According to new clinical evidence, the European Society of Cardiology (ESC) and European Association for Cardio-Thoracic Surgery (EACTS) updated and published 2021 ESC/EACTS guidelines for the management of valvular heart disease. This new guideline gives recommendation for clinical assessment, internal treatment and intervention for patients with valvular heart disease with/without comorbidities, which is a globally approbatory reference for clinical practice. This article summarized the updated contents of the new guideline in terms of transcatheter therapy for valvular heart disease.
ObjectiveTo investigate clinical outcomes and risk factors of patients with valvular heart disease (VHD) and giant left ventricle undergoing heart valve replacement (HVR). MethodsClinical data of 144 VHD patients with giant left ventricle who underwent HVR in Union Hospital of Tongji Medical College, Huazhong University of Science and Technology from January 2009 to December 2012 were retrospectively analyzed. There were 116 male and 28 female patients with their age of 15-69 (44.9±11.9) years and disease duration of 57.8±98.3 months (range, 1 month to 40 years). There were 92 patients with rheumatic VHD, 28 patients with degenerative VHD, 15 patients with congenital VHD, and 9 patients with infective endocarditis. A total of 137 patients who were discharged alive were followed up. Risk factors of postoperative mortality, morbidity and late death of VHD patients with giant left ventricle undergoing HVR were analyzed with t-test, chi-square test or Fisher's exact test, and logistic regression analysis. The life-table method was used to calculate long-term survival rate and draw the survival curve. ResultsMajor postoperative complications included low cardiac output syndrome (LCOS) in 19 patients (13.2%), ventricular arrhythmias in 56 patients (38.9%), prosthetic paravalvular leaks in 7 patients (4.9%), pleural effusion in 33 patients (22.9%), pericardial effusion in 8 patients (5.6%), liver failure in 23 patients (16.0%), and renal failure in 5 patients (3.5%). Seven patients (4.9%) died postoperatively. Logistic univariate analysis showed that advanced-age ( > 50 years), rheumatic VHD, higher preoperative NYHA class (Ⅲ or Ⅳ), long disease duration, poor preoperative left ventricular function[left ventricular ejection fraction (LVEF) < 40%], double valve replace-ment (DVR), other concomitant intracardiac procedures, prolonged cardiopulmonary bypass (CPB) time and aortic cross-clamping time, postoperative LCOS and ventricular arrhythmias were risk factors of early mortality of VHD patients with giant left ventricle undergoing HVR (P < 0.05). Logistic multivariate analysis showed that advanced age ( > 50 years), long disease duration, higher preoperative NYHA class (Ⅳ), poor preoperative left ventricular function (LVEF < 40%), DVR, prolonged CPB time were independent predictors of early mortality (P < 0.05). Logistic multivariate analysis showed that higher preoperative NYHA class (Ⅲ or Ⅳ), other concomitant intracardiac procedures, poor preoperative left ventricular function (LVEF < 50%) were independent predictors of postoperative LCOS (P < 0.05). Higher preoperative NYHA class (Ⅲ or Ⅳ) and preoperative non-sinus rhythm were independent predictors of postoperative ventricular arrhy-thmias (P < 0.05). Within 2 weeks after the operation, left ventricular end-diastolic dimension (LVEDD), left atrial diameter (LAD), LVEF and left ventricular fractional shortening (LVFS) were all significantly reduced compared with preoperative parameters (P < 0.05). Five patients died during follow-up. One-year, 2-year, 3-year and 4-year survival rates were 97.1%, 95.0%, 92.7% and 92.7% respectively. Preoperative LVEF, LVEDD and NYHA were significantly different between patients who died or survived during follow-up. ConclusionsHVR can produce low postoperative mortality, high long-term survival rates and satisfactory clinical outcomes for VHD patients with giant left ventricle. Advanced age ( > 50 years), long disease duration, higher preoperative NYHA class (Ⅳ), preoperative non-sinus rhythm, poor preoperative left ventricular function (LVEF < 40%), DVR and prolonged operation time may be risk factors of postoperative mortality and morbidity. Poor preoperative left ventricular function and significantly enlarged left ventricle may be risk factors of late death after HVR.
The 2020 ACC/AHA Guideline for the Management of Patients with Valvular Heart Disease not only updates aortic valve stenosis, mitral regurgitation, prosthetic valves, infective endocarditis and antithrombotic treatment on the basis of the 2017 guidelines update for valvular heart disease, but also involves aortic valve regurgitation, bicuspid aortic valve, mitral stenosis, tricuspid regurgitation, combined valve disease, pregnancy with valvular disease, valve disease complicated with coronary heart disease, valve disease complicated with non-cardiac surgery and the prospect of comprehensive management of valve disease. It covers a wide range of contents, which are introduced in detail and comprehensively. This paper interprets some highlights and core issues, including the top 10 take-home messages, the severity of valvular heart disease, and the updates in the management of aortic valve stenosis, aortic valve regurgitation, bicuspid aortic valve, mitral stenosis and mitral regurgitation.
