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2024年7月10日,在北京瓣膜会(2024)首日以二尖瓣为主题的线上学术活动期间,首都医科大学附属北京安贞医院宋光远教授带领团队与香港亚洲心脏病中心林逸贤教授、Cedars-Sinai Medical Center的Sabah Skaf教授携手,以线上直播的形式圆满完成一台复杂TEER手术!该患者LVOT阻塞、二尖瓣A1区脱垂,术中术者在TEE 3D指导下反复调整夹子位置、角度两次夹闭夹子,最终获得满意的植入效果,夹子释放后超声示二尖瓣反流明显改善,跨瓣压差良好。此例TEER手术的圆满成功,不仅体现了我国处理复杂二尖瓣疾病的高水平诊疗能力,还展现了中外TEER领域专家切磋技艺、互动交流的热烈学术氛围!
基本情况|二尖瓣反流、A1区脱垂伴LVOT阻塞
患者77岁女性,因“劳力性呼吸困难1个月”来院就诊,既往肥厚性心肌病,NT-proBNP 2503 pg/ml(>1194 pg/ml),STS评分4.9%。术前超声示室间隔较厚、最厚处19 mm,LVEDD(舒张期左室内径)58 mm,左心房扩张明显、前后径50 mm、M-L径66mm,LVOT阻塞、峰值压差68 mmHg,AR VC 3.36 mm;二尖瓣明显反流、二尖瓣峰值跨瓣压差2 mmHg、二尖瓣反流体积135 ml、二尖瓣瓣口面积3.25 cm2,三尖瓣峰值跨瓣压差28 mmHg,TAPSE 19.2mm,提示右心功能良好。二维影像示二尖瓣反流偏外侧区,三维影像示二尖瓣A1区脱垂延伸至A2区,但A2区无明显交界区反流,提示A1区为真性脱垂、A2区为假性脱垂,脱垂宽度13.5 mm;A1 19.4 mm、P1 9.8 mm,具有充足的空间进行钳夹;二尖瓣瓣环略微扩大,二尖瓣M-L径33.7 mm,A-P径31.4 mm。综合上述评估结果,考虑到二尖瓣反流消失后LVOT阻塞症状往往会改善,手术团队决定优先处理二尖瓣反流。
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手术过程
患者取平卧位,气管插管全麻后,术者经股静脉置入导丝和鞘管后,在TEE引导下靠下靠后穿刺房间隔。TTE示穿刺高度4.6 cm,但因心房太大,穿刺鞘和瓣膜无法在同一平面,术者前送鞘管并回拉扩张器后,穿刺鞘和瓣膜位于同一视野,ACT>260秒,平均左房压力为10 mmHg。
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房间隔穿刺
将工作导丝和可操控导引导管送入左房后,术者将MitraClip G3导管输送系统送至左房。在TEE 3D指导下,考虑到二尖瓣反流偏外侧区且LVOT阻塞,术者反复调整夹子角度、位置捕获前叶和后叶,于A1P1区偏外侧区以1-7点左右角度植入一枚夹子。复查彩色多普勒超声示二尖瓣偏内侧区反流,或与夹子增加了前叶张力有关。
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第一次夹闭后评估反流
第二次植入夹子的过程中,术者将夹子向偏外侧区移动,以减小前叶张力,然而后叶被腱索卡住,夹子无法完全捕获后叶,但彩色多普勒超声示二尖瓣跨瓣压差2 mmHg、二尖瓣反流明显改善,故术者在A1P1区以1-7点左右角度夹闭夹子。复查TEE、3D示二尖瓣跨瓣压差2-3 mmHg,偏内侧区和偏外侧区仅存微量反流。最终术者再次调整夹子角度尽力优化后叶钳夹情况后,完全释放夹子;同时考虑到在脱垂处植入第二枚夹子会影响瓣口面积和LVOT压差,术者并未植入第二枚夹子,至此手术圆满结束!
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夹子释放后影像
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