經導管主動脈瓣置換術圍手術期共病診治中國專家共識

6名多學科臨床專家組成，負責提出臨床問題，并對臨床問題重要性及初擬推薦共識專家組分別于2024年1月和2024年3月進行兩輪德爾菲調查，第一輪德爾流是最常見的單發(fā)心臟瓣膜病(VHD)(占原生VHD的26.9%),其次是三尖瓣反流(1支持。截至2023年底，中國大陸地區(qū)進行了23980例TAVR手術，到2023年10月31日，累計手術數量達到了35594例。R手術流程的細節(jié)及手術相關并發(fā)癥處理在其他的一些指南或者共識中可以找同意100%,不同意0,中立0。同意100%,不同意0,中立0。EFT評分(分)TAVR1年死亡率(%)62345發(fā)生率、縮短住院日、改善衰弱、提高6分鐘步行距離及改善預后[19]。Waite能和衰弱程度，從而提高活動耐力和對手術的耐受性[21],提高患者對術后康復后規(guī)范康復可降低手術并發(fā)癥、減少住院日、促進身體各項功能康復[22-26]。同意100%,不同意0,中立0。根據延遲閉塞發(fā)生的時間分為早期(7d以內)閉塞和晚發(fā)閉塞(7d以上),有研究顯示約50%的延遲閉塞多發(fā)生于TAVR術后24h內，另15%發(fā)生于術后2~7d[59]。在瓣膜釋放后再行PCI最大的困難來自于人工瓣架對冠狀動脈入路的干擾三、神經系統(tǒng)并發(fā)癥血風險低的患者可短期雙聯抗血小板治療(3個月)后同意100%,不同意0,中立0。DAPT治療方案比較，阿司匹林單藥治療可顯著降0%比31.1%,95%CI:0.57~0.95,P=0.004),同時未增加患者的心血管原因死亡、缺PT的選擇需進一步結合出血風險的評估。對于出血風險低的患同意100%,不同意0,中立0。抗凝藥(OAC)組在1個月或1年內嚴重出血的發(fā)生率明顯低于0AC加氯吡格雷組了比較，結果提示艾多沙班的主要療效結局不劣于VKA,但艾多沙班組大出血的因此目前尚無證據支持在合并房顫的TAVR患者中NOAC優(yōu)于VKA。同意100%,不同意0,中立0。2.推薦結合腫瘤患者的預期壽命及重度主動脈瓣狹窄的癥狀綜合評估TAVR同意100%,不同意0,中立0?？乖妊迥[瘤標志物及便潛血等結果[101],對高危患者行進一步檢查以排查目前的研究支持腫瘤患者接受TAVR治療是安全及有效的。系統(tǒng)分析顯示接受TAVR治療的活動性腫瘤患者或有腫瘤病史的患者無論短期死亡率(2.4%比3.3%,P<0.001),還是主要圍手術期并發(fā)癥如腦卒中(2.4%比2.7%,P<0.04)及急性年全因死亡率(OR=1.46,95%CI:1.15~1.86,P=0.002)和長期全因死亡率(OR=1.51,95%CI:1.24~1.85,P<0.001)均顯著高于非腫瘤患者，提示腫瘤是影響TAVR術后狀性重度主動脈瓣狹窄且預期壽命≥1年的腫瘤患者接受TAVR,預期壽命<1年的腫瘤患者則需要結合患者的癥狀及意愿進行綜合評估，而對于預期壽命<3個月對于高危NCS,可在NCS術前行主動脈瓣球囊成形術。擇期NCS的管理取決于有無癥狀和外科手術類型(圖1)。ASAS患者非心臟手術(NCS)的管理急診或擇期NCS擇期否癥狀是低-中風險高風險患者瓣膜手術風險高風險低風險心臟團隊決策：NCS術前考慮BAV,或嚴密監(jiān)測下NCSNCS風險高風險嚴密監(jiān)測下NCS急診NCS外科主動脈瓣置換術，NCS:非心臟手術圖1嚴重AS患者NCS的管理流程圖1.TAVR手術的麻醉方式選擇，要考慮患者病情輕重、急慢、預期壽命等因素以及團隊的綜合能力等。同意100%,不同意0,中立0。TAVR麻醉方式包括：局部麻醉(LA);清醒鎮(zhèn)靜(CS)或監(jiān)護麻醉(MAC),在保持一定鎮(zhèn)靜深度(意識可消失)的基礎上，輔以局部麻醉藥完成各項有創(chuàng)操作及手術，術畢可直接喚醒；全身麻醉(GA),維持一定的鎮(zhèn)靜、鎮(zhèn)痛和肌肉松弛，行氣管插管、機械通氣，完成手術。TAVR手術麻醉方式選擇應綜合考慮多方面因素：(1)患者因素患者自身意愿如何，是否配合，是否可以平臥等以及患者是否存在相關合并癥比如阻塞性呼吸睡眠暫停(OSA),慢性阻塞性肺疾病(COPD)、帕金森病等都應是同意95.83%,不同意0,中立4.17%。非心臟手術的已知或者可疑VHD患者做臨床和超聲心動圖評估，已確診VHD的患醉科醫(yī)師及相關科室醫(yī)師進行的MDT討論是管理瓣膜心臟病患者行NCS術的必要環(huán)節(jié)[107]。應向患者和外科團隊交流瓣膜治療的風險主動脈瓣狹窄是最常見的瓣膜疾病。嚴重AS患者分為無癥狀和有癥狀重度S決定應基于患者個人意愿情況、手術風險因素以及對于有癥狀患者，應在NCS前行主動脈瓣膜手術。具體手術類型選擇SAVR算出的主動脈瓣面積從0.6(IQR0.6~0.7)同意100%,不同意0,中立0。死亡率和1年死亡率的風險更高[129]。因此，在血液透析和AS并存的情況下，·合并慢性肺部疾病的TAVR患者預后不良，術后1年死亡的危1.合并慢性肺部疾病的TAVR患者預后不良，術后1年死亡的危險因素包括6同意100%,不同意0,中立0。多項大型研究中將慢性肺疾病定義為1秒用力呼氣容積(1-secondforcedeAVR患者術后1年死亡的危險因素不同于一般人群，主要包括6分鐘步行試驗距術后3年死亡率，超過一半的患者在術后3年死亡[130]。同意100%,不同意0,中立0。合并慢性肺部疾病患者TAVR治療的預后不劣于SAVR,且優(yōu)于保守治療[130]。和肺炎等呼吸相關并發(fā)癥發(fā)生率均顯著低于SAVR,非呼吸相關并發(fā)癥如院內死管此類患者常因肺功能較差而推遲TAVR治療，但在重度主動脈瓣狹窄合并慢阻同意100%,不同意0,中立0。去6個月中跌倒或計劃外的體重下降)、平均跨瓣壓差小均為術后獲益少的預測因素?