生物瓣置换时的固定瓣叶：早期生物瓣失效的新危险因素

Immobile Leaflets at Time of Bioprosthetic Valve Implantation: A Novel Risk Factor for Early Bioprosthetic Failure: A Novel Risk Factor for Early Bioprosthetic Failure.

机构信息

Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.

Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA.

出版信息

Heart Lung Circ. 2022 Aug;31(8):1166-1175. doi: 10.1016/j.hlc.2022.02.011. Epub 2022 Mar 24.

DOI:10.1016/j.hlc.2022.02.011

PMID:35339372

Abstract

OBJECTIVES

The clinical implications of finding immobile leaflet(s) at the time of bioprosthetic valve implantation but with acceptable prosthetic haemodynamics are uncertain. We sought to determine the characteristics of such patients and their impact on outcome.

METHODS

Patients with immobile leaflet at the time of surgical bioprosthetic valve implantation were identified retrospectively by a systematic search of an institutional echocardiography database (2010-2020). Intraoperative echocardiograms were reviewed de-novo to confirm immobile leaflet(s) at the time of implantation. Cases were matched 1:2 to controls with normal bioprosthetic leaflets motion for age, sex, prosthesis position, prosthesis model, size, year of implantation, and pre-implantation left ventricular ejection fraction. Proportional hazards method was used to analyse the composite endpoint of stroke, valve thrombosis or re-intervention.

RESULTS

Immobile leaflet at the time of bioprosthetic valve implantation were found in 26 patients (median age 71 ys 39% males) following tricuspid (n=13), mitral (n=11) and aortic (n=2) valve replacements; 96% received porcine prostheses; prosthesis size was 27 mm or larger in 92%. Immobile leaflet were recorded on intraoperative reports in 16 (62%) cases. It resulted in elevated gradient or mild-moderate prosthetic regurgitation in three (12%), but none led to immediate corrective action intraoperatively. At median follow-up of 21 (4-50) months, presence of immobile leaflet was associated with composite clinical endpoint of stroke, valve thrombosis or re-intervention (hazard ratio 6.8, 95% CI 1.8-25.2, p<0.01) compared to controls.

CONCLUSION

Immobile leaflet immediately post-bioprosthetic valve implantation is frequently under-recognised intraoperatively and appears to be associated with early bioprosthetic dysfunction and worse clinical outcome.

摘要

目的

在植入生物瓣时发现瓣叶活动不良，但人工心脏瓣膜血流动力学可接受的情况下，其临床意义尚不确定。我们旨在确定此类患者的特征及其对预后的影响。

方法

通过对机构超声心动图数据库（2010-2020 年）进行系统检索，回顾性确定在外科生物瓣植入时存在瓣叶活动不良的患者。对术中超声心动图进行重新评估，以确认植入时瓣叶活动不良。根据年龄、性别、假体位置、假体型号、大小、植入年份、植入前左心室射血分数，将病例与正常生物瓣运动的对照组进行 1:2 匹配。采用比例风险法分析中风、瓣周血栓形成或再次干预的复合终点。

结果

在 26 例（中位年龄 71 岁，39%为男性）患者中发现生物瓣植入时瓣叶活动不良，其中三尖瓣（n=13）、二尖瓣（n=11）和主动脉瓣（n=2）置换术各 1 例；96%的患者接受猪瓣；92%的患者使用 27mm 或更大的瓣膜。16 例（62%）患者的术中报告记录了瓣叶活动不良。其中 3 例（12%）导致瓣上压力梯度升高或轻中度瓣周漏，但术中均未立即采取纠正措施。中位随访时间为 21（4-50）个月，与对照组相比，存在瓣叶活动不良与中风、瓣周血栓形成或再次干预的复合临床终点相关（风险比 6.8，95%置信区间 1.8-25.2，p<0.01）。