Transcatheter aortic valve replacement (TAVR) has been confirmed to be safety and efficacy for high-risk elderly aortic stenosis, and the clinical effect of TAVR for medium and low-risk aortic stenosis is not worse than that of surgery. The development of surgical techniques and instruments has made cardiologists attempt to broaden the surgical indications. Many elderly and high-risk patients with pure native aortic regurgitation have been treated “off label” with similar techniques, completing artificial valve replacement, restoring valve function and improving the prognosis. However, due to the high requirements of surgical techniques and surgical complications, there is a lack of randomized controlled studies to confirm its safety and effectiveness. Unlike aortic stenosis, native aortic regurgitation presents unique challenges for transcatheter valves. In this article, the authors review current advances in the treatment of aortic valve regurgitation with TAVR.
The technique of transcatheter aortic valve implantation has become increasingly mature. Although the transapical approach has a certain degree of minimally invasive trauma, it still has the characteristics such as heart beating without cardiopulmonary bypass, and the low technical requirements of catheter guide wire. In particular, the valve path is short and coaxial, which is easy to manipulate, and pure regurgitation and stenosis can be easily operated and are not subject to the limit of peripheral artery stenosis. It is still one of China's main approaches for transcatheter aortic valve replacement. Its perioperative management still has specific features and differs from the femoral artery approach. In addition, there is little relevant literature abroad. Therefore, domestic experts in this field were organized to discuss the development of perioperative management specifications to provide reference and techniques support for developing this field in China and further improve the quality of clinical operation and perioperative management. It will provide more safe and more effective medical services to these patients.
ObjectiveTo assess outcomes of transcatheter aortic valve replacement (TAVR) for pure native aortic valve regurgitation.MethodsA total of 129 patients underwent transfemoral TAVR in Fuwai Hospital from May 2019 to October 2020 were retrospectively analyzed. There were 83 males and 46 females with an average age of 72.26±8.97 years. The patients were divided into a pure native aortic valve regurgitation group (17 patients) and an aortic valve stenosis group (112 patients).ResultsThe incidence of valve in valve was higher in the pure native aortic valve regurgitation group (47.0% vs. 16.1%, P<0.01). There was no statistical difference between the two groups in conversion to surgery, intraoperative use of extracorporeal circulation, intraoperative left ventricular rupture, postoperative use of extracorporeal membrane oxygenation (ECMO), peripheral vascular complications, disabled stroke, death, or pacemaker implantation. There was no statistical difference in the diameter of annulus (25.75±2.21 mm vs. 24.70±2.90 mm, P=0.068) or diameter of outflow tract (25.82±3.75 mm vs. 25.37±3.92 mm, P=0.514) between the pure native aortic valve regurgitation group and the aortic valve stenosis group.ConclusionTransfemoral TAVR is a feasible method for patients with pure native aortic valve regurgitation. The diameter of annulus plane, the diameter of outflow tract and the shape of outflow tract should be evaluated.
Transcatheter aortic valve replacement has revolutionized the management of aortic stenosis and become the gold standard for the treatment of symptomatic and severe aortic valve stenosis in elderly patients. With the improvement in design and materials, newer generation transcatheter aortic valve prostheses had overcome the limitations of early-generation devices that were susceptible to paravalvular leak, atrioventricular block and vascular complications, to a certain extent. This review provides an update on the latest advances in transcatheter aortic valve prostheses.
