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  • 潘佳君,唐小军,乔帆,陆方林,徐志云,李白翎*.经导管主动脉瓣置换术后心脏传导阻滞情况分析[J].第二军医大学学报,2019,40(8):902-908    [点击复制]
  • PAN Jia-jun,TANG Xiao-jun,QIAO Fan,LU Fang-lin,XU Zhi-yun,LI Bai-ling*.Cardiac conduction block after transcatheter aortic valve replacement[J].Acad J Sec Mil Med Univ,2019,40(8):902-908   [点击复制]
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经导管主动脉瓣置换术后心脏传导阻滞情况分析
潘佳君,唐小军,乔帆,陆方林,徐志云,李白翎*
0
(海军军医大学(第二军医大学)长海医院心血管外科, 上海 200433
*通信作者)
摘要:
目的 探讨应用国产瓣膜的经导管主动脉瓣置换(TAVR)疗效和患者术后心脏传导阻滞发生情况及其对患者预后的影响。方法 选择2017年9月至2018年1月在我科行TAVR术的重度主动脉瓣狭窄或反流患者作为研究对象。应用国产的J-Valve或Venus-A瓣膜进行TAVR术,评估TAVR术后疗效和并发症发生情况,观察TAVR术中和术后新发心脏传导阻滞发生情况及住院期间心律失常恢复情况。根据出院时是否存在心脏传导阻滞,将患者分为心律正常组和传导阻滞组,比较两组患者的基线资料、术后情况和左心室结构与功能。结果 共入组16例患者,心律正常组12例、传导阻滞组4例。TAVR术后脑钠肽[(1 114.87±802.32)pg/mL vs(530.39±276.26)pg/mL,P=0.026]、主动脉瓣跨瓣压差[(83.06±37.76)mmHg vs(24.14±9.73)mmHg,P<0.001;1 mmHg=0.133 kPa]和主动脉瓣最大跨瓣流速[(466.00±82.30)cm/s vs(249.30±43.98)cm/s,P<0.001]降低,左心室舒张末期内径缩小[(5.41±0.83)cm vs(4.93±0.52)cm,P=0.010]。术后无或仅有微量至少量主动脉瓣反流,2例有肾功能不全基础疾病的患者出现肾功能恶化,其中1例予以血液透析治疗。所有患者住院期间均无死亡、急性心肌梗死、脑卒中、严重血管并发症等不良事件发生。共有4例(25.00%)患者出现新发心脏传导阻滞,其中1例为完全性房室传导阻滞,住院期间恢复为完全性左束支传导阻滞;1例为室内传导阻滞,住院期间发展为完全性左束支传导阻滞;另2例为完全性左束支传导阻滞。这4例患者出院时完全性左束支传导阻滞均未恢复。无住院期间需要置入永久性心脏起搏器的患者。心律正常组和传导阻滞患者术后肝肾功能、血红蛋白水平、脑钠肽水平及左心室结构与功能上的差异均无统计学意义(P均>0.05)。结论 应用国产介入瓣膜的TAVR术能有效降低患者主动脉瓣跨瓣压差且并发症少,术后可能发生完全性左束支传导阻滞等心脏传导阻滞,但此类传导阻滞在术后短期对心脏不良事件的发生和心功能无明显影响。
关键词:  经导管主动脉瓣置换术  完全性左束支传导阻滞  起搏器置入术  左心室射血分数
DOI:10.16781/j.0258-879x.2019.08.0902
投稿时间:2018-10-15修订日期:2018-11-22
基金项目:国家重点研发计划(2016YFC1100900).
Cardiac conduction block after transcatheter aortic valve replacement
PAN Jia-jun,TANG Xiao-jun,QIAO Fan,LU Fang-lin,XU Zhi-yun,LI Bai-ling*
(Department of Cardiovascular Surgery, Changhai Hospital, Naval Medical University(Second Military Medical University), Shanghai 200433, China
*Corresponding author)
Abstract:
Objective To evaluate the effectiveness of transcatheter aortic valve replacement (TAVR) using domestic valves for treating aortic valve stenosis or regurgitation, and to explore the incidence of cardiac conduction block after surgery and its influence on the prognosis of the patients. Methods The patients with severe aortic valve stenosis or regurgitation receiving TAVR surgery in our department from Sep. 2017 to Jan. 2018 were enrolled in this study. The TAVR surgery was performed with domestic valves (J-Valve or Venus-A), and the outcomes and incidence of complications were assessed after surgery. The patients were observed for the incidence of new-onset cardiac conduction block during and after TAVR and the recovery of arrhythmia during hospitalization. According to the presence of cardiac conduction block at discharge, the patients were divided into normal rhythm group and conduction block group. The baseline and postoperative characteristics, and left ventricular structure and function were compared between the two groups. Results Sixteen patients were enrolled in this study, including 12 in the normal rhythm group and 4 in the conduction block group. Brain natriuretic peptide ([1 114.87±802.32] pg/mL vs[530.39±276.26] pg/mL, P=0.026), aortic transvalvular pressure difference ([83.06±37.76] mmHg vs[24.14±9.73] mmHg, P<0.001; 1 mmHg=0.133 kPa), maximum transvalvular velocity of aortic valve ([466.00±82.30] cm/s vs[249.30±43.98] cm/s, P<0.001) and left ventricular end-diastolic diameters ([5.41±0.83] cm vs[4.93±0.52] cm, P=0.010) were significantly decreased after TAVR. After TAVR, there was no or only mild aortic valve regurgitation. Two patients with renal insufficiency developed deterioration of renal function, and one of whom received hemodialysis treatment. There were no death, acute myocardial infarction, stroke, or severe vascular complications during the hospitalization. A total of 4 patients (25.00%) had new-onset cardiac conduction block, including 1 patient with complete atrioventricular block who recovered to complete left bundle branch block, 1 patient with intraventricular block who progressed to complete left bundle branch block, and 2 patients with complete left bundle branch block during hospitalization. At discharge, the 4 patients still had complete left bundle branch block. There were no patients requiring permanent pacemaker implantation during the hospitalization. There were no significant differences in the postoperative liver function, renal function, hemoglobin, brain natriuretic peptide, or cardiac structure and function between normal rhythm group and conduction block group (all P>0.05). Conclusion TAVR with domestic valves can effectively reduce the aortic transvalvular pressure difference with fewer complications. It may cause complete left bundle branch block, which has no significant influence on the short-term adverse cardiac events and cardiac function after operation.
Key words:  transcatheter aortic valve replacement  complete left bundle branch block  pacemaker implantation  left ventricular ejection fraction