Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
JACC Cardiovasc Interv. 2020 Jul 13;13(13):1544-1553. doi: 10.1016/j.jcin.2020.03.056.
The aim of this study was to investigate the incidence, characteristics, hemodynamic conditions, and clinical significance of right-to-left (R-L) shunt through an iatrogenic atrial septal defect (iASD) after the MitraClip procedure.
R-L shunt through an iASD after the MitraClip procedure has not been well investigated.
From 2014 to 2017, 385 consecutive patients with mitral regurgitation underwent the MitraClip procedure. iASD was assessed using intraprocedural transesophageal echocardiography. Right and left heart catheterization was used to assess the hemodynamic status of patients. All patients provided written informed consent for the procedure. All data for this study were collected from an established interventional cardiology laboratory database approved by the Cedars-Sinai Medical Center Institutional Review Board.
R-L shunt was observed in 20 patients (5%). In 7 of these patients (35%), R-L shunt was accompanied by acute deoxygenation. Prevalence of severe tricuspid regurgitation (55% vs. 20%; p = 0.001), serum B-type natriuretic peptide (664 pg/ml [434 to 1,169 pg/ml] vs. 400 pg/ml [195 to 699 pg/ml]; p = 0.006), mean pulmonary artery pressure (38 mm Hg [34 to 45 mm Hg] vs. 29 mm Hg [22 to 37 mm Hg]; p < 0.001), and right atrial pressure (19 mm Hg [13 to 20 mm Hg] vs. 10 mm Hg [7 to 14 mm Hg]; p < 0.001) were significantly higher in patients with R-L shunt than in those with left-to-right shunt. Patients with R-L shunt also showed a more prominent reduction in the left atrial V-wave and mean pressure from baseline to post-procedure compared with those with left-to-right shunt (-22.8 ± 2.6 mm Hg vs. -11.8 ± 0.9 mm Hg [p = 0.002] and -7.9 ± 0.8 mm Hg vs. -4.0 ± 0.4 mm Hg [p = 0.003], respectively).
R-L shunt through an iASD was observed in 5% of patients who underwent the MitraClip procedure and in one-third of patients with R-L shunt presented acute deoxygenation. Elevated right atrial pressure concomitant with pulmonary hypertension and significant reduction in left atrial pressure after MitraClip deployment were associated with R-L shunt.
本研究旨在探讨经皮缘对缘二尖瓣修复术（MitraClip）后，医源性房间隔缺损（iASD）引起的右向左（R-L）分流的发生率、特征、血流动力学状况和临床意义。
经皮缘对缘二尖瓣修复术后 R-L 分流的情况尚未得到充分研究。
2014 年至 2017 年，385 例二尖瓣反流患者接受了 MitraClip 手术。术中经食管超声心动图评估 iASD。右心和左心导管检查评估患者的血流动力学状态。所有患者均签署了手术知情同意书。本研究所有数据均来自经雪松西奈医疗中心机构审查委员会批准的既定介入心脏病学实验室数据库。
20 名患者（5%）出现 R-L 分流。其中 7 例（35%）患者伴有急性脱氧。严重三尖瓣反流的发生率（55% vs. 20%；p=0.001）、血清 B 型利钠肽（664pg/ml [434 至 1169pg/ml] vs. 400pg/ml [195 至 699pg/ml]；p=0.006）、平均肺动脉压（38mmHg [34 至 45mmHg] vs. 29mmHg [22 至 37mmHg]；p<0.001）和右心房压（19mmHg [13 至 20mmHg] vs. 10mmHg [7 至 14mmHg]；p<0.001）在 R-L 分流患者中显著高于左向右分流患者。与左向右分流患者相比，R-L 分流患者的左心房 V 波和平均压力从基线到术后也明显降低（-22.8±2.6mmHg vs. -11.8±0.9mmHg [p=0.002] 和-7.9±0.8mmHg vs. -4.0±0.4mmHg [p=0.003]）。
在接受 MitraClip 手术的患者中，有 5%出现了医源性房间隔缺损的 R-L 分流，而在出现 R-L 分流的患者中，有三分之一出现了急性脱氧。MitraClip 植入术后右心房压力升高伴肺动脉高压和左心房压力显著降低与 R-L 分流相关。
