31-mm bioprostheses and 28- and 30-mm annuloplasty rings were treated with 26- or 29-mm Sapien XT valves. Postoperative echocardiography on day 10 and after 6 weeks revealed good prosthesis function in all cases. In 2 valve-in-valve patients who solely received anticoagulation therapy with acetylsalicylic acid, signs of beginning valve thrombosis occurred after 8 weeks and 3 months, respectively. During further course, valve function was normalized using warfarin therapy.
Our results demonstrate feasibility of valve-in-valve and valve-in-ring THV procedures in the mitral position. Permanent anticoagulation therapy with warfarin seems to be necessary to prevent valve dysfunction. THV implantation in a calcified native mitral ring for bailout seems not to be reproducible and thus cannot be recommended.
经导管心脏瓣膜（THV）技术不断发展。我们报告了在二尖瓣位置行瓣中瓣、瓣中环和直视下瓣中瓣植入术的经验。
共纳入 14 例行二尖瓣 THV 植入术的患者。分析了包括超声心动图和进一步随访在内的临床和术后数据。
10 例瓣中瓣和 2 例瓣中环手术通过经心尖入路成功完成。对于第 3 例瓣中环手术，我们采用经右侧前外侧小开胸的顺行左心房入路。1 例患者计划行外科二尖瓣置换术。术中发现瓣环严重钙化，无法常规植入生物瓣。作为最后手段，直视下植入 1 枚 29mm Sapien XT 瓣膜（爱德华兹生命科学公司，加利福尼亚州欧文市）。初始结果令人满意，但术后第 1 天出现明显瓣周反流。随后，通过 1 条连续缝线将瓣膜固定到心房袖口。在该系列中，27、29 和 31mm 生物瓣和 28 和 30mm 瓣环环采用 26 或 29mm Sapien XT 瓣膜治疗。术后第 10 天和 6 周的超声心动图显示所有病例的假体功能良好。在仅接受乙酰水杨酸抗凝治疗的 2 例瓣中瓣患者中，分别在术后 8 周和 3 个月出现开始的瓣膜血栓形成迹象。在进一步的过程中，使用华法林治疗使瓣膜功能恢复正常。
我们的结果表明，在二尖瓣位置行瓣中瓣和瓣中环 THV 术是可行的。华法林的持续抗凝治疗似乎是预防瓣膜功能障碍所必需的。在钙化的原生二尖瓣环中植入 THV 作为抢救手段似乎不可重复，因此不推荐使用。
