金沁纯,潘文志,张晓春,管丽华,张蕾,陈莎莎,周达新,葛均波

• 1:复旦大学附属中山医院心内科

摘要(Abstract)：

目的探讨经导管主动脉瓣置换术(TAVR)对主动脉瓣狭窄(AS)患者肺动脉压力的影响。方法回顾性分析2012年6月至2017年7月复旦大学附属中山医院行TAVR的患者资料。纳入71例患者,平均年龄(78.6±6.4)岁,女24例,男47例。按肺动脉收缩压(SPAP)值将患者分为三组:SPAP<40 mmHg(1 mmHg=0.133 kPa;A组,10例),SPAP 40～60 mmHg(B组,42例)和SPAP≥60mmHg的患者(C组,19例)。并对三组患者TAVR术后肺动脉压下降程度及相关因素进行对比分析。结果随着肺动脉压力升高,A、B、C三组患者NYHA心功能分级[(2.22±0.44)级比(2.62±0.59)级比(3.12±0.70)级,P=0.003]、平均主动脉瓣跨瓣压差[(54.11±9.31)mmHg比(56.88±18.40)mmHg比(44.35±18.30)mmHg,P=0.029]、左心室射血分数(LVEF)[(61.73±7.17)%比(56.20±10.89)%比(49.08±15.29)%,P=0.021]比较,差异均有统计学意义。TAVR术后,总体上患者术后1周SPAP较术前下降[(42.10±9.49)mmHg比(47.02±13.74)mmHg,P<0.001],术后1个月、6个月与术后1周比较差异均无统计学意义(均P>0.05)。C组患者术后1周SPAP出现明显下降,较术前有显著变化,差异有统计学意义(P<0.001),并一直延续至1个月、6个月随访。B组术后1周SPAP也出现下降(P<0.001),1个月、6个月随访时,持续下降的肺动脉压力较术前有显著变化,差异有统计学意义(P<0.001)。A组术后肺动脉压力无明显变化。术前A、B、C三组患者S PA P比较差异有统计学意义[(29.89±4.54)mmHg比(47.02±13.74)mmHg比(65.76±8.95)mmHg,P<0.001];术后1周,B、C组SPAP下降,但三组患者比较差异仍有统计学意义[(29.55±2.89)mmHg比(40.74±7.23)mmHg比(51.74±7.12)mmHg,P<0.001],且在这两个时间点,组间两两比较,SPAP差异均有统计学意义(均P<0.001)。但三组患者SPAP术后1个月[(29.44±4.24)mmHg比(33.33±6.51)mmHg比(34.94±5.51)mmHg,P>0.05]和术后6个月[(28.89±4.23)mmHg比(31.35±7.56)mmHg比(32.35±8.02)mmHg,P>0.05]比较,差异无统计学意义。患者按TAVR术后肺动脉压力下降幅度是否≥20%将患者分为两组。SPAP下降≥20%组术前STS评分[9.65(4.08,29.81)分比6.93(3.67,17.29)分,P=0.030]、LVEF升高值[(9.63±8.97)%比(5.77±6.56)%,P=0.048]显著高于SPAP下降<20%组。logistic逐步多元回归分析显示,术前STS评分≥8分、基线SPAP 40～60 mmHg是患者SPAP下降≥20%的相关因素。结论 TAVR能够有效降低AS合并肺动脉高压患者的SPAP,且其效果具有持续性。

关键词(KeyWords)： 经导管主动脉瓣置换术;肺动脉高压;主动脉瓣狭窄;心功能

Abstract:

Keywords:

基金项目(Foundation):

作者(Author): 金沁纯,潘文志,张晓春,管丽华,张蕾,陈莎莎,周达新,葛均波

参考文献(References)：

• [1]Bach DS,Siao D,Girard SE,et al.Evaluation of patients with severe symptomatic aortic stenosis who do not undergo aortic valve replacement:the potential role of subjectively overestimated operative risk.Circ Cardiovasc Qual Outcomes,2009,2(6):533-539.
• [2]Ferrero V,Cervesato E,Pavan D.Pulmonary artery hypertension in adult patients with symptomatic valvular aortic stenosis.Am JCardiol,2000,85(2):204-208.
• [3]Carnero-Alcazar M,Reguillo-Lacruz F,Alswies A,et al.Shortand mid-term results for aortic valve replacement in octogenarians.Interact Cardiovasc Thorac Surg,2010,10(4):549-554.
• [4]Ben-Dor I,Goldstein SA,Pichard AD,et al.Clinical profi le,prognostic implication,and response to treatment of pulmonary hypertension in patients with severe aortic stenosis.Am J Cardiol,2011,107(7):1046-1051.
• [5]Miceli A,Varone E,Gilmanov D,et al.Impact of pulmonary hypertension on mortality after operation for isolated aortic valve stenosis.Int J Cardiol,2013,168(4):3556-3559.
• [6]Falk V,Baumgartner H,Bax JJ,et al.2017 ESC/EACTSguidelines for the management of valvular heart disease.Eur JCardiothorac Surg,2017,52(4):616-664.
• [7]Medvedofsky D,Klempfner R,Fefer P,et al.The signifi cance of pulmonary arterial hypertension pre-and post-transfemoral aortic valve implantation for severe aortic stenosis.J Cardiol,2015,65(4):337-342.
• [8]Roselli EE,Abdel AA,Houghtaling PL,et al.Pulmonary hypertension is associated with worse early and late outcomes after aortic valve replacement:implications for transcatheter aortic valve replacement.J Thorac Cardiovasc Surg,2012,144(5):1067-1074.
• [9]Tang M,Liu X,Lin C,et al.Meta-analysis of outcomes and evolution of pulmonary hypertension before and after transcatheter aortic valve implantation.Am J Cardiol,2017,119(1):91-99.
• [10]D'Ascenzo F,Conrotto F,Salizzoni S,et al.Incidence,predictors,and impact on prognosis of systolic pulmonary artery pressure and its improvement after transcatheter aortic valve implantation:a multicenter registry.J Invasive Cardiol,2015,27(2):114-119.
• [11]Bishu K,Suri RM,Nkomo VT,et al.Prognostic impact of pulmonary artery systolic pressure in patients undergoing transcatheter aortic valve replacement for aortic stenosis.Am JCardiol,2014,114(10):1562-1567.
• [12]Tracy GP,Proctor MS,Hizny CS.Reversibility of pulmonary artery hypertension in aortic stenosis after aortic valve replacement.Ann Thorac Surg,1990,50(1):89-93.