經(jīng)皮主動(dòng)脈瓣置換專(zhuān)家共識(shí)課件

1、歷史背景主動(dòng)脈瓣狹窄常見(jiàn)于老年（75歲）的主動(dòng)脈瓣鈣化、風(fēng)濕性心臟病和先天性二葉瓣。主動(dòng)脈瓣狹窄會(huì)逐漸進(jìn)展，左心室壁肥厚，最終導(dǎo)致左心衰竭。一旦出現(xiàn)癥狀，預(yù)后極差。從癥狀出現(xiàn)到死亡的平均時(shí)間：心衰2年，昏厥3年，心絞痛5年。藥物治療1、2年死亡率為25、50。嚴(yán)重主動(dòng)脈瓣狹窄的定義對(duì)于左心室收縮功能正常的患者：主瓣峰值血流速度4.0 m/s (對(duì)應(yīng)跨主瓣峰值壓差64 mm Hg), 平均壓差40 mm Hg, 或主瓣瓣口面積1.0 cm2. 考慮到患者體表面積不同，主瓣面積常用體表面積指數(shù)表示，0.6 cm2/m2 作為嚴(yán)重主瓣狹窄的標(biāo)準(zhǔn).嚴(yán)重主動(dòng)脈瓣狹窄的治療選擇With severe, s

2、ymptomatic, calcific AS, AVR is the only effective treatment that improves symptoms and prolongs survival (30,31).對(duì)于嚴(yán)重的、有癥狀的、鈣化性主動(dòng)脈瓣狹窄，換瓣術(shù)是能夠改善癥狀和延長(zhǎng)生命的唯一有效治療方法。嚴(yán)重主動(dòng)脈瓣狹窄的治療選擇一、外科AVR。機(jī)械瓣。相對(duì)年輕患者。生物瓣。常會(huì)發(fā)生生物瓣葉的鈣化。在年輕患者平均發(fā)生時(shí)間為1012年，老年患者平均發(fā)生時(shí)間為1518年。實(shí)際上，應(yīng)用現(xiàn)代生物瓣，術(shù)后5年有95的患者瓣膜仍然良好，不必再次手術(shù)；10年時(shí)90；15年時(shí)降為70。嚴(yán)重主動(dòng)脈

3、瓣狹窄的治療選擇外科手術(shù)AVR的限制性Despite substantial contemporary experience with successful AVR in elderly patients, multiple series have documented that 30% to 40% of patients with severe AS do not undergo surgery owing to advanced age, LV dysfunction, multiple coexisting conditions, and patient preference or p

4、hysician recommendation。嚴(yán)重主動(dòng)脈瓣狹窄的治療選擇二、Balloon aortic valvuloplasty.預(yù)后較差。Restenosis or recoil of the aortic valve usually occurs within 6 months. Patients treated with balloon aortic valvuloplasty alone have shown poor prognosis, with survival rates of 50% at 1 year, 35% at 2 years, and 20% at 3 yea

5、rs . In addition, serious complications due to balloon aortic valvuloplasty occur in 15% to 25% of patients。嚴(yán)重主動(dòng)脈瓣狹窄的治療選擇三、經(jīng)皮主動(dòng)脈瓣置換術(shù)Transcatheter Aortic Valve Replacement。TAVR。經(jīng)皮主動(dòng)脈瓣置換術(shù)歷史：1992開(kāi)始動(dòng)物實(shí)驗(yàn)；2002年實(shí)現(xiàn)經(jīng)皮置入人體第一個(gè)可擴(kuò)張的馬心包支架瓣膜。之后多種TAVR瓣膜問(wèn)世。經(jīng)皮主動(dòng)脈瓣置換術(shù)Device Description：（一）Sapien valve (Figure 1) Edwar

6、ds Life Sciences, Inc., Irvine, CA)：三瓣牛心包瓣固定在可球囊擴(kuò)張的鈷鉻合金支架上。The Sapien valve is available in 23-mm and 26-mm sizes in the United States and 23-mm, 26-mm, and 29-mm sizes in Europe. The initial devices required a 22- or 24-French sheath for delivery of the prosthesis. Recent iterations (NovaFlex) have

7、 decreased this to 18-French. Sapien valve經(jīng)皮主動(dòng)脈瓣置換術(shù)（二）CoreValve (Figure 2) (Medtronic, Inc., Minneapolis, MN). 三片豬心包固定于可自膨脹的鎳鈦合金支架上。經(jīng)皮主動(dòng)脈瓣置換術(shù)CoreValve： It is available in 3 sizes26 mm, 29 mm, and 31 mm. This valve has also continued to iterate, with the initial devices being 25-French, but now 18-Fr

8、ench delivery sheaths are used. This valve has only been used by a retrograde approacheither via transfemoral, subclavian, or direct aortic access.經(jīng)皮主動(dòng)脈瓣置換術(shù)An estimated 40,000 patients have received TAVR worldwide. Multiple single and multicenter registries, and a single randomized trial, have docum

9、ented favorable outcomes using a wide spectrum of endpoints, including survival, symptom status, quality of life, and need for repeat hospitalization.經(jīng)皮主動(dòng)脈瓣置換術(shù)There are only limited clinical data on the durability of TAVR valvesup to 2 yearsin the PARTNER trial and up to 5 years in other registry ex

10、periences.Table 1. Edwards Sapien Transcatheter Heart Valve RegistriesTable 2. Medtronic CoreValve Transcatheter Heart Valve RegistriesRandomized Controlled TrialPARTNER Trial DesignA prospective, unblinded, randomized, controlled, multicenter pivotal trial evaluating the safety and effectiveness of

11、 the Edwards Sapien THV transcatheter aortic valve; 2 distinct populations were enrolled Cohort A - high-risk operable,699人; Cohort B inoperable,358人; PARTNER Trial Design表3 人口基線特征Table 4. Major Outcomes at 30 Days and 1 Year in Cohort B of the PARTNER TrialTable 6. Major Outcomes at 30 Days and 1 Year in Cohort A of the PARTNER TrialTable 7. Quality of Life and Symptom Assessment in TAVR TrialsTable 9. Patient Selection: Inclusion and Exclusion Criteria in Clinical TrialsTable 9. Patient Selection: Inclusion and Exclusion Criteria in Clinical TrialsTAVR所需圖像設(shè)備心臟彩超CT心臟磁共振觀察主動(dòng)脈瓣、瓣環(huán)、瓣環(huán)距冠狀動(dòng)脈的距離、升