经导管主动脉瓣植入术(TAVI)适应证和并发症防治策略.pptx
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经导管主动脉瓣植入术(TAVI)适应证和并发症防治策略.pptx
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经导管主动脉瓣植入术(TAVI)适应证和并发症防治策略,世界第1例成功TAVI病例,AlainCribier,April16,2002,TAVI手术量增长趋势,3,内容,TAVI研究背景TAVI适应证TAVI并发症及防治策略,内容,TAVI研究背景TAVI适应证TAVI并发症及防治策略,为什么需要TAVI,TAVI研究背景一,AorticstenosisinSingapore,Tayetal.SMJ2012,TAVI研究背景二,主动脉瓣退行性变是老年主动脉瓣狭窄的主要原因,7,TAVI研究背景三,治疗时机和治疗选择,9,TAVI研究背景四,高龄患者不简单-合并太多的临床情况,10,PARTNERTrialDesign,CohortA84yrsN=699,CohortB83yrsN=358,J.Am.Coll.Cardiol.2012;59;1200-1254,www.nejm.org,PARTNER研究成就了TAVI的地,TAVI研究背景五位,TranscatheterAorticValveImplantation(TAVI),Leon,NEJM,363:
17,October2010,TAVI研究背景六TAVI的入路选择,14,内容,TAVI研究背景TAVI适应证TAVI并发症及防治策略,15,经导管主动脉瓣植入术(TA,证,VI),应,症,经导管主动脉瓣植入术(TAVI)禁忌,内容,TAVI研究背景TAVI适应证TAVI并发症及防治策略,并发症,TA处V理I并:
根发据临症床状及况处、血理流动策力略学状态等,休克,低心排出量冠脉闭塞严重瓣环破裂心室穿孔,IABP,CPB及药物PCI或CABG心包引流、自体输血、外科开胸闭合;监护、镇静心包引流、自体输血、外科开胸闭合,瓣周漏中心性瓣膜返流,后扩张通常为自限,需软钢丝或导管探查;再次TAVI,心脏阻滞瓣膜位置不良瓣膜血栓房颤轻重度缺血性、出血性卒中严重出血血管并发症急性肾损伤,起搏器植入再次置入瓣膜紧急血管内或外科治疗药物或电转复:
心率或节律控制导管、机械法取栓;阿司匹林、抗凝;中和抗凝及纠正凝血血流动力学支持,输血紧急血管内修补或外科支持治疗;维持最佳液体状态,TAVI并发症之一-心脏传导异常,IncidenceofCHBrequiringpermanentpacemakerimplantationhasbeenhigherwiththeCoreValve(19.2%to42.5%)thanwiththeSapienvalve(1.8%to8.5%)largerprofileandextensionlowintotheLVOTOccurrenceofCHB/LBBBBAV46%Balloon/prosthesispositioning1200-1254,IncidenceofleftbundlebranchblockafterimplantationofMedtronicCoreValveorEdwardsSAPIENvalve,vanderBoon,R.M.etal.(2012)NewconductionabnormalitiesafterTAVIfrequencyandcausesNat.Rev.Cardiol.doi:
10.1038/nrcardio.2012.58,IncidenceofcompleteatrioventriculardissociationafterimplantationofMedtronicCoreValveorEdwardsSAPIENvalve,vanderBoon,R.M.etal.(2012)NewconductionabnormalitiesafterTAVIfrequencyandcausesNat.Rev.Cardiol.doi:
10.1038/nrcardio.2012.58,Anatomyandrelationshipbetweentheaorticvalvularcomplexandtheatrioventricularconductionsystem,vanderBoon,R.M.etal.(2012)NewconductionabnormalitiesafterTAVIfrequencyandcausesNat.Rev.Cardiol.doi:
10.1038/nrcardio.2012.58,Availableprostheticaorticvalves-MedtronicCoreValve,orEdwardsSAPIENvalve,vanderBoon,R.M.etal.(2012)NewconductionabnormalitiesafterTAVIfrequencyandcausesNat.Rev.Cardiol.doi:
10.1038/nrcardio.2012.58,IncidenceofnewimplantationofapermanentpacemakerafterimplantationoftheMedtronicCoreValveortheEdwardsSAPIENvalve,vanderBoon,R.M.etal.(2012)NewconductionabnormalitiesafterTAVIfrequencyandcausesNat.Rev.Cardiol.doi:
