以經導管主動脈瓣置換術(TAVI)為代表的經導管瓣膜介入治療(TVT)技術是CIT持續數年、熱度不減的話題。臨床評估需要對患者各髒器功能進行全麵評估,包括:①是否需要瓣膜置換術;②是否為外科手術禁忌或高危;③有無TAVI禁忌證。
以經導管主動脈瓣置換術(TAVI)為代表的經導管瓣膜介入治療(TVT)技術是CIT持續數年、熱度不減的話題。本屆大會圍繞TVT,以TAVI為重點,於3月18日-19日安排了3場內容。從基本概念、影像學應用、入路選擇、適應證、並發症,到歐洲各國觀點及亞洲各地區現狀,內容全麵深入,可謂“全球視野,全景展示”。全體大會第一場還有來自阜外醫院的TAVI示教演示。
中國現狀
中國醫學科學院阜外醫院吳永健教授:中國自2010年開展首例TAVI以來,受製於瓣膜研發進程,整體進展較緩慢。目前我國隻有十幾家醫院開展了TAVI,總數在500例左右,且大都處於初始階段,隻有3~4家醫院能夠常規開展TAVI治療。我國TAVI器械的研發較西方國家晚了10年,不同於其他技術的“拿來主義”,我國TVT(包括TAVI)走的是自主創新道路,這是我國這幾年TAVI發展相對滯後的原因。
未來幾年我們將迎來本土瓣膜發展的高峰。國產首個瓣膜目前已經完成臨床試驗,即將進入市場,明年至後年中國前4款本土瓣膜將相繼問世,第二代國產瓣膜今年也進入臨床試驗。本土瓣膜的研發會對進口瓣膜提出更高要求,最終將造福於患者。隨著相關研究的開展,TAVI手術操作的安全性也將進一步提升,使更多醫院有能力開展此項技術。
這樣的進度實際上恰到好處。我國患者群還未真正高齡化。中國目前65歲以上人群已經超過兩億,但75歲以上“高齡化”人群還不算太多,未來隨著中國“高齡化”人群的增長,瓣膜病問題會越來越普遍。因此目前我國TAVI的研發進度正好契合中國人群“高齡化”的速度,這是曆史賦予中國的契機。
然而,我國TAVI發展麵臨幾大挑戰。首先,與歐美國家相比,我國患者BAV發生率更高、鈣化積分更高,同樣年齡的老齡患者相對更加虛弱。我國患者對待疾病的態度也非常消極,有著“好死不如賴活著”的觀念,常常拖延病情至非常嚴重才開始求醫問藥。其次,醫生本身素質有待提高。目前我國西醫分科過細而缺乏全麵,而瓣膜疾病涉及多學科,麵對這項新技術,需要探索新的能夠有機整合多學科的醫療模式,這對醫生自身素質及其多學科合作能力提出了進一步要求。最後,任何醫療新技術的順利開展都需要製度上的重視和支持,如此才能解決醫生與患者的後顧之憂。未來想要全麵開展TAVI,以上問題都需要逐一解決。
病例選擇
浙江大學醫學院附屬第二醫院 劉先寶 王建安教授:所有主動脈瓣疾病患者進行TAVI前必須經過嚴格篩選,主要包括臨床評估及影像學評估。
臨床評估需要對患者各髒器功能進行全麵評估,包括:①是否需要瓣膜置換術;②是否為外科手術禁忌或高危;③有無TAVI禁忌證。
影像學評估是TAVI術前評估的重點,包括主動脈根部結構、全程主動脈情況及外周動脈解剖情況,以判斷患者是否適合TAVI及指導瓣膜型號選擇。評估手段包括:①經胸超聲心動圖(TTE)或經食道超聲心動圖(TEE),主要評估心髒形態、功能、瓣膜功能及解剖,主動脈根部解剖,合並其他心髒病及心髒內血栓、贅生物等情況;②多排螺旋計算機體層攝影(MSCT)通過三維重建,可多切麵測量評估主動脈根部解剖,如瓣環內徑、周徑、麵積及瓣膜鈣化程度、左室流出道內徑、主動脈竇內徑、升主動脈內徑、竇管交界處內徑,為瓣膜選擇提供參考,MSCT也可測量冠狀動脈開口高度,防止瓣膜置入過高堵塞冠脈,MSCT還可測量外周血管內徑大小、鈣化程度及迂曲情況,評估手術路徑;③冠脈計算機體層攝影血管造影(CTA)或冠脈造影,評估是否合並冠心病。
病例挑戰:二葉式主動脈瓣
美國西達斯西奈醫學中心 Hasan Jilaihawi:This year at CIT I am delighted to participate in a Live Case from Fu Wai Hospital of TAVI for a case of severe aortic stenosis. The case planned is bicuspid with aortopathy and raises several important issues for contemporary TAVI for discussion. The patient is octogenarian, at high risk for conventional surgery and has critical aortic stenosis.
The Venus-A trial treated over 100 patients at high risk of surgery with low rates of mortality at early and mid-term follow up. Almost half of the patients in this trial had congenital (or anatomically bi-commissural) BAV disease, which may be attributable to the slightly younger age of patients presenting for TAVI in China.
Data from the US suggests that BAV disease may be grossly underestimated, but certainly at this time the vast majority of patients are, in contrast to the Chinese population, tricuspid.
This may change in the near future, however, with the advent of low and intermediate surgical risk clinical trials, which will treat younger patients with a greater frequency of BAV anatomy.
Data from the Venus-A trial will be further discussed at CIT but, importantly, demonstrated no differences in outcomes with Venus-A between patients with tricuspid and BAV disease.
This is in contrast to published data from studies in Europe and the US, which have shown higher rates of paravalvular leak. The differences in outcomes in BAV disease could be attributable to case selection, procedural planning and technique and a high radial force device.
An important caveat with BAV disease is the co-existence of aortopathy with ascending thoracic aneurysms. This aortopathy can also be a risk of cumulative mortality with progressive aortic dilatation and the potential for rupture. The management of co-existing aortopathy presents an enormous challenge to transcatheter therapies.
The conventional surgical treatment is extensive with aortic root replacement combined with valve replacement. Thoracic endovascular aortic repair (TEVAR) is a transcatheter option that shows promise and could be considered for such patients.
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