ESC指南针对TAVI提出建议

慕尼黑——根据新版欧洲瓣膜性心脏病治疗指南，经导管主动脉瓣植入术(TAVI)应禁用于有中度手术风险的患者。

这是首次在指南中针对TAVI提出建议，这一指南是由欧洲心脏病学会和欧洲心胸外科学会联合制定的。

近年来，TAVI已越来越多地被用于有重度主动脉狭窄的高危患者和非手术治疗的候选者，同时也用于很多风险较低的患者。

Alec Vahanian博士

工作组主席、巴黎市Bichat医院心脏病科的Alec Vahanian博士指出，TAVI应由多学科“心脏团队”来进行，其中包括心内科医师、心外科医师和其他专业人员，必要时，仅可在配备有在场心脏外科团队的医院进行。基于随机的PARTNER试验和大型欧洲注册研究的结果，TAVI的适应证包括心脏团队评估认为不适于进行主动脉瓣膜置换术(AVR)的重度、症状性主动脉狭窄(AS)患者，并且预计手术后生活质量将有所改善且寿命超过1年。还应考虑对仍适于手术治疗的有严重症状的高危AS患者使用TAVI，但对于这类患者，基于个体风险特征和解剖特点的心脏团队治疗是有利的。

他报告了一个相当详细的TAVI绝对和相对禁忌证清单，包括环面大小不合适(定义为不足10 mm或超过29 mm)；左心室血栓；活动性心内膜炎；升主动脉或主动脉弓斑块伴活动血栓；经股骨/锁骨下方法的血管通路不足；左心室射血分数极低，不足20%。

Vahanian博士说，对于有重度症状的AS患者，AVR仍是适用的，包括接受冠脉旁路手术或升主动脉或其他瓣膜手术的患者，但应由心脏团队进行手术。他发现，工作组成员对于有症状的低血流量、低压力阶差(定义为不足40 mmHg)主动脉狭窄且射血分数正常患者的手术，仍存在很大分歧。“我们必须非常谨慎，仅对有症状和绝对确认的患者进行治疗，如果我们可以确认主动脉疾病是严重的，”他评论道。

作者未披露相关利益冲突。组委会已要求参与者确保避免所有与项目相关的潜在利益冲突。

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By: PATRICE WENDLING, Cardiology News Digital Network

MUNICH – Transcatheter aortic valve implantation should not be performed in patients at intermediate risk for surgery, according to new European guidelines on the management of valvular heart disease.

"We strongly stress that today, TAVI should not be performed in patients at intermediate risk," said task force chair Dr. Alec Vahanian of the department of cardiology at Bichat Hospital, Paris.

This is the first time that TAVI has been addressed in the guidelines, a joint collaboration between the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery.
 
The use of TAVI has mushroomed in recent years among high-risk patients with severe aortic stenosis and in those who are not candidates for surgery, but also has been performed in patients at lower risk.

The new guidelines update those issued in 2010, and were prompted by new evidence on risk stratification, diagnostic methods, therapeutic options, and the importance of the collaborative approach between cardiologists and cardiac surgeons, Dr. Vahanian said at the annual congress of the European Society of Cardiology.

"The key message – the core of the document – is to stress teamwork," he said.

The guidelines state that TAVI should be undertaken only with a multidisciplinary "heart team" including cardiologists, cardiac surgeons, and other specialists, if necessary, and only in hospitals with cardiac surgery on-site.

The indications for TAVI, based on results of the randomized PARTNER trial and large European registries, include patients with severe, symptomatic aortic stenosis (AS) who are not suitable for aortic valve replacement (AVR) as assessed by a heart team, and who are likely to gain improvement in their quality of life and are expected to live more than 1 year.

TAVI also should be considered in high-risk patients with severe symptomatic AS who may still be suitable for surgery, but in whom TAVI is favored by a heart team based on the individual risk profile and anatomic suitability, Dr. Vahanian said.

He reported a virtual laundry list of absolute and relative contraindications to TAVI, including an inadequate annulus size, defined as less than 10 mm or greater than 29 mm; thrombus in the left ventricle; active endocarditis; plaques with mobile thrombi in the ascending aorta or arch; inadequate vascular access for a transfemoral/subclavian approach; and a very low left ventricular ejection fraction of less than 20%.

Dr. Vahanian said AVR remains suitable for patients with severe symptomatic AS, including those undergoing coronary artery bypass surgery or surgery of the ascending aorta or another valve, as well as those who are suitable for TAVI, but in whom surgery is favored by a heart team. He observed that there was a great deal of debate among the task force members regarding surgery in symptomatic patients with low flow, low- gradient (defined as less than 40 mm Hg) aortic stenosis, and a normal ejection fraction.

"We have to be extremely cautious and treat only the patient while symptomatic and we are absolutely sure, if we can be sure, that the aortic disease is severe," he remarked.

Disclosures were not provided. The Organizing Committee assumed responsibility for ensuring that all potential conflicts of interest relevant to the program are declared to the participants.