生物瓣主动脉根部置换术后远期行经导管主动脉瓣“瓣中瓣”置换术的冠状动脉阻塞风险分析  

Analysis on the Risk of Coronary Artery Obstruction in Valve-in-valve Transcatheter Aortic Valve Replacement After Previous Aortic Root Replacement With Bioprosthetic Valve

作　　者：施浩 万俊义 李琦 刘垚 钱向阳 郭宏伟 潘湘斌 胡晓鹏 SHI Hao;WAN Junyi;LI Qi;LIU Yao;QIAN Xiangyang;GUO Hongwei;PAN Xiangbin;HU Xiaopeng(Department of Structural Heart Disease,National Center for Cardiovascular Diseases and Fuwai Hospital,Chinese Academy of Medical Sciences and Peking Union Medical College,Beijing 100037,China)

机构地区：[1]中国医学科学院、北京协和医学院、国家心血管病中心、阜外医院结构性心脏病中心,北京100037

出　　处：《中国循环杂志》2023年第5期508-514,共7页Chinese Circulation Journal

基　　金：中国医学科学院医学与健康科技创新工程2021年临床与转化医学研究专项(2021-I2M-C&T-B-033)。

摘　　要：目的:分析生物瓣主动脉根部置换术(Bio-Bentall手术)后远期行经导管主动脉瓣“瓣中瓣”置换术(ViV-TAVR)的冠状动脉阻塞风险,并讨论冠状动脉阻塞风险与主动脉根部解剖结构、冠状动脉开口与人工血管的吻合方式、人工血管直径等因素之间的关系,为改良Bio-Bentall手术方法提供依据。方法:回顾性分析2017年1月至2021年6月期间中国医学科学院阜外医院血管外科中心由3位术者完成BioBentall手术的患者的临床资料,筛选出其中能获取清晰、可用CT资料的患者39例。通过3mensio软件分析患者Bio-Bentall术前及术后的CT资料,评估术后远期行ViV-TAVR的冠状动脉阻塞风险及相关影响因素。结果:术后平均随访(4.7±8.8)个月,门控增强心脏CT提示,39例患者术后右冠状动脉开口高度较术前明显降低[18.9(14.8,24.4)mm vs.22.0(18.4,27.4)mm,P=0.028],其中22例(56.4%)为冠状动脉阻塞高风险患者。术后生物瓣与人工血管的同轴性夹角对术后远期右冠状动脉阻塞风险有显著影响(HR=0.55,95%CI:0.37~0.83,P=0.013),冠状动脉开口与人工血管的吻合方式对术后远期冠状动脉阻塞风险无明显影响(HR=1.10,95%CI:0.83~1.40,P=0.648)。结论:在现有手术策略下,Bio-Bentall手术患者术后远期行ViV-TAVR的冠状动脉阻塞风险极高。目前的BioBentall手术方法亟需改进,以降低术后远期因生物瓣衰败行ViV-TAVR的冠状动脉阻塞风险,最大限度地提高未来行ViV-TAVR的可行性。Objectives:To analyze the risk of coronary obstruction in valve-in-valve transcatheter aortic valve replacement(ViVTAVR)after previous biological valve aortic root replacement(Bio-Bentall),and to discuss the relationship between coronary obstruction and aortic root anatomy,coronary anastomosis,artificial vessel diameter and other factors,and provide some clinical evidence for improving Bio-Bentall procedure.Methods:Clinical data of patients undergoing Bio-Bentall operations,which were completed by three surgeons in Vascular Surgery Center of Fuwai Hospital from January 2017 to June 2021,were retrospectively analyzed.Thirty-nine patients with clear CT imaging data were selected.Preoperative and postoperative CT data of all patients were analyzed using 3mensio software.The risk and risk factors of coronary obstruction in ViV-TAVR were evaluated.Results:Gated enhanced cardiac CT examinations of these 39 patients were performed(4.7±8.8)months after operation,and results indicated that the right coronary artery height decreased significantly after operation compared with before operation(18.9[14.8,24.4]mm vs.22.0[18.4,27.4]mm,P=0.028).Twenty-two patients(56.4%)were at high risk for coronary obstruction.The postoperative coaxial angle between prosthetic valve and artificial vessel had a significant impact on the postoperative risk of right coronary obstruction(HR=0.55,95%CI:0.37-0.83,P=0.013),and the coronary anastomosis methods had no significant impact on the risk of coronary obstruction(HR=1.10,95%CI:0.83-1.40,P=0.648).Conclusions:Patients undergoing Bio-Bentall with current surgical strategy are at high risk of future coronary obstruction with ViV-TAVR.We should improve the current Bio-Bentall surgical method to reduce the risk of coronary obstruction after ViV-TAVR in the future and maximize the feasibility of future ViV-TAVR.

关 键 词：经导管主动脉瓣置换术 主动脉根部置换术 瓣中瓣 冠状动脉阻塞 生物瓣膜 

分 类 号：R54[医药卫生—心血管疾病]