经导管肺动脉瓣置换术治疗法洛四联症术后重度肺动脉瓣反流1例

<正>病例资料患者男性,20岁,因“活动后胸闷15年,再发1个月”入院。患者15年前活动后发作胸闷,伴气促、心悸,无明显胸痛,于我院诊断“法洛四联症”。10年前于我院,行室间隔缺损修补、右心室流出道-肺动脉跨瓣补片矫形术,术后患者症状缓解。1个月前于我院复查彩超示：肺动脉瓣重度反流等。门诊遂以“法洛四联症术后”收入我科。无其他慢性病史。辅助检查：血常规、脑钠肽、肝肾功能无异常。心电图：窦性心律。心脏彩超（图1）：法洛四联症矫治术后：肺动脉瓣重度反流,三尖瓣重度反流,二尖瓣、主动脉瓣少量反流,室水平未见残余分流,     

经导管肺动脉瓣置换术亚洲专家共识

经导管肺动脉瓣置换术（TPVR）,又称经皮肺动脉瓣置入术,是指在心脏不停跳状态下,使用X线和（或）超声影像作为引导,将人工肺动脉瓣通过经导管介入的方式置入到病变的肺动脉瓣处,在功能上完成肺动脉瓣置换的一种微创操作技术。近年来,TPVR领域在器械研发、循证医学证据及应用经验等方面取得了重要的进展。为及时更新对TPVR的认识,紧贴最新研究及实践,促进我国TPVR规范、健康地发展,专家组撰写了此共识。本共识对相关文献进行系统性回顾后,对8个核心问题作出深入分析,形成8个核心观点,包括适应证推荐、器械选择、围术期评估、手术操作注意事项、并发症预防处理等几个方面。     

肺动脉分支狭窄支架治疗研究进展

肺动脉分支狭窄是常见的儿童血管畸形之一。未经治疗的肺动脉分支狭窄会导致狭窄远端的肺血管床发育不良以及未发生狭窄的对侧肺血管持续性高肺动脉压力,进而导致右心衰竭甚至危及生命。内科介入治疗是外科治疗的替代治疗,在复杂先天性心脏病外科术后等特殊人群中甚至是首选治疗方式。随着材料学的进步,肺动脉支架蓬勃发展、前景广阔,广泛应用于肺动脉分支狭窄的介入治疗。为帮助临床医师了解肺动脉支架的相关研究进展,现概述不同类型支架在肺动脉分支狭窄中的应用。     

经股动脉经导管主动脉瓣置换术治疗单纯主动脉瓣反流的研究进展

经导管主动脉瓣置换术（TAVR）已成为国内外指南推荐治疗老年主动脉瓣狭窄（AS）的一线治疗方案,也适用于AS合并不同严重程度主动脉瓣反流的患者,但在单纯主动脉瓣反流（PAR）中却不做常规推荐,传统外科主动脉瓣置换术仍然是治疗PAR的金标准。外科手术禁忌或高危PAR患者,常放弃外科手术治疗,选择保守治疗,而后者的死亡率更高。经股动脉TAVR(TF-TAVR)为其提供了一种替代治疗方案,尽管仍面临手术技术要求高、缺乏针对PAR的瓣膜系统和术后长期随访数据等挑战,但随着TAVR技术经验积累、新一代瓣膜系统的发展及长期随访数据的反馈,TF-TAVR治疗PAR逐渐被证实是一种安全、可行的外科手术替代治疗方式,本文对TF-TAVR治疗PAR实施要点、临床研究现状以及未来的发展进行综述。     

重度主动脉瓣狭窄患者经导管主动脉瓣置换术对功能性二尖瓣反流的影响

目的:探讨重度主动脉瓣狭窄(AS)患者行经导管主动脉瓣置换术(TAVR)后,超声心动图参数及功能性二尖瓣反流(FMR)的转归情况,以及影响FMR预后的相关因素.方法:回顾性分析2017年6月至2020年7月,首都医科大学附属北京安贞医院收治的142例接受TAVR治疗的重度AS合并FMR患者,分析基线信息,比较手术前后超...     

一站式经导管主动脉瓣置换术联合经皮冠状动脉介入术治疗主动脉瓣反流一例

<正>患者,女,71岁,因“喘气2月余,加重1天”于2021年3月21日入住我科。患者2个月前无明显诱因出现喘气不适,活动后加重,偶有咳嗽、咳痰、头昏,无明显胸闷、胸痛、恶心、呕吐、咯血、盗汗,未做特殊处理,半个月前于外院就诊,予抗感染、止咳、化痰、改善循环等对症治疗,1天前患者自觉喘气加重,遂至我院进一步治疗。既往史：外院冠状动脉CT血管造影检查提示冠心病;慢性阻塞性肺疾病、肺部恶性肿瘤、脑萎缩、脑梗死、高脂血症;无高血压、糖尿病病史。入院体格检查：T 36.9℃,P 121次/分,R 20次/分,Bp 137/56 mmHg。烦躁不安,颈静脉     

