Impact of patient-prosthesis mismatch and aortic valve design on coronary flow reserve after aortic valve replacement
Impact of patient-prosthesis mismatch and aortic valve design on coronary flow reserve after aortic valve replacement
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DOI：
10.1016/j.jacc.2006.10.052
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发表时间：
2007-02-20
影响因子：
24
通讯作者：
Kleine, Peter
中科院分区：
文献类型：
--
作者：
Bakhtiary, Farhad;Schiemann, Mirko;Kleine, Peter
目的 这项前瞻性随机研究调查了主动脉瓣设计和患者假体不匹配 (PPM) 对主动脉瓣狭窄 (AS) 患者机械或生物主动脉瓣置换 (AVR) 后冠状动脉血流储备 (CFR) 的影响。 背景 冠状动脉血流储备可能是 AS 患者 AVR 后长期生存的重要参数。 CFR降低可能导致更多的心血管事件和更高的死亡率。方法共有48名接受AVR的患者在术前、术后5天和6个月随访时接受磁共振成像测量冠状动脉流量。计划接受机械 AVR 的患者被随机分配至倾斜椎间盘或双叶假体（每组 n = 12）。对于生物 AVR，患者计划接受支架瓣膜 (n = 12) 或无支架瓣膜 (n = 12)。患者还接受了超声心动图测量跨瓣膜压力梯度和左心室质量回归。结果术后，所有组的冠状动脉流量均显着增加（p <0.001）。只有无支架瓣膜表现出正常的 CFR（带支架生物瓣膜为 3.4 +/- 0.3 对比 2.3 +/- 0.1，倾斜盘为 2.1 +/- 0.2，双叶机械瓣膜为 2.2 ± 0.3）。患者与假体不匹配且索引有效孔口面积 < 0.85 cm(2)/m(2) 会导致倾斜椎间盘组、无支架组和带支架组的 CFR 率降低。倾斜椎间盘压力梯度为 14 +/- 3 mm Hg，双叶压力梯度为 12 ± 4 mm Hg，支架瓣膜压力梯度为 19 +/- 6 mm Hg，无支架瓣膜压力梯度为 10 +/- 4 mm Hg。 结论 仅在无支架瓣膜上观察到 AS 患者 AVR 后 CFR 正常化。冠状动脉血流储备可能解释了无支架瓣膜的优异长期效果。
Objectives This prospective-randomized study investigated the effect of aortic valve design and patient-prosthesis mismatch (PPM) on coronary flow reserve (CFR) after mechanical or biological aortic valve replacement (AVR) in patients with aortic stenosis (AS).Background Coronary flow reserve may be an important parameter of long-term survival after AVR in patients with AS. Reduced CFR may contribute to more cardiovascular events and greater rates of mortality.Methods A total of 48 patients undergoing AVR underwent magnetic resonance imaging for the measurement of coronary flow preoperatively, 5 days postoperatively, and at 6-month follow-up with measurement of CFR. Patients scheduled for mechanical AVR were randomized to a tilting disc or bileaflet prosthesis (n = 12 in each group). For biological AVR, patients were scheduled to receive a stented (n = 12) or stentless (n = 12) valve. Patients also underwent echocardiography with measurement of transvalvular pressure gradients and left ventricular mass regression.Results Postoperatively, coronary flow increased significantly in all groups (p < 0.001). Only stentless valves demonstrated a normal CFR (3.4 +/- 0.3 vs. 2.3 +/- 0.1 for stented biological valves, 2.1 +/- 0.2 for tilting disc, and 2.2 0.3 for bileaflet mechanical valves). Patient-prosthesis mismatch with an indexed effective orifice area < 0.85 cm(2)/m(2) led to decreased rates of CFR in the tilting disc, stentless, and stented groups. Pressure gradients were 14 +/- 3 mm Hg for tilting disc, 12 4 mm Hg for bileaflet, 19 +/- 6 mm Hg for stented, and 10 +/- 4 mm Hg for stentless valves.Conclusions Normalization of CFR after AVR in patients with AS was observed only for stentless valves. Coronary flow reserve might explain the excellent long-term results for stentless valves.