Nyman Charles B, Shook Douglas C, Shernan Stanton
1 Brigham and Women's Hospital, Boston, MA, USA.
Semin Cardiothorac Vasc Anesth. 2019 Mar;23(1):48-56. doi: 10.1177/1089253218812425. Epub 2018 Nov 8.
The advent of percutaneous therapies has significantly altered therapeutic options for patients with valvular heart disease. Building on the success of transcatheter aortic valve replacement, both expanded indications and purpose-built devices are now being used to address percutaneous approaches for mitral valve pathology. While surgical mitral valve repair remains the gold standard for addressing significant mitral valve pathology, there has been a progressive increase in the utilization of bioprosthetic valves despite their limited lifespan. The risks of reoperation to address mitral valve repair failure or bioprosthetic valve dysfunction is not insignificant. In light of the aging population and the potential for significant associated comorbidities, less invasive alternative techniques hold particular appeal. Utilization of commercially available transcatheter aortic valve replacement valves for failed surgical valves has been shown to have better short-term mortality than would be predicted for open reoperation. As a result, the US Food and Drug Administration approved the utilization of transcatheter mitral valve-in-valve replacement for the failed bioprosthetic valve in high surgical risk patients. Despite the favorable outcomes, transcatheter mitral valve-in-valve is not without procedural challenges and potential complications including malpositioning, embolization, paravalvular leak, and outflow tract obstruction. Awareness of these challenges, mitigation strategies, and therapeutic options is imperative to optimizing outcomes in this high-risk patient population.
经皮治疗方法的出现显著改变了心脏瓣膜病患者的治疗选择。基于经导管主动脉瓣置换术的成功，目前不仅扩大了适应症，还使用了专门设计的设备来处理二尖瓣病变的经皮治疗方法。虽然外科二尖瓣修复仍然是治疗严重二尖瓣病变的金标准，但生物瓣膜的使用量仍在逐步增加，尽管其使用寿命有限。再次手术以解决二尖瓣修复失败或生物瓣膜功能障碍的风险并非微不足道。鉴于人口老龄化以及可能存在的严重相关合并症，侵入性较小的替代技术具有特别的吸引力。已证明，对于手术失败的瓣膜，使用市售的经导管主动脉瓣置换瓣膜的短期死亡率低于预期的再次开胸手术。因此，美国食品药品监督管理局批准在高手术风险患者中使用经导管二尖瓣瓣中瓣置换术治疗失败的生物瓣膜。尽管取得了良好的效果，但经导管二尖瓣瓣中瓣置换术并非没有操作挑战和潜在并发症，包括位置不当、栓塞、瓣周漏和流出道梗阻。了解这些挑战、缓解策略和治疗选择对于优化这一高风险患者群体的治疗结果至关重要。