10.1038/nrcardio.2012.58,TAVI后传导异常的防治策略,TAVI并发症之二-瓣膜返流,AorticRegurgitationTypicallyparavalvularmildormild-moderateseverityMostofARdisappearsorreducesat1yrfollow-up13%absent,80%mildAR,CardiolClin29(2011)211222J.Am.Coll.Cardiol.2012;59;1200-1254,P1A2years,Kodali,etal.NEJM2012,SeverityofTotalAorticRegurgitationandoutcome,ParavalvularAR,CentralvalvularAR,Post-deploymentballoondilation,rapidRVpacingforstabilization,valveinvalveimplantation,Usuallyself-limited,GentleprobingofleafletswithasoftwireorcatheterDeliveryofa2ndTAVRdevice,valveinvalve,J.Am.Coll.Cardiol.2012;59;1200-1254,TAVI后瓣膜返流的防治策略,RapidPacingforstabilization,ValveinValveImplantation,Reductionofdiastole,CardiolClin29(2011)211222,TAVI后瓣膜返流的防治策略,瓣环测量,CTAngioTEETTECT冠状面矢状面(2mm)瓣环为椭圆形超声一般从短轴测瓣环,SAPIENXTTEE瓣环测量推荐,1719,1822,2125,2427,CoreValve,26mmFor2023mm瓣环,29mmFor2327mm瓣环,31mmFor2629mm瓣环,TAVI并发症之三-脑卒中,TAVI后脑部损伤,Rodes-CabauJACC2011AstarciEJCTS2011KhalertCirculation2010,TFvs.TATAVISAPIENvs.CoreValve均无显著差异,不影响神经认知功能,“静息性”(Silent)或无症状性脑损伤,3,5,DWI(MRI)FollowingAVRShowingSilentStroke,36,TAVI显著高于AVR(PARTNER:
5.5%vs.2.4%)围手术期风险最高缩短操作时间减少植入前BAV次数脑血管保护装置/Embrelladeflector,EmbrellaCardiovascular(deflector),SMT(deflector),ClaretMedical(capture),TAVI后脑卒中的防治策略,TAVI并发症之四-严重血管并发症,术前评估:
CT,TTE,Angio,Righti7li5amcmRightf6e3mmomral,准确测量血管腔内径,降低穿刺鞘管的管径改进鞘管技术,可扩张鞘管,球囊堵塞&带膜支架,Coda,Reliant,Fluency,Viabahn,TAVI并发症之五-急性肾损伤(AKI),TAVI术后:
11.7%27.8%TAVI早期重要并发症显著增加围手术期及中期死亡率VARC-ModifiedRIFLEscore有助于辨别高危因素:
DM周围血管病中晚期CKD等,Nephrology17(2012)445451,发生率:
28.8%(15/52)独立预测因素:
围手术期输血、TA、高血压史局限型:
样本量小,TAVI其它并发症,CausesofhypotensionafterTAVIVascularcomplicationsiliacruptureVentricularruptureAcutevalvedysfunctionCoronaryarteryobstructionMultiplerapidpacingepisodesinptswithpoorLVfunctionSuicidalLVinsevereLVHAfterremovingAVobstructionLVdecompressestosuchanextentthatthesubvalvularhypertrophyobstructsoutflowtreatedwithfluids1200-1254,TAVI其它并发症,Leftmainstemcompromisewithsemi-occlusivedisplacementofcalcifiednodulefromaorticvalve.TreatedwithCPBdeviceexplantationAVRAlsoPCI/CABGCardiolClin29(2011)211222J.Am.Coll.Cardiol.2012;59;1200-1254,TAVI之总结篇,“SymptomaticSevereAorticStenosis”,ProhibitiveriskHighriskforsurgeryInoperability,Complications3%mortality(STS,EuroSCORE)2%Stroke11%prolongedventilationOrganfailureThromboembolicComplicationsBleedingProstheticvalveDysfunction,TAVRSAVR30-40%donotundergoSAVRAdvancedageLVdysfunctionMultipleco-morbiditiesPt.preferencePhysicianassessmentJ.Am.Coll.Cardiol.2012;59;1200-1254,ThankYou,49,
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- 关 键 词:
- 导管 主动脉 植入 TAVI 适应 并发症 防治 策略
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