Amat-Santos及同事在138例无心房颤动（AF）既往史的患者中评估了经导管主动脉瓣植入术（TAVI）后新发心房颤动（NOAF）的发生率及与其有关的并发症。NOAF被定义为任何持续>30 s的AF发作。NOAF发生于32％的患者，1/3的病例是在手术过程中发生。在随访30天时， NOAF与较高的卒中/全身性栓塞率（13.6％ vs. 3.2％）相关。所有晚期卒中（手术后超过24小时）的患者都至少有1次AF发作。在那些未接受抗凝治疗的NOAF患者中，栓塞性事件的风险为40％。这份报告突出了与TAVI后NOAF相关的风险。
 

　　J Am Coll Cardiol 2012 59: 178-188.

　　点评：TAVI途径与NOAF相关
　　Michael Reardon， M.D.， FACC， FACS 美国休斯敦卫理公会医院心胸外科
　　The paper， Incidence， Predictive Factors， and Prognostic Value of New-Onset Atrial Fibrillation Following Transcatheter Aortic Valve Implantation by Amat-Santos et. al.， looked at the risk of developing new onset atrial fibrillation (NOAF) and the related outcome in 138 consecutive patients undergoing TAVI with the Edwards Sapien valve. Almost 3/4 of their patients had a transapical approach to TAVI. NOAF was associated at 30 days and 1 year with a higher stroke rate but not mortality vs. patients with no NOAF. In the short term， NOAF also leads to 33% longer lengths of stay.
　　The three most commonly discussed clinical worries about TAVI are stroke， para valvular leak and valve durability. Most of the patients that we see as candidates for TAVI are older and often their major concern is stroke and not death. The two factors associated with NOAF were a larger left atrium and a transapical approach. A larger left atrium is an anatomic fact that cannot be changed. The approach used for TAVI， however， can be changed. The generally accepted approach is to use a transfemoral insertion when anatomically possible. The transapical approach has been the alternative approach for Sapien insertion when ileofemoral access is not anatomically feasible or safe. The CoreValve by Medtronic has used both trans subclavian insertion as well as a direct aortic insertion as an alternative when transfemoral insertion is not feasible. Early reports of a direct aortic approach to Sapien insertion are also beginning to appear in the literature. Direct aortic insertion can be done through a mini sternotomy or right thoracotomy avoiding the cardiac apex and its attendant difficulties. It will be of great interest to our patients as well as the implanters to see if a direct aortic approach is also associated with a higher stroke rate or behaves more like a transfemoral approach in this regard. If the rate of NOAF is lower with a direct aortic approach， then the transapical approach as a technique may become infrequent.
　　这项研究中138例TAVI患者使用的是Edwards Sapien瓣膜，几乎3/4的患者是经心尖途径，NOAF在30天和1年时与卒中率升高有关，但死亡率与无NOAF者无差异，同时NOAF患者住院时间延长了33%。
　　TAVI最常见的担忧是卒中、瓣周漏和瓣膜的持久性。绝大多数TAVI的候选者年龄较大，主要的担忧常常是卒中，而不是死亡。与NOAF相关的因素是较大的左心房和经心尖途径。较大的左心房是一种无法改变的解剖学事实，而TAVI实施的途径是可以改变的。只要解剖学上可行，一般认可的途径是经股动脉。当髂股途径不可行或不安全时，Sapien插入时的替代途径是经心尖。Medtronics的CoreValve使用经锁骨下插入或直接主动脉插入作为经股途径不可行时的替代。直接主动脉插入Sapien的报告也开始出现在文献中。直接主动脉插入通过微创的胸骨切开术或右胸切开术，避开心尖部及其相关的困难。直接主动脉途径是否也与高卒中率有关或更接近经股途径，对患者和术者都有极大的利害关系。如果直接主动脉途径NOAF发生率低，则经心尖途径将变得不常用了。