Аннотация
При транскатетерной замене аортального клапана (TAVR – transcatheter aortic valve replacement)
сопутствующая митральная регургитация высоких градаций продолжает представлять
сложный клинический аспект. Несмотря на уменьшение степени митральной недостаточности у подавляющего большинства пациентов после TAVR, у ряда пациентов митральная
регургитация персистирует или даже увеличивается, что в итоге может свести на нет все
возможные преимущества интервенционного лечения аортального порока.
В обзоре представлен анализ исследований, посвященных изучению функциональной
митральной недостаточности при интервенционном лечении аортального порока. В исследование включены пациенты группы высокого риска (согласно шкале операционного риска
STS 8% и более), представляющие собой старшую возрастную группу с широким спектром
коморбидной патологии. В ряде случаев они относились к IV функциональному классу по
классификации NYHA, имели выраженную систолическую дисфункцию левого желудочка
или были признаны неоперабельными. На основании проведенного систематического обзора
15 исследований выделены предикторы возможного прогрессирования митральной
недостаточности, а также изучены алгоритмы лечения данной категории больных при
интервенционном лечении аортального порока, что способствует оптимизации долгосрочного
прогноза, как при открытой операции, так и при малоинвазивном вмешательстве. Все это
позволит улучшить непосредственные и отдаленные послеоперационные результаты.
Литература
- Ross Jr J., Braunwald E. Aortic stenosis. Circulation. 1968;
38 (1 Suppl): 61–7. DOI: 10.1161/01.CIR.38.1S5.V-61
- Waisbren E.C., Stevens L.M., Avery E.G., Picard M.H.,
Vlahakes G.J., Agnihotri A.K. Changes in mitral regurgitation
after replacement of the stenotic aortic valve. Ann.
Thorac. Surg. 2008; 86: 56–62. DOI: 10.1016/j.athoracsur.
2008.03.027
-
Tunick P.A., Gindea A., Kronzon I. Effect of aortic valve
replacement for aortic stenosis on severity of mitral
regurgitation. Am. J. Cardiol. 1990; 65: 1219–21. DOI:
10.1016/0002-9149(90)90977-9
-
Adams P.B., Otto C.M. Lack of improvement in coexisting
mitral regurgitation after relief of valvular aortic
stenosis. Am. J. Cardiol. 1990; 66: 105–7. DOI:
10.1016/0002-9149(90)90746-N
-
Barreiro C.J., Patel N.D., Fitton T.P., Williams J.A.,
Bonde P.N., Chan V. et al. Aortic valve replacement
and concomitant mitral valve regurgitation in the elderly:
impact on survival and functional outcome.
Circulation. 2005; 112 (suppl): I443–7. DOI: 10.1161/
CIRCULATIONAHA.104.526046
-
Ruel M., Kapila V., Price J., Kulik A., BurwashI G.,
Mesana T.G. Natural history and predictors of outcome
in patients with concomitant functional mitral regurgitation
at the time of aortic valve replacement. Circulation.
2006; 114 (suppl): I541–6. DOI: 10.1161/CIRCULATIONAHA.105.000976
-
Gilard M., Eltchaninoff H., Iung B., Donzeau-Gouge P.,
Chevreul K., Fajadet J. et al. Registry of transcatheter
aortic-valve implantation in high-risk patients. N. Engl. J.
-
Leon M.B., Smith C.R., Mack M., Miller D.C.,
Moses J.W., Svensson L.G. et al. Transcatheter aorticvalve
implantation for aortic stenosis in patients who cannot
undergo surgery. N. Engl. J. Med. 2010; 363:
1597–607. DOI: 10.1056/NEJMoa1008232
-
Tzikas A., Piazza N., van Dalen B.M., Schultz C.,
Geleijnse M.L., van Geuns R.J. et al. Changes in mitral
regurgitation after transcatheter aortic valve implantation.
