Yanagisawa Ryo, Hayashida Kentaro, Yamada Yoshitake, Tanaka Makoto, Yashima Fumiaki, Inohara Taku, Arai Takahide, Kawakami Takashi, Maekawa Yuichiro, Tsuruta Hikaru, Itabashi Yuji, Murata Mitsushige, Sano Motoaki, Okamoto Kazuma, Yoshitake Akihiro, Shimizu Hideyuki, Jinzaki Masahiro, Fukuda Keiichi
Department of Cardiology, Keio University School of Medicine, Tokyo, Japan.
Department of Cardiology, Keio University School of Medicine, Tokyo, Japan.
JACC Cardiovasc Imaging. 2016 Dec 8. doi: 10.1016/j.jcmg.2016.11.005.
This study sought to clarify the incidence and predictors of hypoattenuated leaflet thickening (HALT) and mid-term outcomes after transcatheter aortic valve replacement.
HALT detected on multidetector computed tomography (MDCT) scanning raised concerns about possible subclinical leaflet thrombosis.
We studied 70 of 100 consecutive patients from a single-center registry who underwent implantation with the Edwards SAPIEN-XT device. MDCT results, echocardiographic data, and laboratory findings obtained at the 6-month and 1-year follow-ups were analyzed.
Of 70 patients, MDCT scans revealed HALT in 1 patient (1.4%) at discharge, 7 (10.0%) at 6 months, and 10 (14.3%) at 1 year post-transcatheter aortic valve replacement cumulatively. The degree of leaflet immobility correlated with the HALT area on 4-dimensional MDCT (r = 0.68) on the basis of data from 10 patients. HALT was associated with male sex (70% vs. 25%; p = 0.008) and larger sinus of Valsalva (31.0 ± 2.0 mm vs. 28.6 ± 2.6 mm; p = 0.005). HALT was found in 3 of 49 patients with a 23-mm bioprosthesis and in 7 of 21 patients with a 26-mm bioprosthesis (6.1% vs. 33.3%; p = 0.006). D-dimer levels were significantly increased in the HALT group at the 6-month (2.3 μg/ml [interquartile range (IQR): 2.1 to 6.1 μg/ml] vs. 1.1 μg/ml [IQR: 0.8 to 2.2 μg/ml]; p = 0.002) and 1-year (2.7 μg/ml [IQR: 1.7 to 4.8 μg/ml] vs. 1.2 μg/ml [IQR: 0.9 to 2.1 μg/ml]; p = 0.006) follow-ups, despite no differences at discharge. The pressure gradient was decreased in the HALT group at the 1-year follow-up (8.3 ± 0.8 mm Hg vs. 11.1 ± 4.9 mm Hg; p = 0.005). After detecting HALT, additional anticoagulation therapy was not administered. Clinical outcomes, including all-cause mortality (0% vs. 1.7%; p = 1.00) and stroke (0% vs. 0%; p = 1.00), were similar between the groups.
HALT with reduced leaflet motion was not rare but usually subclinical. Valve hemodynamics and mid-term outcomes were uneventful even without additional anticoagulant therapy in our limited number of cases. Male sex, larger sinus and bioprosthesis size, and elevated D-dimer levels during follow-up were associated with this phenomenon.
本研究旨在明确经导管主动脉瓣置换术后低衰减瓣叶增厚（HALT）的发生率及预测因素，以及中期预后情况。
在多排螺旋计算机断层扫描（MDCT）中检测到的HALT引发了对可能存在的亚临床瓣叶血栓形成的担忧。
我们研究了来自单中心登记处的连续100例患者中的70例，这些患者接受了爱德华SAPIEN-XT装置植入术。分析了MDCT结果、超声心动图数据以及在6个月和1年随访时获得的实验室检查结果。
70例患者中，MDCT扫描显示，经导管主动脉瓣置换术后出院时1例（1.4%）出现HALT，6个月时7例（10.0%），1年时累计10例（14.3%）。根据10例患者的数据，瓣叶活动度与四维MDCT上的HALT面积相关（r = 0.68）。HALT与男性（70%对25%；p = 0.008）以及较大的主动脉瓣窦（31.0±2.0 mm对28.6±2.6 mm；p = 0.005）相关。在49例植入23 mm生物瓣的患者中有3例出现HALT，在21例植入26 mm生物瓣的患者中有7例出现HALT（6.1%对33.3%；p = 0.006）。HALT组在6个月（2.3 μg/ml[四分位间距（IQR）：2.1至6.1 μg/ml]对1.1 μg/ml[IQR：0.8至2.2 μg/ml]；p = 0.002）和1年（2.7 μg/ml[IQR：1.7至4.8 μg/ml]对1.2 μg/ml[IQR：0.9至2.1 μg/ml]；p = 0.006）随访时D-二聚体水平显著升高，尽管出院时无差异。HALT组在1年随访时压力阶差降低（8.3±0.8 mmHg对11.1±4.9 mmHg；p = 0.005）。检测到HALT后，未给予额外的抗凝治疗。两组间的临床结局，包括全因死亡率（0%对1.7%；p = 1.00）和卒中（0%对0%；p = 1.00）相似。
伴有瓣叶运动减少的HALT并不罕见，但通常为亚临床状态。在我们有限的病例中，即使不进行额外的抗凝治疗，瓣膜血流动力学和中期预后也无异常。男性、较大的主动脉瓣窦和生物瓣尺寸以及随访期间D-二聚体水平升高与这一现象相关。