经导管二尖瓣置换术治疗二尖瓣反流的研究进展

二尖瓣反流（MR）是临床常见瓣膜疾病,传统外科二尖瓣修复和置换治疗手术创伤大、风险较高。经导管二尖瓣置换术（TMVR）是一种经导管通过心尖或股静脉路径将人工瓣膜送至二尖瓣位置治疗MR的微创疗法,目前已在临床逐步开展。TMVR围术期成像主要采用超声心动图、多排CT技术;TMVR治疗系统包括Tendyne、Intrepid、Cardiovalve、AltaValve、Evoque、HighLife系统,对MR患者均有不同程度的治疗效果;各类系统的术后并发症主要为LVOT梗阻、瓣膜错位、瓣周漏。     

经导管主动脉瓣置换术治疗老年主动脉瓣狭窄的安全性和有效性

目的 探讨经导管主动脉瓣置换术(TAVR)在中国老年主动脉瓣狭窄(AS)患者中的安全性和有效性.方法 选取行手术治疗的AS患者132例,其中行外科主动脉瓣置换术(SAVR)手术患者8例(SAVR组);行TAVR手术患者124例(TAVR组).观察两组围术期临床结果.结果 围术期内出现1例(0.76％)死亡及1例(0.7...     

纪念经导管主动脉瓣置换术二十周年

2002年,法国医生Alain Cribier成功完成了全球首例经导管主动脉瓣置换术(TAVR)[1],开创了心脏瓣膜病经导管介入治疗的新纪元.二十年来,器械不断改进、创新,技术不断发展,大量随机对照临床试验证实了其治疗不同外科手术风险的严重主动脉瓣狭窄(AS)的有效性和安全性,使该技术在世界范围内得以推广应用,目前有...     

3D打印心脏模型辅助肺动脉分支狭窄支架置入1例

1临床资料患儿男,7岁10个月。因“法洛四联症纠治术后7年余,气促1个月”于2017年7月2日收入深圳市儿童医院心血管内科。患儿在5个月龄时行法洛四联症纠治术+房间隔修补术+动脉导管缝扎术,术后仍发绀,反复浮肿、腹胀。超声心动图提示肺动脉远端中度狭窄。于1岁9个月时行右心室流出道扩宽术,效果仍欠佳。     

Hybrid pulmonary artery plication followed by transcatheter pulmonary valve replacement: Comparison with surgical PVR

Objective/Background Historically, the sole option for patients with a dysfunctional native right ventricular outflow tract (RVOT) requiring re‐establishment of pulmonary competence has been surgical PVR. We sought to compare early outcomes of hybrid pulmonary valve replacement (PVR) combining surgical plication of the main pulmonary artery followed by transcatheter PVR, with a contemporary cohort of surgical PVR patients. Methods Retrospective chart analysis of all patients with a dilated native RVOT eligible for surgical PVR over 36 months was performed. The cohorts included patients with previous tetralogy of Fallot repair (n = 14), and previous intervention for congenital abnormality of the pulmonary valve (n = 7). Results Twenty‐one patients with a dysfunctional native RVOT met criteria for PVR; 8 using the hybrid procedure (group 1: age, 31.5 +/? 17.4 years) and 13 with cardiopulmonary bypass (CPB) (group 2: age, 31 +/? 18.4 years). Valve delivery was successful in all patients with no procedural mortality. Group 1 had a lesser requirement for blood products (P =< 0.001) and a trend toward shorter hospital stay and higher post‐operative hemoglobin. No patients in group 1 received inotropic support post‐operatively compared to 54% of patients in group 2. Mean follow‐up was 3.4 months for group 1 and 13.6 months for group 2 with the average peak gradient across the RVOT of 20.1 and 15.1 mm Hg respectively (P = 0.12), all with no more than mild PI. Conclusions Transcatheter hybrid PVR following RVOT plication provides a reasonable alternative to surgical PVR particularly in higher risk cohorts, reducing possible longer‐term consequences of repeated runs of CPB. © 2016 Wiley Periodicals, Inc.     

Carotid artery access for transcatheter aortic valve replacement

We report three patients who had successful transcatheter aortic valve replacement (TAVR) via carotid artery access. None were candidates for thoracotomy (including minimal access incisions) and had no other vascular access sites that would accommodate the transcatheter valve sheath. Antegrade carotid perfusion and retrograde insertion of the delivery sheath maintained cerebral blood flow without sequelae. Carotid access for TAVR is an option for unusual patients without other access. © 2012 Wiley Periodicals, Inc.     

