Long Ashleigh, Mahoney Paul
Sentara Heart Hospital, Heart Valve and Structural Disease Center, 600 Gresham Drive, Norfolk, VA 23507 USA.
J Invasive Cardiol. 2018 Sep;30(9):324-328. Epub 2018 Jun 15.
Transcatheter mitral valve-in-valve (TMVIV) or valve-in-ring (TMVIR) replacement has shown early promise in patients deemed poor surgical candidates as a less invasive alternative to conventional reoperative mitral valve (MV) replacement.
This retrospective, single-center study reviewed the procedural outcomes of all TMVIV and TMVIR procedures between 2013-2018 at a large tertiary referral center serving the southeastern United States. An analysis of patient safety measures was also performed, with a retrospective assessment of relative procedural safety that included preoperative risk stratification and postoperative mortality predictors, operative time, average blood loss, length of hospital stay, and readmission rates.
This study included 24 patients with severe MV disease and medical comorbidities who were considered too high risk for conventional MV replacement. All patients underwent TMVIV or TMVIR with Edwards Sapien XT or S3 transcatheter valves (Edwards Lifesciences). A secure database of patient demographics, preoperative risk assessment, and procedural data was created and included technical success rates, blood loss, operative time, and intraoperative and immediate postoperative complications. Subsequent follow-up of patient outcomes reported here include those collected at 30 days, 180 days, and 1 year.
Of the 24 patients in our study, 16 received TMVIV and 8 received TMVIR implantation. Each procedure was performed successfully under general anesthesia via transseptal approach (n = 17) or transapical approach (n = 7), with only 1 patient (8.2%) requiring late operative reintervention 252 days post op. Average procedural time was 76 min and average blood loss was <75 mL, with 20/24 patients (83%) successfully extubated on postoperative day 0. Length of Intensive Care Unit stay was 1.7 ± 1.4 days and length of total inpatient stay was 2.8 ± 1.8 days. Echocardiograms were collected immediately post op, at 30 days, at 180 days, and subsequently at yearly intervals; follow-up demonstrated excellent prosthetic valve function with low transvalvular gradients, and no evidence of valve embolization or thrombosis. In patients with follow-up data available at 1 year (n = 13), there were no readmissions at 30 days or 180 days, and only 1 admission (8.3%) during the first postoperative year for symptoms related to congestive heart failure (CHF).
TMVIV and TMVIR can be safe and effective in a patient population considered at prohibitive risk for conventional surgery. These procedures can be performed efficiently in a hybrid operating room, with relatively short procedural times and high rates of early extubation. Procedural complications, mortality, and readmission rates for CHF at 30 days, 180 days, and 1 year were very low in this high-risk cohort.
经导管二尖瓣瓣中瓣（TMVIV）或瓣中环（TMVIR）置换术已显示出早期前景，对于那些被认为手术风险高的患者而言，它是一种侵入性较小的替代传统再次二尖瓣（MV）置换术的方法。
这项回顾性单中心研究回顾了2013年至2018年期间在美国东南部一家大型三级转诊中心进行的所有TMVIV和TMVIR手术的手术结果。还进行了患者安全措施分析，对相对手术安全性进行回顾性评估，包括术前风险分层和术后死亡率预测因素、手术时间、平均失血量、住院时间和再入院率。
本研究纳入了24例患有严重MV疾病且有内科合并症的患者，这些患者被认为进行传统MV置换术风险过高。所有患者均接受了使用爱德华兹Sapien XT或S3经导管瓣膜（爱德华兹生命科学公司）的TMVIV或TMVIR手术。创建了一个包含患者人口统计学、术前风险评估和手术数据的安全数据库，其中包括技术成功率、失血量、手术时间以及术中和术后即刻并发症。此处报告的患者结局后续随访包括在30天、180天和1年时收集的数据。
在我们研究的24例患者中，16例接受了TMVIV，8例接受了TMVIR植入。每例手术均在全身麻醉下通过经房间隔途径（n = 17）或经心尖途径（n = 7）成功完成，只有1例患者（8.2%）在术后252天需要进行晚期手术再次干预。平均手术时间为76分钟，平均失血量<75 mL，24例患者中有20例（83%）在术后第0天成功拔管。重症监护病房住院时间为1.7±1.4天，总住院时间为2.8±1.8天。术后即刻、30天、180天以及随后每年进行超声心动图检查；随访显示人工瓣膜功能良好，跨瓣压差低，且无瓣膜栓塞或血栓形成的证据。在有1年随访数据的患者（n = 13）中，30天和180天时均无再入院情况，术后第一年仅有1例（8.3%）因充血性心力衰竭（CHF）相关症状入院。
TMVIV和TMVIR对于那些被认为传统手术风险过高的患者群体可能是安全有效的。这些手术可以在杂交手术室高效进行，手术时间相对较短，早期拔管率高。在这个高风险队列中，30天、180天和1年时的手术并发症、死亡率和CHF再入院率非常低。
