Polo Cardio-Toraco Vascolare, Policlinico S. Orsola, Bologna, Italy.
Cedars-Sinai Medical Center, Los Angeles, California.
JACC Cardiovasc Interv. 2020 Mar 23;13(6):739-747. doi: 10.1016/j.jcin.2019.11.024. Epub 2020 Feb 12.
The aim of this study was to investigate the safety and efficacy of coronary protection by preventive coronary wiring and stenting across the coronary ostia in patients at high risk for coronary obstruction after transcatheter aortic valve replacement (TAVR).
Coronary obstruction following TAVR is a life-threatening complication with high procedural and short-term mortality.
Data were collected retrospectively from a multicenter international registry between April 2011 and February 2019.
Among 236 patients undergoing coronary protection with preventive coronary wiring, 143 had eventually stents implanted across the coronary ostia after valve deployment. At 3-year follow-up, rates of cardiac death were 7.8% in patients receiving stents and 15.7% in those not receiving stents (adjusted hazard ratio: 0.42; 95% confidence interval: 0.14 to 1.28; p = 0.13). There were 2 definite stent thromboses (0.9%) in patients receiving stents, both occurring after TAVR in "valve-in-valve" procedures. In patients not receiving stents, there were 4 delayed coronary occlusions (DCOs) (4.3%), occurring from 5 min to 6 h after wire removal. Three cases occurred in valve-in-valve procedures and 1 in a native aortic valve procedure. Distance between the virtual transcatheter valve and the protected coronary ostia <4 mm was present in 75.0% of patients with DCO compared with 30.4% of patients without DCO (p = 0.19).
In patients undergoing TAVR at high risk for coronary obstruction, preventive stent implantation across the coronary ostia is associated with good mid-term survival rates and low rates of stent thrombosis. Patients undergoing coronary protection with wire only have a considerable risk for DCO.
本研究旨在探讨经导管主动脉瓣置换术（TAVR）后发生冠状动脉阻塞高危患者预防性冠状动脉布线和支架置入术对冠状动脉保护的安全性和有效性。
TAVR 后发生冠状动脉阻塞是一种危及生命的并发症，其手术过程和短期死亡率都很高。
本研究回顾性地收集了 2011 年 4 月至 2019 年 2 月期间多中心国际注册中心的数据。
在 236 例行预防性冠状动脉布线的患者中，143 例患者在瓣膜植入后最终在冠状动脉口植入支架。3 年随访时，接受支架治疗的患者心脏死亡率为 7.8%，未接受支架治疗的患者为 15.7%（校正风险比：0.42；95%置信区间：0.14 至 1.28；p=0.13）。接受支架治疗的患者中有 2 例明确的支架血栓形成（0.9%），均发生在“瓣中瓣”手术的 TAVR 后。未接受支架治疗的患者中，有 4 例迟发性冠状动脉闭塞（DCO）（4.3%），发生在移除导丝后 5 分钟至 6 小时之间。其中 3 例发生在“瓣中瓣”手术中，1 例发生在原主动脉瓣手术中。与无 DCO 患者（30.4%）相比，DCO 患者（75.0%）的虚拟经导管瓣膜与受保护的冠状动脉口之间的距离<4mm（p=0.19）。
在 TAVR 高危冠状动脉阻塞患者中，预防性冠状动脉口支架植入术与良好的中期生存率和较低的支架血栓形成率相关。仅用导丝进行冠状动脉保护的患者发生 DCO 的风险较大。