ObjectiveTo summarize the individualized selection of surgical treatment strategies and the key points of perioperative management for patients with heart valve disease complicated with severe chronic heart failure.MethodsThe clinical characteristics of 5 male patients with valvular heart disease complicated with severe chronic heart failure (CHF) were analyzed retrospectively from June 2017 to October 2018 in Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, with an average age of 60.21 years.ResultsFive patients were given angiotensin receptor and neprilysin inhibitor (ARNI)-based anti-heart failure treatment after admission. The operation mode of these patients was decided to be valve replacement under cardiopulmonary bypass after individualized evaluation of patients’ improving symptoms. Three patients were treated with intra-aortic balloon pump (IABP) and continuous renal replacement therapy (CRRT) early after operation to assist patients in improving cardiac function. Five patients recovered oral anti-heart failure after awakening. All patients were discharged smoothly 2 weeks after operation.ConclusionIndividualized evaluation is needed for the choice of operation timing and mode, standardized preoperative treatment for heart failure, shortening the aortic blocking time during cardiopulmonary bypass, and early application of left ventricular adjuvant drugs or instruments are all important measures to help patients recover smoothly.
Abstract: Objective To evaluate myocardial protection effect of different myocardial protective strategies for patients undergoing double valve replacement （DVR）?. Methods From Jun. 2005 to Dec. 2005, 32 patients with predominant aortic valve stenosis undergoing DVR in Xinqiao Hospital were included in this study. These patients were randomly divided into four groups with 8 patients in each group： （1） antegrade perfusion group：Cold-blood cardioplegia was delivered antegradely through aortic root, and mitral valve replacement （MVR）was performed. Then cold-blood cardioplegia was delivered antegradely through left and right coronary ostia, and aortic valve replacement （AVR） was performed； （2）retrograde perfusion group：Cold-blood cardioplegia was delivered retrogradely and intermittently through coronary sinus, and DVR was performed； （3）antegrade＋retrograde perfusion group：The route of cold-blood cardioplegic infusion was antegrade during MVR procedure first and then retrograde during AVR procedure；and （4）beating heart group：Oxygenated blood from cardiopulmonary bypass machine was delivered retrogradely and continuously through coronary sinus, and DVR was performed with beating heart. Early clinical outcomes were observed. Serum cardiac troponin I （cTnI） was measured by enzyme-linked immunosorbent assay（ELISA）. Serum creatine kinase-MB （CK-MB） and myocardial lactic acid release rate were measured by Hitachi7150 Automatic Chemistry Analyzer. Myocardial mitochondria malondialdehyde （MDA） level was measured through thiobarbituric acid reagent species analysis. Results All the 32 patients survived their surgery and were discharged successfully. Myocardial lactic acid release rate at 80 min after aortic cross-clamping, serum cTnI and CK-MB on the first postoperative day, myocardial mitochondria MDA levels of beating heart group were 13.59%±6.27%,（1.17±0.25） ng/ml, （56.43±16.50） U/L and（2.18±1.23） nmol/（ng.prot）respectively, all significantly lower than those of retrograde perfusion group ［（33.49%±8.29%, （1.82±0.58 ）ng/ml, （78.31±21.27） U/L （5.07±2.35） nmol/（ng.prot），P＜0.05］ and antegrade＋retrograde perfusion group［20.87%±7.22%, （1.49±0.23） ng/ml,（66.67±19.13） U/L,（4.34±1.73） nmol/（ng.prot），P＜0.05］, but not statistically different from those of antegrade perfusion group ［18.83%±5.97%, （1.41±0.32） ng/ml, （63.21±37.52） U/L, （3.46±1.62） nmol/?（ng.prot），P＞0.05］. Conclusion All the four myocardial protective strategies are effective myocardial protection methods for DVR patients. Continuous retrograde perfusion with beating heart and intermittent antegrade perfusion can provide better myocardial protection, and therefore are preferred for DVR patients. The combination of antegrade and retrograde perfusion is easy to administer and does not negatively influence surgical procedures. Retrograde perfusion is also effective as it takes only a short time.
