经导管二尖瓣置换术治疗退行性生物瓣、瓣环成形术失败和二尖瓣环钙化的结果。
Outcomes of transcatheter mitral valve replacement for degenerated bioprostheses, failed annuloplasty rings, and mitral annular calcification.
机构信息
Department of Interventional Cardiology, Cedars-Sinai Heart Institute, 8700 Beverly Blvd, Los Angeles, CA, USA.
Division of Cardiovascular Diseases, Intermountain Heart Institute, Salt Lake City, UT, USA.
出版信息
Eur Heart J. 2019 Feb 1;40(5):441-451. doi: 10.1093/eurheartj/ehy590.
AIMS
We sought to evaluate the outcomes of transcatheter mitral valve replacement (TMVR) for patients with degenerated bioprostheses [valve-in-valve (ViV)], failed annuloplasty rings [valve-in-ring (ViR)], and severe mitral annular calcification [valve-in-mitral annular calcification (ViMAC)].
METHODS AND RESULTS
From the TMVR multicentre registry, procedural and clinical outcomes of ViV, ViR, and ViMAC were compared according to Mitral Valve Academic Research Consortium (MVARC) criteria. A total of 521 patients with mean Society of Thoracic Surgeons score of 9.0 ± 7.0% underwent TMVR (322 patients with ViV, 141 with ViR, and 58 with ViMAC). Trans-septal access and the Sapien valves were used in 39.5% and 90.0%, respectively. Overall technical success was excellent at 87.1%. However, left ventricular outflow tract obstruction occurred more frequently after ViMAC compared with ViR and ViV (39.7% vs. 5.0% vs. 2.2%; P < 0.001), whereas second valve implantation was more frequent in ViR compared with ViMAC and ViV (12.1% vs. 5.2% vs. 2.5%; P < 0.001). Accordingly, technical success rate was higher after ViV compared with ViR and ViMAC (94.4% vs. 80.9% vs. 62.1%; P < 0.001). Compared with ViMAC and ViV groups, ViR group had more frequent post-procedural mitral regurgitation ≥moderate (18.4% vs. 13.8% vs. 5.6%; P < 0.001) and subsequent paravalvular leak closure (7.8% vs. 0.0% vs. 2.2%; P = 0.006). All-cause mortality was higher after ViMAC compared with ViR and ViV at 30 days (34.5% vs. 9.9% vs. 6.2%; log-rank P < 0.001) and 1 year (62.8% vs. 30.6% vs. 14.0%; log-rank P < 0.001). On multivariable analysis, patients with failed annuloplasty rings and severe MAC were at increased risk of mortality after TMVR [ViR vs. ViV, hazard ratio (HR) 1.99, 95% confidence interval (CI) 1.27-3.12; P = 0.003; ViMAC vs. ViV, HR 5.29, 95% CI 3.29-8.51; P < 0.001].
CONCLUSION
The TMVR provided excellent outcomes for patients with degenerated bioprostheses despite high surgical risk. However, ViR and ViMAC were associated with higher rates of adverse events and mid-term mortality compared with ViV.
目的
我们旨在评估经导管二尖瓣置换术（TMVR）治疗退行性生物瓣[瓣中瓣（ViV）]、瓣环成形术失败[瓣环内瓣（ViR）]和严重二尖瓣瓣环钙化[瓣环内瓣环钙化（ViMAC）]患者的结局。
方法和结果
根据二尖瓣学术研究联盟（MVARC）标准，从 TMVR 多中心注册研究中比较了 ViV、ViR 和 ViMAC 的手术和临床结局。共有 521 名平均胸外科医师协会评分 9.0±7.0%的患者接受了 TMVR（322 名 ViV 患者、141 名 ViR 患者和 58 名 ViMAC 患者）。经中隔入路和 Sapien 瓣膜的使用率分别为 39.5%和 90.0%。整体技术成功率非常高，为 87.1%。然而，与 ViR 和 ViV 相比，ViMAC 后左心室流出道梗阻更为常见（39.7%比 5.0%比 2.2%；P<0.001），而 ViR 后再次植入瓣膜更为常见（12.1%比 5.2%比 2.5%；P<0.001）。因此，与 ViR 和 ViMAC 相比，ViV 的技术成功率更高（94.4%比 80.9%比 62.1%；P<0.001）。与 ViMAC 和 ViV 组相比，ViR 组术后中重度二尖瓣反流更常见（18.4%比 13.8%比 5.6%；P<0.001），随后的瓣周漏闭合也更常见（7.8%比 0.0%比 2.2%；P=0.006）。30 天（34.5%比 9.9%比 6.2%；对数秩 P<0.001）和 1 年（62.8%比 30.6%比 14.0%；对数秩 P<0.001）时，ViMAC 组的全因死亡率均高于 ViR 和 ViV 组。多变量分析显示，瓣环成形术失败和严重 MAC 的患者 TMVR 后死亡风险增加[ViR 比 ViV，风险比（HR）1.99，95%置信区间（CI）1.27-3.12；P=0.003；ViMAC 比 ViV，HR 5.29，95%CI 3.29-8.51；P<0.001]。
结论
尽管手术风险较高，但 TMVR 为退行性生物瓣患者提供了极好的结果。然而，与 ViV 相比，ViR 和 ViMAC 与更高的不良事件和中期死亡率相关。
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