Catheter Cardiovasc. Interv. 2010; 75: 43–9. DOI:
10.1002/ccd.22197
-
Gotzmann M., Lindstaedt M., Bojara W., Mügge A.,
Germing A. Hemodynamic results and changes in
myocardial function after transcatheter aortic valve
implantation. Am. Heart J. 2010; 159: 926–32. DOI:
10.1016/j.ahj.2010.02.030
-
D'Onofrio A., Gasparetto V., Napodano M., Bianco R.,
Tarantini G., Renier V. et al. Impact of preoperative
mitral valve regurgitation on outcomes after transcatheter
aortic valve implantation. Eur. J. Cardiothorac.
Surg. 2012; 41 (6): 1271–6; disc. 1276–7. DOI:
10.1093/ejcts/ezr236
-
De Chiara B., Moreo A., De Marco F., Musca F.,
Oreglia J., Lobiati E. et al. Influence of CoreValve revalving
system implantation on mitral valve function:
an echocardiographic study in selected patients.
Catheter Cardiovasc. Interv. 2011; 78: 638–44. DOI:
10.1002/ccd.23045
-
Toggweiler S., Boone R.H., Rodés-Cabau J., Humphries
K.H., Lee M., Nombela-Franco L. et al. Transcatheter
aortic valve replacement: outcomes of patients
with moderate or severe mitral regurgitation. J.
Am. Coll. Cardiol. 2012; 59 (23): 2068–74. DOI:
10.1016/j.jacc.2012.02.020
-
Hekimian G., Detaint D., Messika-Zeitoun D.,
Attias D., Iung B., Himbert D. et al. Mitral regurgitation
in patients referred for transcatheter aortic valve
implantation using the Edwards Sapien prosthesis:
mechanisms and early postprocedural changes. J. Am.
Soc. Echocardiogr. 2012; 25: 160–5. DOI: 10.1016/j.echo.2011.10.001
-
Hutter A., Bleiziffer S., Richter V., Opitz A., Hettich I.,
Mazzitelli D. et al. Transcatheter aortic valve implantation
in patients with concomitant mitral and tricuspid
regurgitation. Ann. Thorac. Surg. 2013; 95 (1): 77–84.
DOI: 10.1016/j.athoracsur.2012.08.030
-
Barbanti M., Webb J.G., Hahn R.T., Feldman T.,
Boone R.H., Smith C.R. et al. Placement of aortic
transcatheter valve trial investigators. Impact of preoperative
moderate/severe mitral regurgitation on 2-year outcome
after transcatheter and surgical aortic valve replacement:
insight from the Placement of Aortic Transcatheter
Valve (PARTNER) trial cohort A. Circulation. 2013;
128 (25): 2776–84. DOI: 10.1161/CIRCULATIONAHA.113.003885
-
Bedogni F., Latib A., De Marco F., Agnifili M., Oreglia
J., Pizzocri S. et al. Interplay between mitral regurgitation
and transcatheter aortic valve replacement
with the CoreValve Revalving System: a multicenter
registry. Circulation. 2013; 128 (19): 2145–53. DOI:
10.1161/CIRCULATIONAHA.113.001822
-
O'Sullivan C.J., Stortecky S., Bütikofer A., Heg D.,
Zanchin T., Huber C. et al. Impact of mitral regurgitation
on clinical outcomes of patients with low-ejection fraction,
low-gradient severe aortic stenosis undergoing transcatheter
aortic valve implantation. Circ. Cardiovasc.
Interv. 2015; 8 (2): e001895. DOI: 10.1161/CIRCINTERVENTIONS.
114.001895
-
Cortés C., Amat-Santos I.J., Nombela-Franco L.,
Mun~oz-Garcia A.J., Gutiérrez-Ibanes E., De La Torre
Hernandez J.M. et al. Mitral regurgitation after
transcatheter aortic valve replacement: Prognosis, imaging
predictors, and potential management. JACC
Cardiovasc. Interv. 2016; 9 (15): 1603–14. DOI:
10.1016/j.jcin.2016.05.025
-
Mavromatis K., Thourani V.H., Stebbins A., Vemulapalli
S., Devireddy C., Guyton R.A. et al. Transcatheter
aortic valve replacement in patients with aortic stenosis
and mitral regurgitation. Ann. Thorac. Surg. 2017; 104 (6):
1977–85. DOI: 10.1016/j.athoracsur.2017.05.065
-
Shibayama K., Mihara H., Berdejo J., Harada K.,
Siegel R.J., Makkar R.R. et al. Association of postprocedural
aortic regurgitation with mitral regurgitation
worsened after transcatheter aortic valve replacement.
