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经主动脉与经心尖经导管主动脉瓣置换术后的心肌损伤

Myocardial Injury After Transaortic Versus Transapical Transcatheter Aortic Valve Replacement.

作者信息

Ribeiro Henrique B, Dahou Abdellaziz, Urena Marina, Carrasco Jose Luis, Mohammadi Siamak, Doyle Daniel, Le Ven Florent, Allende Ricardo, Amat-Santos Ignacio, Paradis Jean-Michel, DeLarochellière Robert, Puri Rishi, Abdul-Jawad Altisent Omar, del Trigo Maria, Campelo-Parada Francisco, Pibarot Philippe, Dumont Éric, Rodés-Cabau Josep

机构信息

Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada.

Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada.

出版信息

Ann Thorac Surg. 2015 Jun;99(6):2001-9. doi: 10.1016/j.athoracsur.2015.01.029. Epub 2015 Apr 8.

Abstract

BACKGROUND

The release of cardiac biomarkers of myocardial injury after transcatheter aortic valve replacement (TAVR) is common, but no data exist on patients undergoing TAVR through a transaortic approach. We aimed to evaluate the incidence and prognostic significance of the increase in cardiac biomarkers in nontransfemoral TAVR candidates, comparing transaortic and transapical approaches.

METHODS

After excluding patients deemed suitable for transfemoral TAVR, 251 consecutive patients (transaortic, 45; transapical, 206) were prospectively evaluated. Creatine kinase-myocardial band and cardiac troponin T levels were measured at baseline and at 6, 12, 24, 48, and 72 hours after TAVR. Baseline and 6- to 12-month echocardiographic and clinical follow-up were performed.

RESULTS

After TAVR, cardiac troponin T increased above the upper normal values in all patients (peak value 0.64 μg/L [IQR, 0.39 to 1.03 μg/L]), whereas creatine kinase-myocardial band levels increased in 88% of patients (transaortic 51%, transapical 96%, p < 0.001; peak value 20.1 μg/L [interquartile range, 14.3 to 31.6 μg/L]). Compared with the transaortic approach, the transapical approach was associated with a greater rise in both cardiac biomarkers (p < 0.001 for both), and a lesser improvement in left ventricular ejection fraction (p = 0.058) and global longitudinal strain (p = 0.039) at 6- to 12-month follow-up. Greater increases of cardiac troponin T levels were independently associated with 30-day and 1-year overall and cardiovascular mortality (p < 0.001 for all). A 15-fold rise in cardiac troponin T levels was the optimal threshold for determining poorer outcomes (p < 0.001).

CONCLUSIONS

Periprocedural TAVR-related myocardial injury in nontransfemoral candidates was demonstrated in all patients, but the transapical approach was associated with significantly greater myocardial injury compared with the transaortic approach. A higher degree of myocardial injury translated into reduced left ventricular function improvement and lower early and midterm survival rates.

摘要

背景

经导管主动脉瓣置换术(TAVR)后心肌损伤的心脏生物标志物释放很常见,但尚无经主动脉途径行TAVR患者的数据。我们旨在评估非股动脉TAVR候选患者心脏生物标志物升高的发生率及其预后意义,比较经主动脉和经心尖途径。

方法

排除被认为适合经股动脉TAVR的患者后,对251例连续患者(经主动脉途径45例,经心尖途径206例)进行前瞻性评估。在基线以及TAVR后6、12、24、48和72小时测量肌酸激酶-心肌型同工酶和心肌肌钙蛋白T水平。进行基线以及6至12个月的超声心动图和临床随访。

结果

TAVR后,所有患者的心肌肌钙蛋白T均升高至正常上限以上(峰值0.64μg/L[四分位间距,0.39至1.03μg/L]),而88%的患者肌酸激酶-心肌型同工酶水平升高(经主动脉途径51%,经心尖途径96%,p<0.001;峰值20.1μg/L[四分位间距,14.3至31.6μg/L])。与经主动脉途径相比,经心尖途径的两种心脏生物标志物升高幅度更大(两者p均<0.001),在6至12个月随访时左心室射血分数(p=0.058)和整体纵向应变(p=0.039)改善较小。心肌肌钙蛋白T水平升高幅度更大与30天和1年的全因及心血管死亡率独立相关(所有p均<0.001)。心肌肌钙蛋白T水平升高15倍是判定预后较差的最佳阈值(p<0.001)。

结论

所有非股动脉候选患者均出现了与TAVR相关的围手术期心肌损伤,但与经主动脉途径相比,经心尖途径的心肌损伤明显更严重。更高程度的心肌损伤导致左心室功能改善减少以及早期和中期生存率降低。

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