球囊扩张式经导管主动脉瓣假体的非对称性扩张：对瓣膜血流动力学和临床结局的影响。
Asymmetrical Expansion of Balloon-Expandable Transcatheter Aortic Valve Prostheses: Implications for Valve Hemodynamic and Clinical Outcomes.
机构信息
Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland. Electronic address: https://twitter.com/AMaznyczka.
Department of Clinical Research, University of Bern, Bern, Switzerland.
出版信息
JACC Cardiovasc Interv. 2024 Sep 9;17(17):2011-2022. doi: 10.1016/j.jcin.2024.05.039.
BACKGROUND
Asymmetrical expansion of transcatheter heart valves (THVs), manifesting as stent frame deformation, is an occasional fluoroscopic finding in transcatheter aortic valve replacement (TAVR).
OBJECTIVES
The aim of this study was to investigate the impact of asymmetrical expansion of balloon-expandable THVs on hemodynamic valve performance and clinical outcomes.
METHODS
In a prospective registry, TAVR asymmetry index was measured using freeze-frame fluoroscopic images and was defined as the ratio of THV heights: [(longer height/shorter height) - 1] × 100. THV hemodynamic performance was measured using echocardiography before hospital discharge. Impaired hemodynamic valve performance was defined as a mean residual THV gradient ≥20 mm Hg and/or moderate or greater paravalvular regurgitation.
RESULTS
Among 1,216 patients undergoing transfemoral TAVR for native severe aortic valve stenosis with contemporary balloon-expandable THVs between February 2014 and June 2022, asymmetry index was an excellent predictor of impaired hemodynamic valve performance (area under the receiver-operating characteristic curve: 0.88; 95% CI: 0.84-0.92; P < 0.001). The optimal asymmetry index threshold for predicting impaired THV performance was >5.5% (sensitivity 77%, specificity 86%) and occurred in 17% of patients. Higher asymmetry index, as a continuous variable, was associated with impaired hemodynamic valve performance independent of total aortic valve calcium, bicuspid anatomy, balloon-expandable valve prosthesis type or size, and Society of Thoracic Surgeons Predicted Risk of Mortality score (OR: 1.37; 95% CI: 1.29-1.46; P < 0.001). High TAVR asymmetry index was not associated with all-cause mortality during a median of 376 days of follow-up (HR: 1.00; 95% CI: 0.71-1.41; P = 0.989).
CONCLUSIONS
Asymmetrical expansion of balloon-expandable THVs was associated with impaired hemodynamic valve performance but not with clinical outcomes.
背景
经导管心脏瓣膜（THV）的不对称扩张，表现为支架框架变形，是经导管主动脉瓣置换术（TAVR）中偶尔出现的透视发现。
目的
本研究旨在探讨球囊扩张型 THV 不对称扩张对血流动力学瓣膜性能和临床结局的影响。
方法
在一项前瞻性注册研究中，使用冻结帧荧光透视图像测量 TAVR 不对称指数，并将其定义为 THV 高度比：[(较长高度/较短高度)-1]×100。在出院前使用超声心动图测量 THV 的血流动力学性能。血流动力学瓣膜性能受损定义为平均残余 THV 梯度≥20mmHg 和/或中度或以上瓣周漏。
结果
在 2014 年 2 月至 2022 年 6 月期间，1216 例接受经股动脉 TAVR 治疗的原发性严重主动脉瓣狭窄患者中，使用当代球囊扩张型 THV，不对称指数是血流动力学瓣膜性能受损的优秀预测指标（接受者操作特征曲线下面积：0.88；95%置信区间：0.84-0.92；P<0.001）。预测 THV 性能受损的最佳不对称指数阈值为>5.5%（敏感性 77%，特异性 86%），发生在 17%的患者中。作为连续变量，较高的不对称指数与血流动力学瓣膜性能受损相关，独立于总主动脉瓣钙、二叶式解剖、球囊扩张瓣膜假体类型或大小以及胸外科医生预测死亡率评分（比值比：1.37；95%置信区间：1.29-1.46；P<0.001）。在中位数为 376 天的随访期间，高 TAVR 不对称指数与全因死亡率无关（风险比：1.00；95%置信区间：0.71-1.41；P=0.989）。
结论
球囊扩张型 THV 的不对称扩张与血流动力学瓣膜性能受损相关，但与临床结局无关。
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