Echocardiography. 2018; 35: 346–52. DOI:
10.1111/echo.13780
-
Chiche O., Rodés-Cabau J., Campelo-Parada F.,
Freitas-Ferraz A.B., Regueiro A., Chamandi C. et al.
Significant mitral regurgitation in patients undergoing
TAVR: Mechanisms and imaging variables associated
with improvement. Echocardiography. 2019; 00: 1–10.
DOI: 10.1111/echo.14303
-
Abdelghani M., Abdel-Wahabac M., Hemetsbergera R.,
Landta M., Mertena C., Toelga R. et al. Fate and longterm
prognostic implications of mitral regurgitation
in patients undergoing transcatheter aortic valve replacement.
Int. J. Cardiol. 2019; 288: 39–43. DOI:
10.1016/j.ijcard.2019.03.048
-
Wan C.K., Suri R.M., Li Z., Orszulak T.A., Daly R.C.,
Schaff H.V. et al. Management of moderate functional
mitral regurgitation at the time of aortic valve replacement:
is concomitant mitral valve repair necessary?
J. Thorac. Cardiovasc. Surg. 2009; 137: 635–40. DOI:
10.1016/j.jtcvs.2008.11.015
-
Galloway A.C., Grossi E.A., Baumann F.G., LaMendola
C.L., Crooke GA, Harris L.J. et al. Multiple valve
operation for advanced valvular heart disease: results
and risk factors in 513 patients. J. Am. Coll. Cardiol. 1992;
19: 725–32. DOI: 10.1016/0735-1097(92)90509-L
-
Mueller X.M., Tevaearai H.T., Stumpe F., Fischer A.P.,
Hurni M., Ruchat P. et al. Long-term results of mitralaortic
valve operations. J. Thorac. Cardiovasc. Surg. 1998;
115: 1298–309. DOI: 10.1016/S0022-5223(98)70212-0
-
Bach D.S., Siao D., Girard S.E., Duvernoy C.,
McCallister Jr B.D., Gualano S.K. Evaluation of patients
with severe symptomatic aortic stenosis who do not
undergo aortic valve replacement: the potential role of
subjectively overestimated operative risk. Circ. Cardiovasc.
Qual. Outcomes. 2009; 2 (6): 533–9. DOI:
10.1161/CIRCOUTCOMES.109.848259
-
Cribier A., Eltchaninoff H., Bash A., Borenstein N.,
Tron C., Bauer F. et al. Percutaneous transcatheter
implantation of an aortic valve prosthesis for calcific aortic
stenosis: first human case description. Circulation.
2002; 106 (24): 3006–8.
-
Mack M.J., Leon M.B., Thourani V.H., Makkar R.,
Kodali S.K., Russo M. et al. Transcatheter aortic-valve
replacement with a balloon-expandable valve in low-risk
patients. N. Engl. J. Med. 2019; 380 (18): 1695–705.
DOI: 10.1056/NEJMoa1814052
-
Leon M.B., Smith C.R., Mack M.J., Makkar R.R.,
Svensson L.G., Kodali S.K. et al. PARTNER 2 Investigators.
Transcatheter or surgical aortic-valve replacement
in intermediate-risk patients. N. Engl. J. Med. 2016; 374:
1609–20. DOI: 10.1056/NEJMoa1514616
-
Kapadia S.R., Leon M.B, Makkar R.R., Tuzcu E.M.,
Svensson L.G., Kodali S. et al. for the PARTNER trial
investigators. 5-year outcomes of transcatheter aortic
valve replacement compared with standard treatment for
patients with inoperable aortic stenosis (PARTNER 1): a
randomized controlled trial. Lancet. 2015; 385 (9986):
2485–91. DOI: 10.1016/S0140-6736(15)60290-2
-
Unger P., Dedobbeleer C., Van Camp G., Plein D.,
Cosyns B., Lancellotti P. Mitral regurgitation in patients
with aortic stenosis undergoing valve replacement. Heart.
