TAVR失败后的外科取出与再干预策略：基于瓣膜失效机制的决策思路与技术要点

Surgical explantation and reintervention strategies after TAVR failure: decision-making framework and technical considerations based on mechanisms of valve failure

摘要

随着经导管主动脉瓣置换术（TAVR）适应证扩展至更年轻、预期寿命更长的人群，术后瓣膜失效后的再干预选择已成为主动脉瓣疾病长期管理中的现实问题。对此类患者，再干预决策不宜仅在再次经导管主动脉瓣置换术（redo-TAVR）与外科取出术之间做程序性二选一，而应先识别失效机制，并结合感染状态、预期术后血流动力学表现、冠状动脉通路保留与后续介入可及性，以及同期外科手术需求综合判断。本文围绕结构性瓣膜退化、瓣叶血栓或临床瓣膜血栓、感染性心内膜炎、重度瓣周漏或位置异常及机械性失败，以及影响redo-TAVR选择的冠状动脉与人工瓣膜-患者不匹配等关键限制因素，综述TAVR失败后的再干预路径、外科取出的优先适用情形及相关技术要点。对局灶性失效、无感染且预计redo-TAVR后残余梯度和冠状动脉介入可及性均可接受者，可优先考虑redo-TAVR；对感染、明显机械性失败、预计残余高梯度、冠状动脉通路保留与后续介入可及性受限，或需同期外科重建者，通常应优先评估外科取出。现有证据主要来自观察性研究，两种路径的直接比较仍受选择偏倚和人群异质性影响。

Abstract

As the indications for transcatheter aortic valve replacement (TAVR) expand to younger patients with longer life expectancy, the choice of reintervention after post-TAVR valve failure has become a practical issue in the long-term management of aortic valve disease. For such patients, decision-making should not be reduced to a binary procedural choice between redo-TAVR and surgical explantation. Instead, it should begin with identification of the mechanism of valve failure and should integrate infection status, expected postprocedural hemodynamic performance, preservation of coronary access and feasibility of future coronary intervention, and the need for concomitant cardiac surgery. This review focuses on structural valve deterioration, leaflet thrombosis or clinical valve thrombosis, infective endocarditis, severe paravalvular leak or malposition and mechanical failure, as well as key limiting factors affecting the selection of redo-TAVR, including coronary access preservation, future coronary intervention feasibility, and prosthesis-patient mismatch. It summarizes the major reintervention pathways after TAVR failure, the circumstances in which surgical explantation should be prioritized, and the relevant technical considerations. Redo-TAVR may be preferentially considered in patients with localized failure, no infection, and acceptable predicted residual gradients and preserved feasibility of coronary access and future coronary intervention after reintervention. By contrast, surgical explantation should generally be prioritized in patients with infection, major mechanical failure, an expected high residual gradient, markedly restricted coronary access or feasibility of future coronary intervention, or a need for concomitant cardiac reconstruction. Current evidence is derived mainly from observational studies, and direct comparisons between the two approaches remain limited by selection bias and population heterogeneity.

关键词

经导管主动脉瓣置换术 / 瓣膜失效 / 瓣膜失效机制 / 再干预策略 / 外科取出 / 再次经导管主动脉瓣置换术

Key words

transcatheter aortic valve replacement / valve failure / mechanisms of valve failure / reintervention strategies / surgical explantation / redo-TAVR

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基金资助

国家自然科学基金项目(81200136)