经导管主动脉瓣置换术围手术期共病诊治中国专家共识

6名多学科临床专家组成，负责提出临床问题，并对临床问题重要性及初拟推荐共识专家组分别于2024年1月和2024年3月进行两轮德尔菲调查，第一轮德尔流是最常见的单发心脏瓣膜病(VHD)(占原生VHD的26.9%),其次是三尖瓣反流(1支持。截至2023年底，中国大陆地区进行了23980例TAVR手术，到2023年10月31日，累计手术数量达到了35594例。R手术流程的细节及手术相关并发症处理在其他的一些指南或者共识中可以找同意100%,不同意0,中立0。同意100%,不同意0,中立0。EFT评分(分)TAVR1年死亡率(%)62345发生率、缩短住院日、改善衰弱、提高6分钟步行距离及改善预后[19]。Waite能和衰弱程度，从而提高活动耐力和对手术的耐受性[21],提高患者对术后康复后规范康复可降低手术并发症、减少住院日、促进身体各项功能康复[22-26]。同意100%,不同意0,中立0。根据延迟闭塞发生的时间分为早期(7d以内)闭塞和晚发闭塞(7d以上),有研究显示约50%的延迟闭塞多发生于TAVR术后24h内，另15%发生于术后2~7d[59]。在瓣膜释放后再行PCI最大的困难来自于人工瓣架对冠状动脉入路的干扰三、神经系统并发症血风险低的患者可短期双联抗血小板治疗(3个月)后同意100%,不同意0,中立0。DAPT治疗方案比较，阿司匹林单药治疗可显著降0%比31.1%,95%CI:0.57~0.95,P=0.004),同时未增加患者的心血管原因死亡、缺PT的选择需进一步结合出血风险的评估。对于出血风险低的患同意100%,不同意0,中立0。抗凝药(OAC)组在1个月或1年内严重出血的发生率明显低于0AC加氯吡格雷组了比较，结果提示艾多沙班的主要疗效结局不劣于VKA,但艾多沙班组大出血的因此目前尚无证据支持在合并房颤的TAVR患者中NOAC优于VKA。同意100%,不同意0,中立0。2.推荐结合肿瘤患者的预期寿命及重度主动脉瓣狭窄的症状综合评估TAVR同意100%,不同意0,中立0。抗原等血清肿瘤标志物及便潜血等结果[101],对高危患者行进一步检查以排查目前的研究支持肿瘤患者接受TAVR治疗是安全及有效的。系统分析显示接受TAVR治疗的活动性肿瘤患者或有肿瘤病史的患者无论短期死亡率(2.4%比3.3%,P<0.001),还是主要围手术期并发症如脑卒中(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)和长期全因死亡率(OR=1.51,95%CI:1.24~1.85,P<0.001)均显著高于非肿瘤患者，提示肿瘤是影响TAVR术后状性重度主动脉瓣狭窄且预期寿命≥1年的肿瘤患者接受TAVR,预期寿命<1年的肿瘤患者则需要结合患者的症状及意愿进行综合评估，而对于预期寿命<3个月对于高危NCS,可在NCS术前行主动脉瓣球囊成形术。择期NCS的管理取决于有无症状和外科手术类型(图1)。ASAS患者非心脏手术(NCS)的管理急诊或择期NCS择期否症状是低-中风险高风险患者瓣膜手术风险高风险低风险心脏团队决策：NCS术前考虑BAV,或严密监测下NCSNCS风险高风险严密监测下NCS急诊NCS外科主动脉瓣置换术，NCS:非心脏手术图1严重AS患者NCS的管理流程图1.TAVR手术的麻醉方式选择，要考虑患者病情轻重、急慢、预期寿命等因素以及团队的综合能力等。同意100%,不同意0,中立0。TAVR麻醉方式包括：局部麻醉(LA);清醒镇静(CS)或监护麻醉(MAC),在保持一定镇静深度(意识可消失)的基础上，辅以局部麻醉药完成各项有创操作及手术，术毕可直接唤醒；全身麻醉(GA),维持一定的镇静、镇痛和肌肉松弛，行气管插管、机械通气，完成手术。TAVR手术麻醉方式选择应综合考虑多方面因素：(1)患者因素患者自身意愿如何，是否配合，是否可以平卧等以及患者是否存在相关合并症比如阻塞性呼吸睡眠暂停(OSA),慢性阻塞性肺疾病(COPD)、帕金森病等都应是同意95.83%,不同意0,中立4.17%。非心脏手术的已知或者可疑VHD患者做临床和超声心动图评估，已确诊VHD的患醉科医师及相关科室医师进行的MDT讨论是管理瓣膜心脏病患者行NCS术的必要环节[107]。应向患者和外科团队交流瓣膜治疗的风险主动脉瓣狭窄是最常见的瓣膜疾病。严重AS患者分为无症状和有症状重度S决定应基于患者个人意愿情况、手术风险因素以及对于有症状患者，应在NCS前行主动脉瓣膜手术。具体手术类型选择SAVR算出的主动脉瓣面积从0.6(IQR0.6~0.7)同意100%,不同意0,中立0。死亡率和1年死亡率的风险更高[129]。因此，在血液透析和AS并存的情况下，·合并慢性肺部疾病的TAVR患者预后不良，术后1年死亡的危1.合并慢性肺部疾病的TAVR患者预后不良，术后1年死亡的危险因素包括6同意100%,不同意0,中立0。多项大型研究中将慢性肺疾病定义为1秒用力呼气容积(1-secondforcedeAVR患者术后1年死亡的危险因素不同于一般人群，主要包括6分钟步行试验距术后3年死亡率，超过一半的患者在术后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治疗的预后不劣于SAVR,且优于保守治疗[130]。和肺炎等呼吸相关并发症发生率均显著低于SAVR,非呼吸相关并发症如院内死管此类患者常因肺功能较差而推迟TAVR治疗，但在重度主动脉瓣狭窄合并慢阻同意100%,不同意0,中立0。去6个月中跌倒或计划外的体重下降)、平均跨瓣压差小均为术后获益少的预测因素。基线跨瓣压差小的患者术后改善差提示症状与慢性肺疾病相关[131]。肺[2]XuH,LiuQ,CamanagementofolderpatientswithvalvularheartdiseaseinChina:Chcasi.2021.11.013.流程优化专家共识2022版[J].中华急诊医学杂志，2022,31(2):154-160.EmergMed,2022,31(2):154-160.DOI:10.3760/cma.j.issn.1671-0282.[4]国家心血管病中心，国家结构性心脏病介入质控中心，中华医学会心血管病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]RogersP,Al-AidrousS,Banyaontoimprovehealth-relatedqualityoflifefollowiRECOVER-TAVIPilot,ORCA4,FortheOptimalRestorationofCardiacAc/s40814-018-0363-8.[26]SolaM,RammCJ,KolarczykLM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