Objective To analyze the echocardiographic characteristics of above grade 3+ mitral regurgitation (MR) patients by 3D transesophageal echocardiography (3D-TEE) in transcatheter edge-to-edge repair (TEER) and compare the intervention rate of TEER treatment in patients with different risk stratification. Methods We retrospectively analyzed the clinical data of 91 patients with above grade 3+ MR in Anzhen Hospital between June 2021 and April 2022. There were 45 males and 46 females aged 66.5±15.9 years. According to pathogenesis, the patients were divided into different anatomical groups and risk stratification groups. There were 34 patients in a simple degenerative group (simple DMR group), 28 patietns in a complex disease group (Complex group), 14 patients in a simple ventricular functional reflux group (simple VFMR group), 9 patients in a simple atrial functional reflux group (simple AFMR group), and 6 patients in a mixed functional reflux group (mixed FMR group). All patients were examined with a unified standard of transthoracic echocardiography (TTE) and 3D-TEE to compare the characteristic three-dimensional structural changes of the mitral valve in each group. According to the three partition strategy of preoperative anatomical evaluation of TEER, the risk stratification was conducted for the enrolled patients, which was divided into three regions from light to heavy: green area, yellow area, and red area. TEER treatment intervention rate of patients with different risk stratification was calculated. Results Ant leaf angle and post leaf angle were negative in the simple DMR and Complex groups, and non-planar angle, prolapse height and prolapse volume were higher than those of the other groups (P=0.000). Ant leaf angle and post leaf angle were positive in the VFMR group and the mixed FMR group. Anterior and posterior (AP) diameter of valve ring (P=0.036), tenting height and tenting volume were higher than those of other groups (P=0.000). AP diameter, tenting height and tenting volume were changed mildly in patients with simple AFMR. MR patients in red and yellow zone achieved a 28.1% TEER intervention rate.Conclusion Standardized TTE and TEE examinations are crucial for the qualitative and quantitative diagnosis of MR in the echo core-lab. 3D-TEE mitral valve parameter can help determine the exact pathogenesis of MR and to improve the interventional rate of challenging MR patients.
Objective To evaluate a score system to allow stratification of complexity in degenerative mitral valve repair. Methods We retrospectively reviewed the clinical data of 312 consecutive patients who underwent surgery for mitral valve repair and whose preoperative echocardiography was referable in our hospital from January 2012 to December 2013. A scoring system for surgical complexity was used based mainly on the preoperative echocardiography findings. Complexity of mitral valve repair was scored as 1 to 9, and patients were categorized into 3 groups based on the score for surgical complexity: a simple group (1 point), an intermediate group (2-4 points) and a complex group (≥5 points). There were 86 males and 35 females in the simple group (n=121) with an average age of 51.6±12.6 years, 105 males and 53 females in the intermediate group (n=158) with an average age of 51.1±12.8 years and 25 males and 8 females in the complex group (n=33) with an average age of 49.3±13.0 years. Results There was significant difference in surgical complexity in different groups. In the simple, intermediate and complex groups, the mean cardiopulmonary bypass time was 111.7±45.5 min, 117.7±40.4 min and 153.4±74.2 min (P<0.001), the mean cross-clamping time was 77.5±33.8 min, 83.2±29.9 min and 108.8±56.2 min (P<0.001), and the mean number of repair techniques utilized was 2.1±0.4, 2.4±0.6 and 2.8±0.8 (P<0.001). However, there was no significant difference in the early and late outcomes in different groups. Conclusion It is feasible to use echocardiography to quantitatively evaluate the difficulty of mitral valvuloplasty.
ObjectiveTo analyze short-and long-term results of mitral valve repair for the treatment for mitral anterior leaflet prolapse (ALP), and summarize our clinical experience. MethodsClinical data of 67 patients with mitral ALP who underwent mitral valve repair in Department of Cardiac Surgery of Beijing Anzhen Hospital from January 2002 to June 2013 were retrospectively analyzed. There were 41 male and 26 female patients with their age of 18-71 (46.34±7.68)years and body weight of 43-91 (65.30±18.60)kg. Preoperatively, there were 5 patients in New York Heart Association (NYHA)function class Ⅱ, 27 patients in class Ⅲ, and 35 patients in class Ⅳ. Surgical techniques included 'edge-to-edge' technique, artificial chordal replacement, chordal shortening and edge-to-edge chordal transformation. There were 46 patients with chordal rupture and 21 patients with chordal elongation. Mean mitral regurgitation (MR)area was 15.36±4.53 cm2, and left ventricular ejection fraction (LVEF)was 29%-71%. Echocardiography was performed before discharge, 6 months and every 1 to 2 years after the operation for all the patients to observe short-and long-term results of mitral valve repair for the treatment for mitral ALP. ResultsThere was no in-hospital death. One patient underwent mitral valve replacement because of anterior leaflet perforation 3 days after the operation. Another patient underwent a second mitral valve repair because of avulsion of mitral annulus and proteinuria 6 months after the first operation. None of the other patients received reoperation. All the 67 patients (100%)were followed up for 2-138 (65.6±17.3)months. During follow-up, there was not late death, and all the patients were in NYHA functional class I. Echocardiography showed that cross-sectional area of the mitral valve was 2.3-4.8 (3.63±0.79)cm2. There was no significant MR, and mean MR area was 0.57±0.37 cm2. Left atrium diameter (38.23±11.56 mm vs. 49.26±10.36 mm, P < 0.05)and left ventricular end-diastolic diameter (43.35±13.74 mm vs. 64.29±12.54 mm, P < 0.05)were significantly smaller than preoperative values. ConclusionNearly all the patients with mitral ALP can receive personalized mitral valve repair with satisfactory surgical outcomes.
