冠状动脉旋磨及支架置入+TAVR“一站式”手术的可行性探讨

目的探讨合并冠状动脉重度钙化及狭窄的重度主动脉瓣狭窄(AS)患者行经导管冠状动脉旋磨及支架置入+经导管主动脉瓣置换(TAVR)“一站式”手术的可行性。方法本研究为回顾性研究,连续入选2019年4到10月于阜外医院接受冠状动脉旋磨及支架置入+TAVR“一站式”手术治疗的患者3例。收集患者的术前临床、影像学(包括超声心动图及主动脉根部及全主动脉CT)评估资料,及冠状动脉介入、TAVR手术资料和手术效果、术后6个月随访结果。结果本研究共纳入3例患者,其中2例为女性,年龄范围66~80岁,平均胸外科医师学会(STS)风险评分为7.8%,术前平均主动脉瓣最大流速为4.4 m/s,平均跨瓣压差为52.3 mmHg(1 mmHg=0.133 kPa),平均左心室射血分数为48.6%。2例患者需旋磨靶病变位于前降支中段,1例位于左主干到前降支,3例均合并非旋磨靶病变,平均SYNTAX积分为20分。术中均采用股动脉入路,先进行主动脉瓣跨瓣留置猪尾导管,然后行冠状动脉靶病变旋磨并置入药物洗脱支架,同期进行非旋磨靶病变的支架置入,冠状动脉介入术后予以主动脉瓣球囊扩张及自膨胀瓣膜置入,1例因瓣膜位置偏高予以“瓣中瓣”置入。3例患者均顺利完成手术,即刻效果满意,术中均无并发症。术后复查超声心动图示:平均主动脉瓣最大流速为2.1 m/s,平均跨瓣压差为9.3 mmHg,平均左心室射血分数为59%。随访6个月内无死亡,无冠状动脉再次血运重建。结论对于合并冠状动脉重度钙化及狭窄且外科风险较高的AS患者,行冠状动脉旋磨及支架置入+TAVR“一站式”手术治疗初步结果满意,该技术具有可行性。

Feasibility of single-stage stent implantation following rotational atherectomy combined with TAVR

Objective To explore the feasibility of the single-stage stent implantation following rotational atherectomy combined with transcatheter aortic valve replacement(TAVR)in treating patients with severe aortic stenosis(AS)and severe calcified coronary artery stenosis.Methods Three patients who received single-stage stent implantation following rotational atherectomy combined with TAVR in Fuwai hospital from April to October 2019 were included in this retrospective analysis.Clinical and anatomical features(including echocardiography and aortic CT)of the patients were collected,efficacy and safety of this operation strategy were observed and 6 months follow up results were summarized.Results Three patients(2 females,66-80 years old)were included.The mean Society of Thoracic Surgeons(STS)risk score was 7.8%.The mean maximum velocity of aortic valve was 4.4 m/s,the mean transvalvular pressure gradient was 53.2 mmHg(1 mmHg=0.133 kPa),mean left ventricular ejection fraction(LVEF)was 48.6%.All three patients had severe calcified coronary artery stenosis:left anterior descending artery(LAD,n=2)and left main coronary artery(LM,n=1),requiring rotary grinding.The mean SYNTAX score was 20.All the procedures were performed through transfemoral access.After aortic valve crossing,all coronary lesions were successfully treated with stent implantation following rotational atherectomy,transfemoral TAVR was then immediately performed with a self-expandable Venus-A valve.One patient underwent“valve-in-valve”implantation due to the high-implantation position of the first valve.The procedures were completed without complications in all the three patients.The immediate effect was satisfactory.Echocardiography results showed that the mean maximum velocity of aortic valve was 2.1 m/s,mean gradient was 9.3 mmHg,and mean LVEF was 59%after the procedure.There was no death and revascularization during the 6 months follow-up.Conclusion In patients with severe calcified coronary artery and severe AS with high risk of cardiac surgery,the single-stage stent implantation following rotational atherectomy combined with TAVR is feasible and results are satisfactory in this patient cohort.