Hybrid approach for harmony transcatheter pulmonary valve replacement

The Harmony™ Transcatheter Pulmonary Valve (Medtronic) was recently approved by the Food and Drug Administration for transcatheter pulmonary valve replacement in native right ventricular outflow tracts. Despite this milestone, some patients have main pulmonary arteries that are severely dilated and continue to require surgical pulmonary valve replacement. The hybrid approach combines surgical creation of a landing zone, transcatheter valve deployment, and suture stabilization of the implanted valve. In this case series, we report the first use of a hybrid approach for Harmony™ transcatheter pulmonary valve replacement. Two cases are reported with varying approaches for surgical creation of a landing zone followed by successful placement of a Harmony™ valve.     

Hybrid transcatheter pulmonary valve replacement with a SAPIEN S3 valve after pulmonary artery banding via left lateral thoracotomy

For many patients with repaired congenital heart disease, the need for reintervention on dysfunctional right ventricular outflow tracts is pervasive. Many such patients are poor candidates for both transcatheter pulmonary valve replacement and cardiopulmonary bypass, and hybrid surgical and transcatheter procedures have evolved to meet this need. We present two cases of hybrid pulmonary valve replacement involving pulmonary artery band placement via left anterior thoracotomy followed by transvenous placement of a SAPIEN S3 valve without prestenting. This approach avoids cardiopulmonary bypass as well as redo sternotomy and will likely see an increase in utilization in the future.     

Impact of left bundle branch block after transcatheter aortic valve replacement

The number of patients with severe aortic stenosis getting treated with transcatheter aortic valve replacement (TAVR) is rapidly growing and the outcome after the procedure is very good. However, the incidence of new persistent left bundle branch block (LBBB) following the TAVR procedure is high and the impact of this new conduction disturbance has been studied in four major studies with divergent result. This review investigates the differences between these studies that might explain the divergent results and concludes that future studies are needed to characterize whether or not new LBBB after TAVR fulfills the new strict LBBB criteria, whether these new LBBB patients develops left ventricular dyssynchrony, and which, if any, might benefit from cardiac resyncronization therapy (CRT).     

Simultaneous transapical transcatheter aortic valve replacement and transcatheter mitral valve replacement for native valvular stenosis

Transcatheter aortic valve replacement (TAVR) is well established for patients who cannot undergo surgery (Leon et al., N Engl J Med 2010;363:1597) or are high risk for surgery (Smith et al., N Engl J Med 2011;364:2187–2198). Experience with the TAVR procedure has led to recent reports of successful transcatheter mitral valve replacement (TMVR) procedures (Cheung et al., J Am Coll Cardiol 2014;64:1814; Seiffert et al., J Am Coll Cardiol Interv 2012;5:341–349) separately or simultaneously with the TAVR. However, these reports were of simultaneous valve‐in‐valve procedures (Cheung Anson, et al. J Am Coll Cardiol 2013;61:1759–1766). A recent report from Portugal also reported simultaneous transpical implantation of an inverted transcatheter aortic valve‐in‐ring in the mitral position and transcatheter aortic valve (Hasan et al., Circulation 2013;128:e74–e76). There has been an experience of TMVR only in native mitral valve for mitral valve stenosis, but none in both aortic and mitral valves. We report the first in human case of simultaneous transapical TAVR and TMVR in native valves secondary to valvular stenosis. Our patient was not a candidate for percutaneous balloon mitral valvuloplasty secondary to a high Wilkins Score. Sizing of the aortic valve was based on the transesophageal echocardiogram (TEE), whereas sizing of the mitral valve was based on TEE measurements and balloon inflation during left ventriculography. © 2015 Wiley Periodicals, Inc.     

经导管主动脉瓣置换的介入瓣膜的现状及展望

经导管主动脉瓣置换术（TAVR）经过最近几年快速发展已经取得巨大进步。迄今为止全球接受TAVR的患者数已近3万例,已成为无法耐受传统手术患者的标准备选治疗措施。从目前已临床应用的介入瓣膜到正在实验研究的新型介入瓣膜可以看出,未来介入瓣膜的发展目标是尺寸更小、长期有效、安全性高、并发症少、操作简单及定位精准。随着TAVR的推广,新型介入瓣的研发,操作者经验的积累,以及长期随访的开展,将给TAVR提供更科学的病例选择标准,减少介入手术的相关并发症,提高更安全有效的治疗效果。未来此项技术还会逐渐扩大适用人群的范围,成为代替传统的主动脉瓣置换术举足轻重的治疗措施。     

Coronary artery compression three months after transcatheter pulmonary valve implantation

We report a case of a 29‐year‐old man who developed exercised‐induced myocardial infarction 3 months post Melody valve implantation. We introduce the concept of ruling out dynamic coronary artery compression by simulating transcatheter pulmonary valve implant while increasing cardiac output and thus aortic dimensions in the catheterization laboratory. © 2014 Wiley Periodicals, Inc.