Heart Center, Segeberger Kliniken (Academic Teaching Hospital of the Universities of Kiel, Lübeck, and Hamburg), Bad Segeberg, Germany; Christian Medical College Hospital, Vellore, Tamil Nadu, India.
Heart Center, Segeberger Kliniken (Academic Teaching Hospital of the Universities of Kiel, Lübeck, and Hamburg), Bad Segeberg, Germany.
JACC Cardiovasc Interv. 2017 Apr 10;10(7):686-697. doi: 10.1016/j.jcin.2017.01.045.
The aim of this study was to determine the incidence, characteristics, and treatment outcomes of patients diagnosed with clinical transcatheter heart valve thrombosis.
Limited data exists on clinical or manifest transcatheter heart valve thrombosis. Prior studies have focused on subclinical thrombosis.
A retrospective analysis was conducted of prospectively collected data from a single-center registry that included 642 consecutive patients who underwent transcatheter aortic valve replacement between 2007 and 2015 (305 patients had self-expanding valves; balloon-expandable, n = 281; mechanically expanding, n = 56). Long-term oral anticoagulation (OAC) was indicated in 261 patients, while 377 patients received dual-antiplatelet therapy post-procedure. All patients underwent scheduled clinical and echocardiographic follow-up.
The overall incidence of clinical valve thrombosis was 2.8% (n = 18). No patient on OAC developed thrombosis. Of the detected thrombosis cases, 13 patients had balloon-expandable, 3 had self-expanding, and 2 had mechanically expanding valves. Thrombosis occurred significantly more often with balloon-expandable valves (odds ratio: 3.45; 95% confidence interval: 1.22 to 9.81; p = 0.01) and following valve-in-valve procedures (odds ratio: 5.93; 95% confidence interval: 2.01 to 17.51; p = 0.005). Median time to diagnosis of valve thrombosis was 181 days. The median N-terminal pro-brain natriuretic peptide level was 1,318 pg/ml (interquartile range: 606 to 1,676 pg/ml). The mean transvalvular gradient and valve area were 34 ± 14 mm Hg and 1.0 ± 0.46 cm, respectively. Computed tomography showed hypoattenuating areas with reduced leaflet motion. Initiation of OAC resulted in significant reduction of transvalvular gradient and clinical improvement. No deaths were related to valve thrombosis.
Clinical transcatheter heart valve thrombosis is more common than previously considered, characterized by imaging abnormalities and increased gradients and N-terminal pro-brain natriuretic peptide levels. It occurred more commonly after balloon-expandable transcatheter aortic valve replacement and valve-in-valve procedures. OAC appeared to be effective in the prevention and treatment of valve thrombosis. Randomized control trials are needed to define optimal antithrombotic therapy after transcatheter aortic valve replacement.
本研究旨在确定经导管心脏瓣膜血栓形成患者的发病率、特征和治疗结果。
关于临床或显性经导管心脏瓣膜血栓形成的资料有限。先前的研究集中在亚临床血栓形成上。
对 2007 年至 2015 年间在单中心注册中心接受经导管主动脉瓣置换术的 642 例连续患者的前瞻性收集数据进行回顾性分析（305 例患者为自膨式瓣膜；球囊扩张型，n=281；机械扩张型，n=56）。261 例患者长期接受口服抗凝治疗（OAC），377 例患者术后接受双联抗血小板治疗。所有患者均接受计划的临床和超声心动图随访。
临床瓣膜血栓形成的总发生率为 2.8%（n=18）。未接受 OAC 的患者均未发生血栓形成。在检测到的血栓形成病例中，13 例为球囊扩张型，3 例为自膨式，2 例为机械扩张型。球囊扩张型瓣膜血栓形成的发生率明显更高（比值比：3.45；95%置信区间：1.22 至 9.81；p=0.01），并且在瓣膜内植入术（比值比：5.93；95%置信区间：2.01 至 17.51；p=0.005）后更为常见。诊断为瓣膜血栓形成的中位时间为 181 天。中位 N 端脑钠肽前体水平为 1318pg/ml（四分位间距：606 至 1676pg/ml）。平均跨瓣梯度和瓣膜面积分别为 34±14mmHg 和 1.0±0.46cm。计算机断层扫描显示低衰减区伴有瓣叶运动减少。开始 OAC 治疗可显著降低跨瓣梯度并改善临床症状。无死亡与瓣膜血栓形成有关。
经导管心脏瓣膜血栓形成比先前认为的更为常见，其特征为影像学异常、梯度和 N 端脑钠肽前体水平升高。它更常见于球囊扩张式经导管主动脉瓣置换术和瓣膜内植入术后。OAC 似乎对预防和治疗瓣膜血栓形成有效。需要进行随机对照试验来确定经导管主动脉瓣置换术后最佳的抗血栓治疗。
