University Hospital, Department of Cardiology and Cardiovascular Medicine, Eberhard Karls University Tuebingen, Tuebingen, Germany.
University Hospital, Department of Anesthesiology and Intensive Care Medicine, Eberhard Karls University Tuebingen, Tuebingen, Germany.
JACC Cardiovasc Interv. 2016 Jan 25;9(2):151-9. doi: 10.1016/j.jcin.2015.09.038. Epub 2015 Dec 23.
This study sought to evaluate a ventilation maneuver to facilitate percutaneous edge-to-edge mitral valve repair (PMVR) and its effects on heart geometry.
In patients with challenging anatomy, the application of PMVR is limited, potentially resulting in insufficient reduction of mitral regurgitation (MR) or clip detachment. Under general anesthesia, however, ventilation maneuvers can be used to facilitate PMVR.
A total of 50 consecutive patients undergoing PMVR were included. During mechanical ventilation, different levels of positive end-expiratory pressure (PEEP) were applied, and parameters of heart geometry were assessed using transesophageal echocardiography.
We found that increased PEEP results in elevated central venous pressure. Specifically, central venous pressure increased from 14.0 ± 6.5 mm Hg (PEEP 3 mm Hg) to 19.3 ± 5.9 mm Hg (PEEP 20 mm Hg; p < 0.001). As a consequence, the reduced pre-load resulted in reduction of the left ventricular end-systolic diameter from 43.8 ± 10.7 mm (PEEP 3 mm Hg) to 39.9 ± 11.0 mm (PEEP 20 mm Hg; p < 0.001), mitral valve annulus anterior-posterior diameter from 32.4 ± 4.3 mm (PEEP 3 mm Hg) to 30.5 ± 4.4 mm (PEEP 20 mm Hg; p < 0.001), and the medio-lateral diameter from 35.4 ± 4.2 mm to 34.1 ± 3.9 mm (p = 0.002). In parallel, we observed a significant increase in leaflet coaptation length from 3.0 ± 0.8 mm (PEEP 3 mm Hg) to 5.4 ± 1.1 mm (PEEP 20 mm Hg; p < 0.001). The increase in coaptation length was more pronounced in MR with functional or mixed genesis. Importantly, a coaptation length >4.9 mm at PEEP of 10 mm Hg resulted in a significant reduction of PMVR procedure time (152 ± 49 min to 116 ± 26 min; p = 0.05).
In this study, we describe a novel ventilation maneuver improving mitral valve coaptation length during the PMVR procedure, which facilitates clip positioning. Our observations could help to improve PMVR therapy and could make nonsurgical candidates accessible to PMVR therapy, particularly in challenging cases with functional MR.
本研究旨在评估一种通气手法，以促进经皮缘对缘二尖瓣修复术（PMVR）并评估其对心脏几何形状的影响。
在解剖结构具有挑战性的患者中，PMVR 的应用受到限制，可能导致二尖瓣反流（MR）的减轻程度不足或夹合器脱落。然而，在全身麻醉下，可以使用通气手法来促进 PMVR。
共纳入 50 例行 PMVR 的连续患者。在机械通气过程中，施加不同水平的呼气末正压（PEEP），并使用经食管超声心动图评估心脏几何形状参数。
我们发现，增加 PEEP 会导致中心静脉压升高。具体而言，中心静脉压从 14.0±6.5mmHg（PEEP 3mmHg）增加到 19.3±5.9mmHg（PEEP 20mmHg；p<0.001）。因此，前负荷的减少导致左心室收缩末期直径从 43.8±10.7mm（PEEP 3mmHg）减少到 39.9±11.0mm（PEEP 20mmHg；p<0.001），二尖瓣瓣环前后直径从 32.4±4.3mm（PEEP 3mmHg）减少到 30.5±4.4mm（PEEP 20mmHg；p<0.001），以及从中到外侧直径从 35.4±4.2mm 减少到 34.1±3.9mm（p=0.002）。平行地，我们观察到瓣叶对合长度从 3.0±0.8mm（PEEP 3mmHg）显著增加到 5.4±1.1mm（PEEP 20mmHg；p<0.001）。在功能性或混合性病因的 MR 中，对合长度的增加更为明显。重要的是，在 PEEP 为 10mmHg 时对合长度>4.9mm 可显著缩短 PMVR 手术时间（152±49min 至 116±26min；p=0.05）。
在这项研究中，我们描述了一种新的通气手法，该手法可在 PMVR 过程中改善二尖瓣的对合长度，从而有助于夹合器的定位。我们的观察结果可能有助于改善 PMVR 治疗，并使非手术候选者能够接受 PMVR 治疗，特别是在具有功能性 MR 的挑战性病例中。
