经导管主动脉瓣植入术（TAVI）适应证和并发症防治策略PPT文件格式下载.pptx

经导管主动脉瓣植入术（TAVI）适应证和并发症防治策略PPT文件格式下载.pptx

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1200-1254,www.nejm.org,PARTNER研究成就了TAVI的地,TAVI研究背景五位,TranscatheterAorticValveImplantation（TAVI）,Leon,NEJM,363:

17,October2010,TAVI研究背景六TAVI的入路选择,14,内容,TAVI研究背景TAVI适应证TAVI并发症及防治策略,15,经导管主动脉瓣植入术（TA,证,VI）,应,症,经导管主动脉瓣植入术（TAVI）禁忌,内容,TAVI研究背景TAVI适应证TAVI并发症及防治策略,并发症,TA处V理I并：

根发据临症床状及况处、血理流动策力略学状态等,休克，低心排出量冠脉闭塞严重瓣环破裂心室穿孔,IABP，CPB及药物PCI或CABG心包引流、自体输血、外科开胸闭合；

监护、镇静心包引流、自体输血、外科开胸闭合,瓣周漏中心性瓣膜返流,后扩张通常为自限，需软钢丝或导管探查；

再次TAVI,心脏阻滞瓣膜位置不良瓣膜血栓房颤轻重度缺血性、出血性卒中严重出血血管并发症急性肾损伤,起搏器植入再次置入瓣膜紧急血管内或外科治疗药物或电转复：

心率或节律控制导管、机械法取栓；

阿司匹林、抗凝；

中和抗凝及纠正凝血血流动力学支持，输血紧急血管内修补或外科支持治疗；

维持最佳液体状态,TAVI并发症之一-心脏传导异常,IncidenceofCHBrequiringpermanentpacemakerimplantationhasbeenhigherwiththeCoreValve（19.2%to42.5%）thanwiththeSapienvalve（1.8%to8.5%）largerprofileandextensionlowintotheLVOTOccurrenceofCHB/LBBBBAV46%Balloon/prosthesispositioning1200-1254,IncidenceofleftbundlebranchblockafterimplantationofMedtronicCoreValveorEdwardsSAPIENvalve,vanderBoon,R.M.etal.（2012）NewconductionabnormalitiesafterTAVIfrequencyandcausesNat.Rev.Cardiol.doi:

10.1038/nrcardio.2012.58,IncidenceofcompleteatrioventriculardissociationafterimplantationofMedtronicCoreValveorEdwardsSAPIENvalve,vanderBoon,R.M.etal.（2012）NewconductionabnormalitiesafterTAVIfrequencyandcausesNat.Rev.Cardiol.doi:

10.1038/nrcardio.2012.58,Anatomyandrelationshipbetweentheaorticvalvularcomplexandtheatrioventricularconductionsystem,vanderBoon,R.M.etal.（2012）NewconductionabnormalitiesafterTAVIfrequencyandcausesNat.Rev.Cardiol.doi:

10.1038/nrcardio.2012.58,Availableprostheticaorticvalves-MedtronicCoreValve,orEdwardsSAPIENvalve,vanderBoon,R.M.etal.（2012）NewconductionabnormalitiesafterTAVIfrequencyandcausesNat.Rev.Cardiol.doi:

10.1038/nrcardio.2012.58,IncidenceofnewimplantationofapermanentpacemakerafterimplantationoftheMedtronicCoreValveortheEdwardsSAPIENvalve,vanderBoon,R.M.etal.（2012）NewconductionabnormalitiesafterTAVIfrequencyandcausesNat.Rev.Cardiol.doi:

10.1038/nrcardio.2012.58,TAVI后传导异常的防治策略,TAVI并发症之二-瓣膜返流,AorticRegurgitationTypicallyparavalvularmildormild-moderateseverityMostofARdisappearsorreducesat1yrfollow-up13%absent,80%mildAR,CardiolClin29（2011）211222J.Am.Coll.Cardiol.2012;

1200-1254,P1A2years,Kodali,etal.NEJM2012,SeverityofTotalAorticRegurgitationandoutcome,ParavalvularAR,CentralvalvularAR,Post-deploymentballoondilation,rapidRVpacingforstabilization,valveinvalveimplantation,Usuallyself-limited,GentleprobingofleafletswithasoftwireorcatheterDeliveryofa2ndTAVRdevice,valveinvalve,J.Am.Coll.Cardiol.2012;

1200-1254,TAVI后瓣膜返流的防治策略,RapidPacingforstabilization,ValveinValveImplantation,Reductionofdiastole,CardiolClin29（2011）211222,TAVI后瓣膜返流的防治策略,瓣环测量,CTAngioTEETTECT冠状面矢状面（2mm）瓣环为椭圆形超声一般从短轴测瓣环,SAPIENXTTEE瓣环测量推荐,1719,1822,2125,2427,CoreValve,26mmFor2023mm瓣环,29mmFor2327mm瓣环,31mmFor2629mm瓣环,TAVI并发症之三-脑卒中,TAVI后脑部损伤,Rodes-CabauJACC2011AstarciEJCTS2011KhalertCirculation2010,TFvs.TATAVISAPIENvs.CoreValve均无显著差异,不影响神经认知功能,“静息性”（Silent）或无症状性脑损伤,3,5,DWI（MRI）FollowingAVRShowingSilentStroke,36,TAVI显著高于AVR（PARTNER：

5.5%vs.2.4%）围手术期风险最高缩短操作时间减少植入前BAV次数脑血管保护装置/Embrelladeflector,EmbrellaCardiovascular（deflector）,SMT（deflector）,ClaretMedical（capture）,TAVI后脑卒中的防治策略,TAVI并发症之四-严重血管并发症,术前评估:

CT,TTE,Angio,Righti7li5amcmRightf6e3mmomral,准确测量血管腔内径,降低穿刺鞘管的管径改进鞘管技术,可扩张鞘管,球囊堵塞&

带膜支架,Coda,Reliant,Fluency,Viabahn,TAVI并发症之五-急性肾损伤（AKI）,TAVI术后：

11.7%27.8%TAVI早期重要并发症显著增加围手术期及中期死亡率VARC-ModifiedRIFLEscore有助于辨别高危因素:

DM周围血管病中晚期CKD等,Nephrology17（2012）445451,发生率：

28.8%（15/52）独立预测因素：

围手术期输血、TA、高血压史局限型：

样本量小,TAVI其它并发症,CausesofhypotensionafterTAVIVascularcomplicationsiliacruptureVentricularruptureAcutevalvedysfunctionCoronaryarteryobstructionMultiplerapidpacingepisodesinptswithpoorLVfunctionSuicidalLVinsevereLVHAfterremovingAVobstructionLVdecompressestosuchanextentthatthesubvalvularhypertrophyobstructsoutflowtreatedwithfluids1200-1254,TAVI其它并发症,Leftmainstemcompromisewithsemi-occlusivedisplacementofcalcifiednodulefromaorticvalve.TreatedwithCPBdeviceexplantationAVRAlsoPCI/CABGCardiolClin29（2011）211222J.Am.Coll.Cardiol.2012;

1200-1254,TAVI之总结篇,“SymptomaticSevereAorticStenosis”,ProhibitiveriskHighriskforsurgeryInoperability,Complications3%mortality（STS,EuroSCORE）2%Stroke11%prolongedventilationOrganfailureThromboembolicComplicationsBleedingProstheticvalveDysfunction,TAVRSAVR30-40%donotundergoSAVRAdvancedageLVdysfunctionMultipleco-morbiditiesPt.preferencePhysician