；€跨瓣壓差小的患者術后改善差提示癥狀與慢性肺疾病相關[131]。肺[2]XuH,LiuQ,CamanagementofolderpatientswithvalvularheartdiseaseinChina:Chcasi.2021.11.013.流程優(yōu)化專家共識2022版[J].中華急診醫(yī)學雜志，2022,31(2):154-160.EmergMed,2022,31(2):154-160.DOI:10.3760/cma.j.issn.1671-0282.[4]國家心血管病中心，國家結構性心臟病介入質控中心，中華醫(yī)學會心血管病103(12):886-900.DOI:10.3760/cma.jcatheterAorticValveReplacement(2020UpdatedEdition)[J].ChinJIntervCardiol,2020(6):301-309.DOI:10.3969/j.issn.1004-8StructuralCardiologyProfessionalCommitteeoftheCardiologistBranchoftheChineseMedicalAssociation.ExpertConsensusonClinicalP[7]RichterD,Guay.AconsensusdocumentssociationforAcuteCardioVascularCare(ACVC),AssociationofCardiovascularNursingandAlliedProfessnofPreventiveCardiology(EAPC),EuropeanHeartRhythmAssociation(CHT),CouncilofCardio-Oncology(CCO),WorkingeripheralVascularDiseases,WGe-Catientsundergoingtranscatheteraorticvalvereplacescorestofrailty-basedmanagement[J].JGeriatr479-486.DOI:10.11909/j.issn.1671-5411.2021.06.002.linesforthemanagementofvalvularheartdisease[J].EurHeartJ,2022,43(7):561-632.DOI:10.1093/eul1Cardiol,2017,70(6):689-700.DOI:10.1016/j.jacc.2017.06.024tionshipoffrailtyindicesonsurvivalaftertranscatheteraorticvalvereplacement[J].JACCCardiovasI:10.1016/j.jcin.2019.08.015.ollCardiol,2019,74(25):3178-3180.DOI:10.1016/j.jaicts30-daymortalityaftertranscatheteraorticvalvereplacement:ResultsfromtheSocietyofThoracicSurgeiologytranscathetervalvetherapyregistry[J].Cir33(14):1351-1359.DOI:10.1161/CIRCULATIONAHA.115.020279[14]ShimuraT,Yam[15]RockwoodK,Songasureoffitnessandfrailtyinelderlypeople[J].CMAJ,2005,173(5):489-495.DOI:10.1503/cmaj.050051.[16]SteinvilA,BuchananKD,Kiramijyanadditivefrailtyowingtranscatheteraorticvalvereplacement[[17]StorteckyS,SchoenenbergerAW,MoserA,etfmultidimensionalgeriatricassessmentasapredictorofmortalityan[J].JACCCardiovascI[18]HermillerJB,yandlatemortalityaftertranscatheteraorticvalvereplacement[J].JAmCollCardiol,2016,68(4):343-352.DOI:10.1016/j.jacc.SAguidelineforthemanagementofheartfailure:AreportoftheAmericanCollegeofCardiology/AmericanHeartAssociationjointcommitteeonclinicalpracticeguidelines[J].Circuitallengthofstayforfrailpatientsundergoingcoronaryarterybypassgraftandvalvesurgery[J].JDOI:10.1186/s13019-017-0655-8.[21]BieniekJ,Wipeassessmentcomponentsasappliedtogeriatricinpa[22]ImranHM,BaigM,MujibM,etal.Comparisonofphase2card5(15):1577-1584.DOI:10.1177/2047487318792099.[24]PresslerA,ChristleJW,LechnerB,improvesexercisecapacityandqualityoflifeaftertranscatrticvalveimplantation:Arandomizedpilottrial[J[25]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