Objective To evaluate the efficacy of transcatheter aortic valve implantation (TAVI) for native aortic valve regurgitation. MethodsLiterature from The Cochrane Library, PubMed, EMbase, Cochrane Controlled Trials Registry, ClinicalTrials.gov and China Biomedical Literature Database from January 2002 to May 2021 were searched by computer. The literature on TAVI or transcatheter aortic valve replacement treatment for simple aortic reflux were collected. Two reviewers independently screened the literature according to the inclusion and exclusion criteria, extracted data, and assessed the quality of the literature. Meta-analysis was performed using STATA 14.0 software. ResultsA total of 15 studies including 1 394 patients were included. The Newcastle-Ottawa Scales of the studies were≥6 points. The success rate of prosthetic valve implantation was 72.0%-100.0%, and there was no report of serious complications such as surgical death, myocardial infarction, and valve annulus rupture. The 30-day all-cause mortality rate was 6.3% [95%CI (3.4%, 9.1%)]. The incidence of stroke within 30 days and the rate of postoperative permanent pacemaker implantation were 2.0% [95%CI (1.0%, 4.0%)] and 6.0% [95%CI (4.0%, 10.0%)], respectively, and were both within acceptable limits. ConclusionFor patients with simple high-risk aortic regurgitation, TAVI can obtain satisfactory treatment effects and has low postoperative complications rate, and it may be a potential treatment option for such patients.
ObjectiveTo review the characteristics of patients who underwent atrioventricular septal defects (AVSD) repair with prosthetic valve ring implantation in our hospital, and to analyze the safety and effectiveness of this intervention.MethodsThe clinical data of all patients diagnosed with AVSD who received surgery repair and prosthetic valve ring implantation from January 1, 2018 to July 12, 2020 in Guangdong Provincial People's Hospital were collected and analyzed. There were 22 patients with 9 males and 13 females at a median age of 35.00 (14.10, 53.00) years. There were 9 (40.9%) patients with prosthetic half or full rings placed on the left atrioventricular valve and 18 (81.8%) patients with prosthetic half or full rings placed on the right atrioventricular valve. ResultsThe median postoperative hospital stay was 7.00 (6.00, 8.80) d, and the postoperative mechanically assisted ventilation time was 11.00 (6.25, 19.00) h. There were 2 (9.1%) patients of moderate or higher postoperative atrioventricular valve regurgitation, 1 on the left and 1 on the right. There was one patient (4.5%) of the postoperative residual septal defect. There was no left ventricular inflow or outflow tract obstruction and no postoperative residual atrial septal defect during the follow-up of 152.00 (124.00, 1 030.00) d.ConclusionImplantation of a prosthetic ring is safe and effective in patients with AVSD, and the structural strength of the ring may be improved after the implantation. The physiological development of the AVSD annulus after prosthetic ring implantation and the results of long-term follow-up needs further attention.
ObjectiveTo summarize the reoperation experience for complete atrioventricular septal defect (CAVSD) with severe left atrioventricular valve regurgitation (LAVVR) by standardized mitral repair-oriented strategy.MethodsFrom 2016 to 2019, 11 CAVSD patients underwent reoperation for severe LAVVR by standardized mitral repair-oriented strategy at Fuwai Hospital, including 5 males and 6 females with a median age of 56 (22-152) months. The pathological characteristics of severe LAVVR, key points of repair technique and mid-term follow-up results were analyzed.ResultsThe interval time between the initial surgery and this surgery was 48 (8-149) months. The aortic cross-clamp time was 54.6±21.5 min and the cardiopulmonary bypass time was 107.4±38.1 min, ventilator assistance time was 16.4±16.3 h. All patients recovered smoothly with no early or late death. The patients were followed up for 29.0±12.8 months, and the echocardiograph showed trivial to little mitral regurgitation in 5 patients, little regurgitation in 5 patients and moderate regurgitation in 1 patient. The classification (NYHA) of cardiac function was class Ⅰ in all patients.ConclusionStandardized mitral repair-oriented strategy is safe and effective in the treatment of severe LAVVR after CAVSD surgery, and the mid-term results are satisfied.