经导管主动脉瓣置换术后瓣叶血栓形成对瓣膜血流动力学状态的影响。
Impact of leaflet thrombosis on valve haemodynamic status after transcatheter aortic valve replacement.
机构信息
Ulsan University Hospital, Ulsan, Korea.
Cardiology, Asan Medical Center, Seoul, Korea.
出版信息
Heart. 2023 Dec 20;110(2):140-147. doi: 10.1136/heartjnl-2023-322946.
OBJECTIVES
The effect of subclinical leaflet thrombosis, characterised by hypoattenuated leaflet thickening (HALT), on the valve haemodynamic function and durability of the bioprosthetic valve, is not yet determined. We determined the impact of HALT on valve haemodynamics after transcatheter aortic valve replacement (TAVR) and the predictors of haemodynamic structural valve deterioration (SVD).
METHODS
The Anticoagulation vs Dual Antiplatelet Therapy for Prevention of Leaflet Thrombosis and Cerebral Embolization after Transcatheter Aortic Valve Replacement(ADAPT-TAVR) trial is a multicenter, randomised trial that compared edoxaban and dual antiplatelet therapy in patients who had undergone successful TAVR. The presence of HALT was evaluated by four-dimensional CT at 6 months and serial echocardiography performed at baseline, immediately post-TAVR and after 6 months. SVD was defined as at least one of the following: (1) mean transprosthetic gradient ≥20 mm Hg, (2) change in the mean gradient ≥10 mm Hg from baseline, or (3) new or increase in intraprosthetic aortic regurgitation of at least ≥1 grade, resulting in moderate or greater regurgitation.
RESULTS
At 6 months, HALT was found in 30 of 211 (14.2%) patients. The presence of HALT did not significantly affect aortic valve mean gradients (with vs without HALT; 14.0±4.8 mm Hg vs 13.7±5.5 mm Hg; p=0.74) at 6 months. SVD was reported in 30 of 206 patients (14.6%) at 6-month follow-up echocardiography. Older age (OR: 1.138; 95% CI: 1.019 to 1.293; p=0.033), use of aortic valve size ≤23 mm (OR: 6.254; 95% CI: 2.230 to 20.569; p=0.001) and mean post-TAVR pressure gradient (OR: 1.233; 95% CI: 1.123 to 1.371; p<0.001) were independent predictors of haemodynamic SVD; however, the presence of HALT was not identified as a predictor of SVD.
CONCLUSIONS
In patients who had undergone successful TAVR, aortic valve haemodynamic status was not influenced by the presence of HALT. Although HALT was not a predictor of haemodynamic SVD at 6 months, it warrants further longer-term follow-up to evaluate the effect on long-term valve durability.
TRIAL REGISTRATION NUMBER
NCT03284827 (https://www.
CLINICALTRIALS
gov).
目的
亚临床瓣叶血栓形成（表现为低衰减瓣叶增厚（HALT））对生物瓣阀的血流动力学功能和耐久性的影响尚未确定。我们研究了经导管主动脉瓣置换术（TAVR）后 HALT 对瓣叶血流动力学的影响，以及血流动力学结构性瓣叶恶化（SVD）的预测因素。
方法
抗凝与双联抗血小板治疗预防经导管主动脉瓣置换术后瓣叶血栓形成和脑栓塞（ADAPT-TAVR）试验是一项多中心、随机试验，比较了 edoxaban 和双联抗血小板治疗在成功接受 TAVR 的患者中的效果。通过 6 个月时的四维 CT 和基线、TAVR 后即刻和 6 个月时的连续超声心动图评估 HALT 的存在。SVD 的定义为以下至少一种情况：（1）平均跨瓣压差≥20mmHg；（2）与基线相比，平均梯度变化≥10mmHg；（3）至少增加或增加 1 级以上的瓣内主动脉瓣反流，导致中度或以上反流。
结果
在 211 例患者中，211 例（14.2%）患者在 6 个月时发现 HALT。HALT 的存在并未显著影响主动脉瓣平均梯度（有 vs 无 HALT；14.0±4.8mmHg vs 13.7±5.5mmHg；p=0.74）。在 6 个月的超声心动图随访中，30 例患者（14.6%）报告有 SVD。年龄较大（OR：1.138；95%CI：1.019 至 1.293；p=0.033）、使用主动脉瓣尺寸≤23mm（OR：6.254；95%CI：2.230 至 20.569；p=0.001）和平均 TAVR 后压差（OR：1.233；95%CI：1.123 至 1.371；p<0.001）是血流动力学 SVD 的独立预测因素；然而，HALT 的存在并未被确定为 SVD 的预测因素。
结论
在成功接受 TAVR 的患者中，主动脉瓣血流动力学状态不受 HALT 存在的影响。尽管 HALT 不是 6 个月时血流动力学 SVD 的预测因素，但需要进一步的长期随访，以评估其对长期瓣膜耐久性的影响。
试验注册号
NCT03284827（https://www.clinicaltrials.gov）。
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