经导管二尖瓣缘对缘修复术后医源性房间隔缺损的双心室生理
Biventricular Physiology of Iatrogenic Atrial Septal Defects Following Transcatheter Mitral Valve Edge-to-Edge Repair.
作者信息
Blazek Stephan, Unterhuber Matthias, Rommel Karl-Philipp, von Roeder Maximilian, Kresoja Karl-Patrik, Kister Tobias, Besler Christian, Fengler Karl, Sandri Marcus, Daehnert Ingo, Thiele Holger, Lurz Philipp
机构信息
Department of Internal Medicine/Cardiology, Heart Center Leipzig, University of Leipzig and Leipzig Heart Institute, Leipzig, Germany.
Department of Pediatric Cardiology, Heart Center Leipzig, University of Leipzig, Leipzig, Germany.
出版信息
JACC Cardiovasc Interv. 2021 Jan 11;14(1):54-66. doi: 10.1016/j.jcin.2020.10.032.
OBJECTIVES
The study sought to assess the acute hemodynamic effects of iatrogenic atrial septal defect (iASD) closure following transcatheter mitral valve edge-to-edge repair (TMVR).
BACKGROUND
The potential hemodynamic and clinical consequences of an iASD following TMVR are currently subject to controversial debates.
METHODS
In 21 patients with relevant left-to-right shunt flow (50% [IQR: 38% to 60%] of systemic perfusion volume) across an iASD following TMVR, interventional closure was performed with recordings of left ventricular (LV) and right ventricular (RV) pressure-volume loops during iASD occlusion.
RESULTS
iASD occlusion led to a volume shift from the RV (RV end-diastolic volume index: pre 102 [IQR: 80 to 120] ml/m, post 92 [IQR: 70 to 111] ml/m; p < 0.001) to the LV (LV end-diastolic volume index: pre 91 [IQR: 74 to 124] ml/m, post 97 [IQR: 77 to 127] ml/m; p < 0.001) with reduced RV (3.49 [IQR: 2.07 to 3.58] l/min/m vs. 2.68 [IQR: 2.07 to 3.58] l/min/m; p < 0.001) but increased LV cardiac index (2.25 [IQR: 1.80 to 3.28] l/min/m vs. 2.77 [IQR: 1.90 to 3.34] l/min/m; p = 0.039). Although RV end-diastolic pressure decreased (pre 5.0 [IQR: 4.0 to 8.5] mm Hg, post 4.5 [IQR: 3.0 to 8.3] mm Hg; p = 0.024), LV end-diastolic pressure remained unchanged (pre 11.0 [IQR: 9.5 to 14.0] mm Hg, post 13.0 [IQR: 9.0 to 15.5] mm Hg; p = 0.142). LV transmural pressure increased (7.0 [IQR: 4.0 to 11.0] mm Hg vs. 11.0 [IQR: 7.0 to 15.0] mm Hg; p = 0.001) and LV eccentricity index decreased (p < 0.001). The change in LV transmural pressure correlated significantly with the change in LV-to-RV end-diastolic volume ratio (r = 0.674; p = 0.018). Right heart failure symptoms declined at 1-month follow-up (71% vs. 35%; p = 0.003) as did New York Heart Association functional class (≥III: 48% vs. 25%; p < 0.001).
CONCLUSIONS
iASD closure following TMVR leads to a volume shift from the RV to the LV with reduced pulmonary but increased systemic cardiac index and with favorable biventricular interaction at maintained LV filling pressure, resulting in a decline in heart failure symptoms at 1-month follow-up.
目的
本研究旨在评估经导管二尖瓣缘对缘修复术（TMVR）后医源性房间隔缺损（iASD）封堵的急性血流动力学效应。
背景
TMVR后iASD潜在的血流动力学和临床后果目前存在争议。
方法
对21例TMVR后经iASD存在相关左向右分流（分流流量占体循环灌注量的50%[四分位间距：38%至60%]）的患者，在封堵iASD期间记录左心室（LV）和右心室（RV）压力-容积环的同时进行介入封堵。
结果
iASD封堵导致容量从右心室（右心室舒张末期容积指数：术前102[四分位间距：80至120]ml/m²，术后92[四分位间距：70至111]ml/m²；p<0.001）转移至左心室（左心室舒张末期容积指数：术前91[四分位间距：74至124]ml/m²，术后97[四分位间距：77至127]ml/m²；p<0.001），右心室心输出量降低（3.49[四分位间距：2.07至3.58]l/min/m²对2.68[四分位间距：2.07至3.58]l/min/m²；p<0.001），但左心室心指数增加（2.25[四分位间距：1.80至3.28]l/min/m²对2.77[四分位间距：1.90至3.34]l/min/m²；p=0.039）。虽然右心室舒张末期压力降低（术前5.0[四分位间距：4.0至8.5]mmHg，术后4.5[四分位间距：3.0至8.3]mmHg；p=0.024），但左心室舒张末期压力保持不变（术前11.0[四分位间距：9.5至14.0]mmHg，术后13.0[四分位间距：9.0至15.5]mmHg；p=0.142）。左心室跨壁压增加（7.0[四分位间距：4.0至11.0]mmHg对11.0[四分位间距：7.0至15.0]mmHg；p=0.001），左心室偏心指数降低（p<0.001）。左心室跨壁压的变化与左心室与右心室舒张末期容积比的变化显著相关（r=0.674；p=0.018）。在1个月随访时，右心衰竭症状减轻（71%对35%；p=0.003），纽约心脏协会心功能分级也有所改善（≥III级：48%对25%；p<0.001）。
结论
TMVR后iASD封堵导致容量从右心室转移至左心室，肺循环心输出量降低但体循环心指数增加，且在维持左心室充盈压的情况下双心室相互作用良好，并导致1个月随访时心力衰竭症状减轻。
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