瓣周漏(PVL)是经导管主动脉瓣置换术(TAVR)的常见并发症之一,本文报道的是一例主动脉瓣重度钙化TAVR“瓣中瓣”术后发生重度复杂PVL的老年患者,行经导管主动脉瓣多封堵器PVL封堵术,手术成功,术后心脏超声提示轻中度瓣周反流。介入封堵治疗PVL可以作为外科手术的一种替代方案,对于复杂PVL且难以承受外科手术的患者来说,多封堵器进行介入封堵更是一种直接有效的治疗手段。
Paravalvular leakage (PVL) is one of the common complications of transcatheter aortic valve re-placement (TAVR). This paper reports a case of an elderly patient with severe complicated PVL after TAVR “valve-in-valve” surgery for severe aortic calcification who underwent percutaneous PVL clo-sure with multiple occluders. The operation was successful. Postoperative echocardiography showed mild to moderate perivalvular regurgitation. Transcatheter closure therapy PVL can be an alternative to surgical procedures, and multiple occluder to interventional closure is a straightfor-ward and effective treatment for patients with complex PVL who are difficult to withstand surgical procedures.
Paravalvular leakage (PVL) is one of the common complications of transcatheter aortic valve replacement (TAVR). This paper reports a case of an elderly patient with severe complicated PVL after TAVR “valve-in-valve” surgery for severe aortic calcification who underwent percutaneous PVL closure with multiple occluders. The operation was successful. Postoperative echocardiography showed mild to moderate perivalvular regurgitation. Transcatheter closure therapy PVL can be an alternative to surgical procedures, and multiple occluder to interventional closure is a straightforward and effective treatment for patients with complex PVL who are difficult to withstand surgical procedures.
手术过程(图3):全身麻醉后穿刺右侧股动脉置入6Fr血管鞘,肝素化(1 mg/kg),经鞘管送6Fr猪尾导管行升主动脉造影,造影显示主动脉瓣人工瓣膜瓣周漏,程度达到极重度,更换Fusmart 6Fr可调弯导管,由超滑导丝引导至左冠窦处造影探及左冠窦侧PVL1处,并经术中TTE证实;结合术前CTA及3D模型模拟评估(图4),在S曲线中确定左冠切线位投照角度,并在此角度下经数字减影血管造影(Digital Subtraction Angiography, DSA)引导,由直头超滑导丝引导导管穿过PVL口至左心室,随后更换提前塑形后的超硬导丝(Amplatz Super Stiff, Boston Scientific)建立轨道。沿导丝使用5Fr封堵器介入输送装置(上海形状记忆合金材料有限公司)输送ADOII08封堵器(上海形状记忆合金材料有限公司)至左心室,于左心室内释放左伞盘,回撤输送鞘至PVL口处,于主动脉侧释放右伞盘,透视下见封堵器形态良好,位置理想,腰征明显,完成第1枚6 mm ADOII释放。术中TTE提示瓣周反流较前明显改善,程度接近中–重度。
继续在第1枚封堵器旁造影,探查到1处左冠脉窦侧较明显PVL,结合术前CTA及3D模拟评估,沿上述同样方法再次置换鞘管后置入第2枚封堵器,仍选择6 mm ADOII。封堵器释放后位置良好。TTE提示2枚封堵器位置良好,瓣周反流较前减少,程度已达到中–重度。遂在已植入封堵器旁再次造影探
图3. 手术过程。(a):主动脉造影提示重度瓣周漏;(b):塑形后的超硬导丝在DSA引导下通过PVL;(c):置换鞘管,置入入第一枚封堵器6 mm ADOII;(d):确定第一枚封堵器置入位置理想,但造影仍提示瓣周中度以上反流;(e):置换鞘管后置入第2枚6 mm ADOII;(f):在已植入封堵器旁再次探查,导丝再次通过PVL;(g):因交换鞘管困难,采用LOOP法建立轨道;(h):释放第三枚封堵器,仍选用6 mm ADOII;(i):最终再次造影显示轻中度瓣周反流
图4. 术前CTA评估(在S曲线中确定左冠切线位投照角度为LAO32 CRA6)
查,发现仍有一处较明显PVL。因已释放两枚封堵器,瓣周空间有限,再次交换鞘管困难,遂更换0.035 mm × 260 cm超滑导丝穿过该PVL处,并穿刺左侧股动脉置入6Fr血管鞘,经鞘管送6Fr造影导管,置入20号圈套器(上海形状记忆合金材料有限公司),使用圈套器抓捕超滑导丝(LOOP法)建立轨道,引导输送鞘管通过PVL,释放第三枚封堵器,仍选用6 mm ADOII,释放后再次行升主动脉造影,见主动脉瓣PVL处造影剂量较前明显减少,再次行术中TTE显示患者PVL程度达到轻中度水平,考虑已为患者解决主要问题,根据术前CTA及3D模拟评估PVL位置及大小,其他细小PVL口封堵成功可能性极小,决定结束手术。患者恢复顺利,出院前复查TTE:主动脉瓣位人工生物瓣功能正常,收缩期峰值流速3.0 m/s,最大跨瓣压差35 mmHg,DVI 0.5,LVEF 31%,左心室舒张期内径7.0 cm,中度PVL,左室壁节段性运动异常,二尖瓣轻-中度反流,三尖瓣轻-中度反流,左心功能减低,右心功能减低(轻度),全心扩大,升主动脉扩张。
术前与术后TTE对比见图5。
图5. 手术前后TEE对比。(a):心尖切面显示人工瓣周重度反流;(b):短轴切面显示瓣周舒张期轻中度反流,反流束宽约0.2 cm
杨宝童,屈占军,国鹏飞,傅天瑞,高 政,江 磊. 多封堵器经导管主动脉瓣置换术后瓣周漏封堵1例A Case of Paravalvular Leakage Closure after Transcatheter Aortic Valve Replacement with Multiple Occluders[J]. 临床医学进展, 2022, 12(11): 10265-10272. https://doi.org/10.12677/ACM.2022.12111481
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