Rogers Toby, Steinvil Arie, Gai Jiaxiang, Torguson Rebecca, Koifman Edward, Kiramijyan Sarkis, Negi Smita, Lee Sang Yeub, Okubagzi Petros, Satler Lowell F, Ben-Dor Itsik, Pichard Augusto D, Waksman Ron
Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia; Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland.
Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia.
Am J Cardiol. 2017 Mar 15;119(6):900-904. doi: 10.1016/j.amjcard.2016.11.044. Epub 2016 Dec 18.
We sought to determine whether balloon-expandable valve (BEV) and self-expanding valve (SEV) affect valve hemodynamics differently according to native aortic annulus size. Transcatheter aortic valve replacement can achieve superior prosthetic valve hemodynamics compared with surgical aortic valve replacement, particularly in patients with small aortic annulus. One hundred ninety-three consecutive transcatheter aortic valve replacement patients were grouped into tertiles defined by computed tomography derived aortic annulus systolic perimeter. The predischarge echocardiogram was analyzed for prosthetic valve hemodynamics. Tertile perimeter cutoffs were 73 and 80 mm. STS score decreased as annulus size increased (7.8% vs 7.6% vs 6.0%, p ≤0.05 for small, medium, and large annulus, respectively). In patients with small aortic annulus, SEV was associated with significantly higher dimensionless index (0.64 vs 0.53, p = 0.02) and lower peak velocity (1.8 vs 2.4 m/sec, p <0.001) and a trend toward lower mean gradient (7.5 vs 10.0 mm Hg, p = 0.07) compared with BEV. These differences were attenuated and absent in patients with medium and large annulus, respectively. Few patients had moderate/severe paravalvular leak, with no association with valve type or annulus size. There was no difference in mortality between tertiles or valve type at 30 days or 1 year. There was no association between aortic annulus perimeter and 1-year mortality by univariate analysis (hazard ratio 1.00, 95% CI 0.95 to 1.05, p = 0.86) or multivariate analysis (hazard ratio 1.02, 95% CI 0.95 to 1.09, p = 0.60). In conclusion, SEV hemodynamics was superior to BEV in patients with small aortic annulus. This difference was diminished in patients with larger aortic annulus. This study highlights the importance of valve selection in patients with small aortic annulus.
我们试图确定球囊扩张瓣膜（BEV）和自膨胀瓣膜（SEV）是否会根据原生主动脉瓣环大小对瓣膜血流动力学产生不同影响。与外科主动脉瓣置换相比，经导管主动脉瓣置换可实现更优的人工瓣膜血流动力学，尤其是在主动脉瓣环较小的患者中。193例连续接受经导管主动脉瓣置换的患者根据计算机断层扫描得出的主动脉瓣环收缩周长分为三分位数组。对出院前超声心动图进行人工瓣膜血流动力学分析。三分位数周长临界值分别为73和80毫米。随着瓣环大小增加，胸外科医师协会（STS）评分降低（小、中、大瓣环患者分别为7.8%、7.6%和6.0%，p≤0.05）。在主动脉瓣环较小的患者中，与BEV相比，SEV与显著更高的无因次指数（0.64对0.53，p = 0.02）、更低的峰值速度（1.8对2.4米/秒，p <0.001）以及更低平均梯度的趋势（7.5对10.0毫米汞柱，p = 0.07）相关。这些差异在中、大瓣环患者中分别减弱和消失。很少有患者出现中度/重度瓣周漏，且与瓣膜类型或瓣环大小无关。在30天或1年时，三分位数组或瓣膜类型之间的死亡率无差异。经单因素分析（风险比1.00，95%置信区间0.95至1.05，p = 0.86）或多因素分析（风险比1.02，95%置信区间0.95至1.09，p = 0.60），主动脉瓣环周长与1年死亡率之间无关联。总之，在主动脉瓣环较小的患者中，SEV的血流动力学优于BEV。在主动脉瓣环较大患者中这种差异减小。本研究强调了在主动脉瓣环较小患者中瓣膜选择的重要性。
