【摘要】 目的：探讨经导管主动脉瓣置换-瓣中瓣（TAVR-VIV）手术治疗外科生物瓣衰败中超声心动图在术前、术中及术后的应用价值。方法：纳入2016年11月至2021年6月接受TAVR-VIV手术治疗的32例外科生物瓣衰败患者（天津市胸科医院15例，中国医学科学院阜外医院17例），其中重度狭窄16例（50%），重度反流5例（15.6%），混合型（至少中度狭窄合并中度反流）11例（34.4%）。术前经胸超声心动图（TTE）测量主动脉瓣峰值流速（AVmax）、峰值跨瓣压差（PGmax）、平均跨瓣压差（PGmean）、有效瓣口面积（EOA）、左心室射血分数（LVEF）。术中经食道超声心动图（TEE）全程监测有无并发症，瓣膜置入后即刻评估瓣膜置入效果。对比术前、术后7 d、术后3个月血流动力学参数的变化。结果：32例患者均成功置入人工主动脉瓣，置入后即刻无或微量瓣周反流。术后7 d AVmax、PGmax、PGmean、EOA均较术前明显改善（P均<0.05），术后7 d与术后3个月相比AVmax、PGmax、PGmean、EOA差异无统计学意义，LVEF增高（P<0.05）。随访过程中未发现瓣周反流增多。术后3个月，有8例患者PGmean≥20 mmHg(1 mmHg=0.133 kPa)，残留高压差发生率为25%。7例小瓣环患者中3例发生残留高压差；25例中瓣环患者中5例发生残留高压差。8例残留高压差患者中衰败类型为狭窄型者有4例，反流型者有1例，混合型者有3例。结论：TAVR-VIV为外科生物瓣衰败患者提供了一种微创且有效的治疗方法，而超声心动图在术前评估、术中监测、术后即刻评估手术效果及术后随访中均有重要价值。更多还原

【Abstract】 Objectives: To investigate the pre-procedural, intra-procedural, and post-procedural value of echocardiography in elderly patients with surgical bioprostheses failure undergoing valve-in-valve transcatheter aortic valve replacement(TAVRVIV).Methods: TAVR-VIV were performed in 32 patients with surgical bioprostheses failure from November 2016 to June 2021. Failed modes were severe stenosis(n=16), severe regurgitation(n=5) and mixed aortic valve disease(n=11, at least moderate stenosis combined with moderate regurgitation). Pre-procedural aortic valve peak velocity(AVmax), maximum pressure gradient(PGmax), mean pressure gradient(PGmean), effective valve orifice area(EOA), and left ventricular ejection fraction(LVEF) were measured by transthoracic echocardiography(TTE). Intra-procedural transesophageal echocardiography(TEE) was used to monitor complications throughout the TAVR-VIV, and evaluate the function of the prosthetic valve immediately after implantation. The changes of hemodynamic parameters were compared before surgery and 7 days and 3months after TAVR-VIV.Results: Implantation was successful with immediate restoration of satisfactory valve function in all patients. None or trace paravalvular regurgitation was documented immediately post procedure by TEE. AVmax, PGmax, PGmean and EOA value were significantly improved at 7 days after TAVR-VIV compared to pre-procedual level(all P<0.05). Compared with results at 7 days after TAVR-VIV, AVmax, PGmax, PGmean and EOA remained unchanged and the LVEF value was significantly higher at 3 months after TAVR-VIV. Incidence of paravalvular regurgitation remained unchaged during the follow-up period. It should be noted that 8 patients(25%) experienced PGmean≥20 mmHg at 3 months after TAVR-VIV.Elevated residual gradient occurred in 3 of 7 patients with small annulus, occurred in 5 of 25 patients with middle annulus,and the number of stenosis type(4/8) was more than regurgitation(1/8) and mixed(3/8) type.Conclusions: TAVR-VIV provides a safe, minimally invasive, and effective treatment option for aged patients with surgical bioprostheses failure. Echocardiography is a valuable tool at pre-procedural evaluation, intra-procedural monitoring,immediate post-procedural assessment, and long-term follow-up for patients undergoing TAVR-VIV.更多还原