Objective To evaluate the risk factors for postoperative in-hospital mortality in elderly patients receiving cardiac valvular surgery, and develop a new prediction models using the least absolute shrinkage and selection operator (LASSO)-logistic regression. Methods The patients≥65 years who underwent cardiac valvular surgery from 2016 to 2018 were collected from the Chinese Cardiac Surgery Registry (CCSR). The patients who received the surgery from January 2016 to June 2018 were allocated to a training set, and the patients who received the surgery from July to December 2018 were allocated to a testing set. The risk factors for postoperative mortality were analyzed and a LASSO-logistic regression prediction model was developed and compared with the EuroSCOREⅡ. Results A total of 7 163 patients were collected in this study, including 3 939 males and 3 224 females, with a mean age of 69.8±4.5 years. There were 5 774 patients in the training set and 1389 patients in the testing set. Overall, the in-hospital mortality was 4.0% (290/7163). The final LASSO-logistic regression model included 7 risk factors: age, preoperative left ventricular ejection fraction, combined coronary artery bypass grafting, creatinine clearance rate, cardiopulmonary bypass time, New York Heart Association cardiac classification. LASSO-logistic regression had a satisfying discrimination and calibration in both training [area under the curve (AUC)=0.785, 0.627] and testing cohorts (AUC=0.739, 0.642), which was superior to EuroSCOREⅡ. Conclusion The mortality rate for elderly patients undergoing cardiac valvular surgery is relatively high. LASSO-logistic regression model can predict the risk of in-hospital mortality in elderly patients receiving cardiac valvular surgery.
Transcatheter aortic valve replacement (TAVR) is an important treatment for patients with symptomatic severe aortic stenosis. The 2020 updated version of Chinese Expert Consensus on Transcatheter Aortic Valve Replacement was born in the process of Chinese exploration for TAVR. It is of epochal guiding significance for TAVR in China, which has entered a stage of rapid development from the initial stage. Moreover, it further promotes the standardized and healthy development of TAVR in China. The 2020 updated version of Chinese Expert Consensus on Transcatheter Aortic Valve Replacement, based on its 2015 version, has included aortic valve stenosis with a low risk of surgical operation as an indication, made more detailed recommendations on the operating specifications of balloon dilation and valve placement during TAVR, added the antithrombotic program after TAVR, and important opinions on the treatment of coronary atherosclerotic heart disease, renal insufficiency, and emergency TAVR. In this article, we will focus on all these updates to interpret the updated consensus in detail.
ObjectiveTo investigate clinical outcomes and summarize perioperative management experience of heart valve replacement (HVR)in elderly patients. MethodsWe retrospectively analyzed clinical data of 47 elderly patients undergoing HVR in Affiliated Hospital of Xuzhou Medical College from January 2011 to May 2014. There were 19 male and 28 female patients with their age of 60-79 years. There were 35 patients with rheumatic heart disease, 10 patients with degenerative valvular disease, and 2 patients with congenital bicuspid aortic valve. Preoperatively, there were 23 patients in NYHA functional class Ⅱ, 19 patients in class Ⅲ, and 5 patients in class Ⅳ. All the patients received HVR under cardiopulmonary bypass (CPB), and some patients received concomitant tricuspid valvuloplasty (TVP), left atrial thrombectomy or coronary artery bypass grafting (CABG). Postoperative mortality, morbidity and heart function improvement were evaluated. ResultsTwenty-seven patients received mitral valve replacement (MVR), 15 patients received aortic valve replacement (AVR), and 5 patients received MVR+AVR. Concomitantly, 4 patients received TVP, 3 patients received left atrial thrombectomy, and 6 patients received CABG. Operation time was 138-412 (196±52)minutes, CPB time was 48-301 (108±33)minutes, aortic cross-clamping time was 34-196 (87±21)minutes, and length of hospital stay was 12-31 (19±5)days. There was no intraoperative death, and 2 patients (4.3%)died postoperatively because of left ventricular failure and multiple organ dysfunction syndrome respectively. Twenty-three patients (51.1%)had postoperative complications including respiratory failure in 6 patients, pulmonary infection in 5 patients, arrhythmias in 5 patients, wound infection in 2 patients, pleural effusion in 2 patients, low cardiac output syndrome in 2 patients, and acute renal failure in 1 patient. Forty-five survival patients were followed up by telephone, online video and at the outpatient department for 1-32 months, and follow-up rate was 100%. There were 11 patients in NYHA functional classⅠ, 32 patients in class Ⅱ, and 2 patients in class Ⅲ. ConclusionAccording to clinical characteristics of elderly patients with valvular heart disease, meticulous surgical techniques and perioperative management can effectively reduce mortality and morbidity after HVR.