International Circulation: I am with Prof. Marc Shelton and Prof. Huo Yong at ACC2009. Prof. Shelton， could you talk about the challenges of transcatheter therapy for valve diseases?
《国际循环》：我现在正在和Marc Shelton 教授和霍勇教授在一起，Shelton教授，您能谈一谈经导 管治疗瓣膜病面临的挑战吗？

Prof. Shelton: Well it’s a very important topic and we are seeing calcific aortic stenosis of the elderly more frequently these days I believe than we used to because people are living longer to have the disease. It’s almost like miles on a tyre， eventually， if you live long enough， you are going to have one of your valves is going to get some wear and tear. It’s becoming a very common problem. Part of the issue is that these patients present often at elderly ages， in their eighties， late seventies. They are not ideal candidates for a surgical approach so we’ve needed other methods， other ways to deal with them and the percutaneous valvuloplasties and the stent valves certainly are a viable approach， although technically challenging. The approach is from the femoral area and can be challenging often because the delivery size of the catheter is so large， some， especially young ladies， don’t have femoral arteries big enough to hold the sheath and then often as we get older the arteries are more tortuous， so it is technically challenging. One of the approaches that I think may be promising is a kind of a hybrid approach where we get the surgeons to help us make a little keyhole and go through the vortex of the heart antegrade and put it in that way. We’ve got a couple of options and， quite honestly， our friends in Europe have been doing a lot more percutaneous valvuloplasties than we have and it’s starting to catch on a little bit. I predict in the future there will be many cases of percutaneous valvuloplasty， predominantly in the older population that would otherwise not be good surgical candidates.
Shelton教授：这个话题非常重要，我们现在看到比从前更多的老年患者出现主动脉钙化狭窄，我想这 是因为人的寿命比以前更长了。这就像使用了很久的轮胎，如果你活的时间足够长，你的瓣膜最终就 会像轮胎一样出现磨损。现在这已经很常见了。现在的问题是出现症状的都是老年人，大多数在80岁 左右，或者快到80岁。他们显然不适合做外科手术，所以我们需要其他方法解决问题，那么经皮瓣膜 成形术和支架瓣膜就成了非常合适的手段，当然在技术上还存在一定的挑战。手术途径是经过腹股沟 区的血管入路，但这通常有一定难度，常常因为输送导管的管径 较大，特别对于年轻女性患者，她们 的股动脉管径不足以容纳管鞘，而且随着年龄的增长，动脉也会变得迂曲，这就是目前技术上存在的 困难。我想有一个途径非常有前景，那就是镶嵌治疗，这样我们可以让外科医生帮助我们建立一个通 道，然后顺行通过心脏进行操作。我们还有一些其他的方法，不过，坦率的说，我在欧洲的同事们比 我们做的经皮瓣膜成形要多，不过目前我们也在迎头赶上。我预测在未来肯定会有越来越多的经皮瓣 膜成形术，主要集中于不适合外科手术的老年人群。
 
Prof. Huo: Yes， I totally agree with Prof. Shelton about the promise and also we have a lot of challenges for the problem of percutaneous valvular replacement. As for the situation in China， we don’t have a lot of valvular disease patients. Especially in the mitral valve we have a lot of experience with so many procedures in China but for the aortic valve replacement， we have no experience so far， we have no devices that we are allowed to use on the Chinese market. For myself， I have a prediction for percutaneous valvular replacement， in that it is very promising in the future because we have such a large population in China， so many patients. Maybe we have a long way to go because so far we have no perfect devices. Also the risk with the procedure is very high， a mortality of around 10%. So there are a lot of things we should get approved.
霍勇教授：我非常同意Shelton教授的预测，另外，我们也遇到了很多经皮瓣膜成形的问题。对目前中 国的情况而言，我们没有很多瓣膜病的患者。对于二尖瓣，我们因为有很多患者所以有很多操作体会 ，但对于主动脉瓣置换，我们到目前还没有经验，我们也没有可应用于中国市场的器械。对我本人而 言，我对经皮瓣膜置换有个预期，那就是它在未来非常有前景，但是中国的人口数目实在太大，患者 太多了。也许我们要走的路还很长，因为到目前为止我们还没有特别令人满意的器械。所以操作的风 险也非常高，死亡率大概有10%左右。而且我们还有很多事情要去获得批准。

International Circulation: What about the challenges in the various valve replacements， for example， mitral valve versus aortic valve? Are the challenges different and can we apply one a bit easier than the other?
《国际循环》：不同瓣膜置换的困难是怎样的？比如以二尖瓣和主动脉瓣做对比？困难程度不一样， 是不是其中一个相对简单呢？

Prof. Shelton: I think， clearly， mitral valves that are pliable and can be ballooned are technically a very viable approach right now and those procedures are being done fairly commonly and with some good results. The new procedures of trying to put clips and tether the leaflets of the mitral valve are more technically challenging and are still very much in the development stage as I view them. The aortic valve has a lot of future promise. That patient population， if you just leave them on medicine， they all tend to go downhill and die anyway. Even though the mortality rate may be 10%， it’s nearly 100% if you leave them alone in the elderly population. It’s a compelling potential need. And we will see. I suspect， in the end， we will have some patients go through the percutaneous approach and some patients go through the little keyhole surgical approach.
Shelton教授：我想，很明显，二尖瓣柔软光滑且可以充启气囊从技术角度讲是可行的，目前这些操作 比较成功而且效果也比较好。新的操作正在尝试放置微型夹然后控制住二尖瓣瓣叶，这在技术上难度 更大，而且目前正在研究发展阶段。主动脉瓣膜有很好的前景，这类患者，如果你仅仅给他们药物治 疗，他们肯定每况愈下并最终死亡。尽管这项技术的死亡率可能在10%，但是如果你不对这些人群干预 ，那么死亡率就是100%。这是一种刚性需求。到最后，我想我们会看到我们有些患者采用经皮通道， 有些患者可能需要外科帮助建立介入通道。

International Circulation: How common is that surgical approach at this point?
《国际循环》：目前这样的外科操作普遍吗？
 
Prof. Shelton: It is very early， phase one studies and some are randomizing to the surgical approach and some are randomizing to the percutaneous approach， so honestly， the data is just being collected.
Shelton教授：目前一期研究正在进行，有些患者随机分到外科入路组，有些分到经皮入路组，截止到 目前为止，正在收集数据阶段。

International Circulation: What do you think about the future directions for anticoagulants compared with some of the more traditional anticoagulants? What advantage do the new generation of anticoagulants have?
《国际循环》：您认为与传统的抗凝药物相比，未来抗凝药物的方向是什么？新一代抗凝药物有什么样的优势？

Prof. Shelton: I think it is almost always true that something that is a stronger anticoagulant， no matter what it is， is going to be associated with maybe some reduction in thrombus burden on the one hand which is good， and then some increased bleeding risk on the other hand and that is of course bad. It’s that balance that we continue to struggle with. The hirudin analogues， I’m a big believer that they have advanced the acute care during PCI . I like them predominantly in patients that have already been preloaded with dual antiplatelet therapy with clopidogrel and aspirin. If they have had adequate time for the clopidogrel to soak in and work， then I like the hirudin analogue approach. If it is somebody who presents emergently and they have not had four or five or six hours to absorb the clopidogrel yet， I still use GII/IIIB platelet inhibitors because I think it takes a