2010; 96: 9–14. DOI: 10.1136/hrt.2009.165548
-
Unger P., Plein D., Van Camp G., Cosyns B., Pasquet A.,
Henrard V. et al. Effects of valve replacement for aortic
stenosis on mitral regurgitation. Am. J. Cardiol. 2008;
102: 1378–82. DOI: 10.1016/j.amjcard.2008.07.021
-
León Del Pino C., Ruíz Ortiz M., Delgado Ortega M.,
Sánchez Fernández J., Ferreiro Quero C., Durán
Jiménez E. et al. Prosthesis-patient mismatch after
transcatheter aortic valve replacement: prevalence and
medium term prognostic impact. Int. J. Cardiovasc.
Imaging. 2019; 35 (5): 827–36. DOI: 10.1007/s10554-
018-01519-z
-
Giordana F., Capriolo M., Frea S., Marra W.G.,
Giorgi M., Bergamasco L. et al. Impact of TAVI on
mitral regurgitation: a prospective echocardiographic
study. Echocardiography. 2013; 30: 250–7. DOI:
10.1111/echo.12050
-
Clavel M.A., Webb J.G., Pibarot P., Altwegg L., Dumont
E., Thompson C. et al. Comparison of the
hemodynamic performance of percutaneous and surgical
bioprostheses for the treatment of severe aortic stenosis.
J. Am. Coll. Cardiol. 2009; 53: 1883–91. DOI:
10.1016/j.jacc.2009.01.060
-
Schultz C.J., Weustink A., Piazza N., Otten A., Mollet
N., Krestin G. et al. Geometry and degree of apposition
of the CoreValve ReValving system with multislice
computed tomography after implantation in patients with
aortic stenosis. J. Am. Coll. Cardiol. 2009; 54: 911–8.
DOI: 10.1016/j.jacc.2009.04.075
-
Unger P., Dedobbeleer C., Vanden Eynden F., Lancellotti
P. Mitral regurgitation after transcatheter aortic valve
replacement: does the prosthesis matter? Int. J. Cardiol.
2013; 168: 1706–9. DOI: 10.1016/j.ijcard.2013.03.055
-
Mack M.J., Leon M.B., Smith C.R., Miller D.C.,
Moses J.W., Tuzcu E.M. et al. PARTNER 1 Trial Investigators.
5-year outcomes of transcatheter aortic valve
replacement or surgical aortic valve replacement for high
surgical risk patients with aortic stenosis (PARTNER 1):
a randomised controlled trial. Lancet. 2015; 385:
2477–84. DOI: 10.1016/S0140-6736(15)60308-7
-
Amat-Santos I.J., Dahou A., Webb J., Dvir D., Dumesnil
J.G., Allende R. et al. Comparison of hemodynamic
performance of the balloon-expandable SAPIEN 3 versus
SAPIEN XT transcatheter valve. Am. J. Cardiol. 2014;
114: 1075–82. DOI: 10.1016/j.amjcard.2014.07.019
-
Webb J., Gerosa G., Lefe`vre T., Leipsic J., Spence M.,
Thomas M. et al. Multicenter evaluation of a next-generation
balloon-expandable transcatheter aortic valve.
J. Am. Coll. Cardiol. 2014; 64: 2235–43. DOI:
10.1016/j.jacc.2014.09.026
-
Matsumura Y., Gillinov A.M., Toyono M., Oe H.,
Yamano T., Takasaki K. et al. Echocardiographic predictors
for persistent functional mitral regurgitation after
aortic valve replacement in patients with aortic valve
stenosis. Am. J. Cardiol. 2010; 106: 701–6. DOI:
10.1016/j.amjcard.2010.04.030
-
Nombela-Franco L., Eltchaninoff H., Zahn R.,
Testa L., Leon M.B., Trillo-Nouche R. et al. Clinical
impact and evolution of mitral regurgitation following
transcatheter aortic valve replacement: a metaanalysis.
