Liu Yang, Zhai Mengen, Xu Chennian, Li Lanlan, Mao Yu, Ma Yanyan, Jin Ping, Xue Wuchao, Yang Jian
Department of Cardiovascular Surgery, Xijing Hospital, Air Force Medical University, 710032 Xi'an, Shaanxi, China.
Department of Cardiovascular Surgery, General Hospital of Northern Theater Command, 110016 Shenyang, Liaoning, China.
Rev Cardiovasc Med. 2023 Feb 6;24(2):50. doi: 10.31083/j.rcm2402050. eCollection 2023 Feb.
Percutaneous transseptal transcatheter mitral valve-in-valve implantation (TMViV) has become an alternative minimally invasive treatment choice for patients with degenerated mitral bioprosthesis and high surgical risk. However, transseptal approach is more technically challenging than transapical approach in TMViV procedures.
The objective of this study was to introduce the experience of applying long pre-curved sheaths in transseptal TMViV procedures and to evaluate the effect of long pre-curved sheath techniques in TMViV procedures.
Between January 2020 and December 2021, 27 patients with degenerated bioprosthetic mitral valve underwent TMViV procedures using a balloon-expandable valve via the transseptal approach. The regular 14/16F expandable sheath were used for low-profile delivery in first 10 cases, and 22F long pre-curved sheath were used in the next 17 cases during procedures. We retrospectively reviewed the catheter techniques, perioperative characteristics, and prognosis. The median follow-up time was 12 (1-21) months. To further scrutinize our data, we divided the group into the early 10 patients using 14/16F expandable sheath and the subsequent 17 patients with long pre-curved sheath in order to assess the impact of different sheaths and procedural details on outcomes.
Procedural success was obtained in all patients with no in-hospital mortality. Seventeen patients received 26 mm prostheses; the remaining ten patients received 29 mm prostheses. Post balloon dilatation was performed in one case. Total procedure time was (96.1 28.2) min, the fluoroscopic time was (27.4 6.5) min, and total contrast volume was (50.7 10.1) mL. One patient received blood transfusion because of hemorrhage at the femoral puncture site. One patient received a permanent pacemaker implantation due to high-degree atrioventricular block at postoperative day 3. There were no other major post-procedure complications and the median length of hospital stay was 4 days. Twenty-five (92.6%) patients improved by 1 New York Heart Association (NYHA) functional class at 30 days. In subsequent sub analysis, there were shorter procedural time [(85.2 24.3) vs. (115.2 25.6) min, = 0.0048] and shorter fluoroscopic time [(24.3 5.2) vs. (31.3 5.1) min, = 0.0073] in cases with the long pre-curved sheath than ones with regular expandable sheath. The iatrogenic atrial septal defect (ASD) closure was performed because of the transeptal large right to left shunt in 2 cases with regular expandable sheath, but no patient needed intraoperative ASD closure in cases with the long pre-curved sheath.
Transseptal TMViV using long pre-curved sheath could simplify transseptal approach with reliable outcomes for patients of degenerated mitral bioprosthesis.
经皮经间隔经导管二尖瓣瓣中瓣植入术（TMViV）已成为二尖瓣生物瓣退化且手术风险高的患者的一种替代性微创治疗选择。然而，在TMViV手术中，经间隔入路比经心尖入路在技术上更具挑战性。
本研究的目的是介绍在经间隔TMViV手术中应用长预弯鞘管的经验，并评估长预弯鞘管技术在TMViV手术中的效果。
2020年1月至2021年12月，27例二尖瓣生物瓣退化患者经间隔入路采用球囊扩张瓣膜行TMViV手术。前10例使用常规14/16F可扩张鞘管进行低调输送，后17例在手术中使用22F长预弯鞘管。我们回顾性分析了导管技术、围手术期特征和预后情况。中位随访时间为12（1 - 21）个月。为了进一步仔细分析我们的数据，我们将该组患者分为使用14/16F可扩张鞘管的前10例患者和随后使用长预弯鞘管的17例患者，以评估不同鞘管和手术细节对结果的影响。
所有患者手术均成功，无院内死亡。17例患者植入26 mm人工瓣膜；其余10例患者植入29 mm人工瓣膜。1例患者进行了球囊扩张。总手术时间为（96.1 ± 28.2）分钟，透视时间为（27.4 ± 6.5）分钟，总造影剂用量为（50.7 ± 10.1）毫升。1例患者因股动脉穿刺部位出血接受输血。1例患者在术后第3天因高度房室传导阻滞接受永久性起搏器植入。术后无其他重大并发症，中位住院时间为4天。25例（92.6%）患者在30天时纽约心脏协会（NYHA）心功能分级改善1级。在随后的亚组分析中，使用长预弯鞘管的患者手术时间[（85.2 ± 24.3）分钟对（115.2 ± 25.6）分钟，P = 0.0048]和透视时间[（24.3 ± 5.2）分钟对（31.3 ± 5.1）分钟，P = 0.0073]均短于使用常规可扩张鞘管的患者。2例使用常规可扩张鞘管的患者因经间隔大量右向左分流进行了医源性房间隔缺损（ASD）封堵，但使用长预弯鞘管的患者术中均无需进行ASD封堵。
使用长预弯鞘管的经间隔TMViV可简化经间隔入路，为二尖瓣生物瓣退化患者带来可靠的手术效果。
