经导管主动脉瓣置换术营养筛查工具的 研究进展

Advances in Research on Nutritional Screening Tools for Transcatheter Aortic Valve Replacement

摘要: 经导管主动脉瓣置换术(transcatheter aortic valve replacement, TAVR)是一种微创治疗主动脉瓣疾病的技术，通过血管(如股动脉)植入人工瓣膜，替换病变主动脉瓣，改善血流动力学。有研究表明，大约30%~70%的患者接受TAVR术后被认为是虚弱的，虚弱是TAVR后死亡和致残的主要风险因素。虚弱是一种多维综合征，包括缓慢、虚弱、疲惫、消瘦和营养不良、耐力差和缺乏活动，丧失独立性，代表生理储备受损和对压力的抵抗力下降。而营养不良是虚弱其中一个核心指标，同时，营养状态是影响手术患者恢复预后的重要因素之一。既往文献中，心脏瓣膜手术的术后并发症及死亡率的危险因素分析中较少考虑术前营养不良的影响。也有研究表明，在接受TAVR术人群中营养不良患者很常见，同时TAVR术后大约25.2%的患者存在营养不良风险；因此，TAVR术前对患者进行营养评估是十分必要的。现阶段临床中虽有多种营养筛查工具应用，但针对心脏瓣膜病的专用筛查工具，相较于其他临床学科仍存在明显的研发和应用滞后性，并且专为心脏瓣膜病患者使用营养筛查工具预测价值尚未明确。现有主要筛查工具或评分如老年营养风险指数(GNRI)、控制营养状况(CONUT)评分、预后营养指数(PNI)、甘油三酯(TG) × 总胆固醇(TC) × 体重(BW)指数(TBBI)。本研究将聚焦于经导管主动脉瓣置换术(TAVR)患者的术前营养评估体系，进行综述。研究重点围绕营养不良评估指标的临床适用性、量化计算方法、病理生理学干扰因素、机制，以及其对术后死亡率及不良事件的预测效能展开深入探讨。通过5种营养筛查工具对TAVR术前风险分成中的不同预测效能进行对比分析，旨在为临床医师对TAVR术前营养评估选择科学的营养筛查工具。

Abstract: Transcatheter aortic valve replacement (TAVR) is a minimally invasive therapeutic modality for severe aortic valve disease, in which a prosthetic valve is implanted via a vascular approach (most commonly the femoral artery) to replace the diseased native aortic valve and restore optimal hemodynamics. Studies have shown that approximately 30%~70% of patients are classified as frail after TAVR, and frailty has been identified as a leading risk factor for post-procedural mortality and disability in this population. Frailty is a multidimensional geriatric syndrome characterized by impaired physiological reserve, diminished stress resilience, and a constellation of clinical manifestations including slowness, weakness, fatigue, wasting, malnutrition, poor exercise tolerance, physical inactivity, and loss of independence. Malnutrition is a core component of the frailty phenotype, and nutritional status is a well-established determinant of post-procedural recovery and long-term clinical outcomes in patients undergoing valvular intervention. Historically, the impact of preoperative malnutrition has been infrequently incorporated into risk factor analyses for post-procedural complications and mortality in patients undergoing heart valve surgery. Compelling evidence has demonstrated a high prevalence of malnutrition in the TAVR population, with approximately 25.2% of patients presenting with malnutrition risk following the procedure. Accordingly, routine preoperative nutritional assessment is imperative for patients scheduled for TAVR. Although numerous nutritional screening tools are widely used in current clinical practice, the development of disease-specific nutritional screening tools for valvular heart disease lags significantly behind that of other medical specialties, and the predictive value of dedicated tools for this patient population has not been clearly defined. The most widely used nutritional screening tools and scores include serum albumin (Alb), Geriatric Nutritional Risk Index (GNRI), Controlling Nutritional Status (CONUT) score, Prognostic Nutritional Index (PNI), and Triglyceride (TG) × Total Cholesterol (TC) × Body Weight (BW) Index (TCBI). In this narrative review, we focus on the preoperative nutritional assessment system for patients undergoing TAVR. We conduct an in-depth exploration of the clinical applicability, quantitative calculation methods, pathophysiological confounders, and underlying mechanisms of these nutritional assessment markers, as well as their predictive efficacy for post-procedural mortality and adverse clinical events. Through a comparative analysis of the differential predictive performance of the 5 nutritional screening tools in preoperative risk stratification for TAVR, this review aims to provide clinicians with evidence-based recommendations for selecting scientific and appropriate nutritional screening tools in the pre-TAVR setting.