Heart. 2015; 101 (17): 1395–405. DOI: 10.1136/heartjnl-2014-307120
-
Katte F., Frenz M., Jung C., Figulla H.R., Leistner D.,
Jakob P. et al. Impact of concomitant mitral regurgitation
on transvalvular gradient and flow in severe aortic stenosis:
a systematic ex vivo analysis of a subentity of low-flow
low-gradient aortic stenosis. EuroIntervention. 2018; 13:
1635–44. DOI: 10.4244/EIJ-D-17-00476
-
Clavel M.A., Burwash I.G., Pibarot P. Cardiac imaging
for assessing low-gradient severe aortic stenosis. JACC
Cardiovasc. Imaging. 2017; 10: 185–202. DOI:
10.1016/j.jcmg.2017.01.002
-
Clavel M.A., Magne J., Pibarot P. Low-gradient aortic
stenosis. Eur. Heart J. 2016; 37: 2645–57. DOI:
10.1093/eurheartj/ehw096
-
Baumgartner H., Falk V., Bax J.J., De Bonis V.,
Hamm C., Holm P.G. et al. ESC Scientific Document
Group. 2017 ESC/EACTS Guidelines for the management
of valvular heart disease. Eur. Heart J. 2017; 38:
2739–91. DOI: 10.1093/eurheartj/ehx391
-
Clavel M.A., Messika-Zeitoun D., Pibarot P., Aggarwal
S., Malouf J., Araoz P. et al. The complex nature of
discordant severe calcified aortic valve disease grading:
new insights from combined Doppler echocardiographic
and computed tomographic study. J. Am. Coll. Cardiol.
2013; 62: 2329–38. DOI: 10.1016/j.jacc.2013.08.1621
-
Ong G., Clavel M.A., Pibarot P. Concomitant mitral
regurgitation: an insidious cause of lowflow, low-gradient
severe aortic stenosis. EuroIntervention. 2018; 13 (14):
1622–5. DOI: 10.4244/EIJV13I14A261
-
Rodes-Cabau J., Webb J.G., Cheung A., Ye J., Dumont
E., Feindel C.M. et al. Transcatheter aortic valve
implantation for the treatment of severe symptomatic
aortic stenosis in patients at very high or prohibitive surgical
risk: acute and late outcomes of the multicenter
Canadian experience. J. Am. Coll. Cardiol. 2010; 55:
1080–90. DOI: 10.1016/j.jacc.2009.12.014
-
Nombela-Franco L., Ribeiro H.B., Urena M., Allende
R., Amat-Santos I., DeLarochellie`re R. et al. Significant
mitral regurgitation left untreated at the time of aortic
valve replacement: a comprehensive review of a frequent
entity in the transcatheter aortic valve replacement
era. J. Am. Coll. Cardiol. 2014; 63: 2643–58. DOI:
10.1016/j.jacc.2014.02.573
-
Kizilbash A.M., Willett D.L., Brickner M.E., Heinle
S.K., Grayburn P.A. Effects of afterload reduction on
vena contracta width in mitral regurgitation. J. Am. Coll.
Cardiol. 1998; 32: 427–31.
-
Enriquez-Sarano M., Akins C.W., Vahanian A. Mitral
regurgitation. Lancet. 2009; 373: 1382–94. DOI:
10.1016/S0140-6736(09)60692-9
Об авторах
- Скопин Иван Иванович, доктор мед. наук, профессор, заведующий отделением реконструктивной хирургии клапанов сердца и коронарных артерий, директор Института коронарной и сосудистойхирургии, orcid.org/0000-0001-7411-202X
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Сливнева Инесса Викторовна, канд. мед. наук, науч. сотр., врач ультразвуковой диагностики,orcid.org/0000-0001-7935-7093
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Латышев Михаил Сергеевич, мл. науч. сотр., orcid.org/0000-0003-1771-4264
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Мурысова Дарья Владимировна, врач-кардиолог, orcid.org/0000-0003-2885-6225
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Сахаров Эмиль Романович, ординатор, orcid.org/0000-0003-1057-2777
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Вавилов Александр Владимирович, врач – сердечно-сосудистый хирург, orcid.org/0000-0002-0488-5630
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Топорков Николай Олегович, аспирант, orcid.org/0000-0002-7089-9539
