Shiota Takahiro
Cedars-Sinai Medical Center, Los Angeles, CA, USA.
J Cardiol. 2017 Jan;69(1):66-73. doi: 10.1016/j.jjcc.2016.09.015. Epub 2016 Nov 15.
Catheter-based treatment of valvular heart disease, such as transvalvular aortic valve replacement (TAVR) or mitral clip procedure, has been increasingly accepted as a treatment choice for the past several years. Such new treatment options have been changing the management of patients with valvular heart disease drastically while socio-economic factors regarding their application need to be taken into consideration. The use of echocardiography, including transesophageal echocardiography (TEE), for such catheter-based treatments is essential for the success of the procedures. Severe hypotension after TAVR is a life-threatening emergency. Rapid assessment and diagnosis in the catheterization or hybrid laboratory is essential for safety and a positive outcome. Possible diagnoses in this critical situation would include severe left ventricular dysfunction due to coronary obstruction, cardiac tamponade, aortic rupture, acute severe aortic and/or mitral valve regurgitation, and hypovolemia due to bleeding. Although new types of TAVR valves reduce para-valvular aortic regurgitation (AR) significantly, it is still important to judge the severity of para-valvular AR correctly in the laboratory. As for mitral clip procedure, TEE is vital for guiding and monitoring the entire process. Accurate identification of the location and the geometry of the regurgitant orifice is necessary for proper placement of the clip. Real-time 3D TEE provides helpful en face view of the mitral valve and clip together to this end. Residual mitral regurgitation (MR) after the first clip is not uncommon. Quick and precise imaging of the residual MR (location and severity) with TEE is extremely important for the interventionist to place the second clip and possibly third clip properly. After the completion of the clip procedure, mitral valve stenosis and also iatrogenic atrial septal defect need to be checked by TEE. Echocardiography, especially TEE, is also vital for the success of other newer trans-catheter procedures such as device closure of para-valvular MR of the artificial valve, valve in valve procedure, and native valve replacement.
在过去几年中，基于导管的心脏瓣膜病治疗方法，如经瓣膜主动脉瓣置换术（TAVR）或二尖瓣夹合术，已越来越被视为一种治疗选择。此类新的治疗方案正在极大地改变心脏瓣膜病患者的治疗管理方式，同时在应用这些方案时需要考虑社会经济因素。对于此类基于导管的治疗，使用超声心动图，包括经食管超声心动图（TEE），对于手术的成功至关重要。TAVR术后严重低血压是危及生命的紧急情况。在导管室或杂交手术室进行快速评估和诊断对于安全和取得良好结果至关重要。在这种危急情况下，可能的诊断包括冠状动脉阻塞导致的严重左心室功能障碍、心脏压塞、主动脉破裂、急性严重主动脉瓣和/或二尖瓣反流以及出血导致的血容量不足。尽管新型TAVR瓣膜显著减少了瓣周主动脉反流（AR），但在手术室正确判断瓣周AR的严重程度仍然很重要。至于二尖瓣夹合术，TEE对于指导和监测整个过程至关重要。准确识别反流口的位置和几何形状对于正确放置夹子是必要的。实时三维TEE为此提供了二尖瓣和夹子的有用正面视图。首次夹合后残留二尖瓣反流（MR）并不少见。用TEE对残留MR（位置和严重程度）进行快速精确成像对于介入医生正确放置第二个夹子甚至可能是第三个夹子极为重要。在夹合手术完成后，需要通过TEE检查二尖瓣狭窄以及医源性房间隔缺损。超声心动图，尤其是TEE，对于其他更新的经导管手术的成功也至关重要，如人工瓣膜瓣周MR的器械封堵、瓣中瓣手术和自体瓣膜置换术。
