Seshiah Puvi, Garcia Santiago, Choo Joseph, Smith J Michael, Answini Geoffrey A, Stewart Terri, Kereiakes Dean J
The Christ Hospital Heart and Vascular Institute, Cincinnati, Ohio.
The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, Ohio.
J Soc Cardiovasc Angiogr Interv. 2023 Jan 10;2(1):100540. doi: 10.1016/j.jscai.2022.100540. eCollection 2023 Jan-Feb.
Transcatheter mitral valve replacement (TMVR) is evolving; however, limitations include severe calcification of the mitral valve leaflets and mitral annular calcification (MAC), which may be associated with incomplete valve expansion. Shockwave intravascular lithotripsy (IVL)-assisted percutaneous mitral valvuloplasty to treat calcific mitral stenosis has been reported. We describe the first human use of IVL-assisted transseptal TMVR with the Intrepid valve to treat a severely calcified mitral valve in a patient with severe stenosis and regurgitation.
An 83-year-old man with rheumatic heart disease and severe MAC (MAC score, 10; calcium volume score, 7756 cm) presented with combined mitral stenosis and regurgitation (valve area, 1.5 cm; 3+ mitral regurgitation [MR]) and medically refractory heart failure symptoms and was enrolled into the APOLLO (Transcatheter Mitral Valve Replacement With the Medtronic Intrepid TMVR System in Patients With Severe Symptomatic Mitral Regurgitation) trial of Intrepid valve TMVR. Transseptal implantation of a 48-mm Intrepid valve was facilitated by Shockwave IVL delivered via two 8.0 × 60-mm M5+ balloons placed across the mitral annulus before implantation. Cerebral embolic protection during IVL and valve implant was provided by a Sentinel device and left subclavian balloon occlusion.
Despite initial postimplant valve frame deformation and moderate central MR, postdilation achieved valve frame expansion and reduced MR. Echocardiography and computed tomography performed before hospital discharge and at 30 days show progressive valve frame expansion in the anteroposterior dimension, increased valve area, and resolution of MR.
Intravascular lithotripsy of severe MAC before self-expanding TMVR may enhance annular compliance, mitigate fibroelastic recoil, and minimize TMVR valve frame deformation. Although promising, further study is required before IVL is considered a routine adjunct for TMVR in severe MAC.
经导管二尖瓣置换术（TMVR）正在不断发展；然而，其局限性包括二尖瓣叶严重钙化和二尖瓣环钙化（MAC），这可能与瓣膜扩张不完全有关。已有报道采用冲击波血管内碎石术（IVL）辅助经皮二尖瓣成形术治疗钙化性二尖瓣狭窄。我们描述了首例在人体使用IVL辅助经间隔TMVR并采用Intrepid瓣膜治疗一名患有严重狭窄和反流的严重钙化二尖瓣患者的情况。
一名83岁患有风湿性心脏病和严重MAC（MAC评分10分；钙容积评分7756立方厘米）的男性患者，同时存在二尖瓣狭窄和反流（瓣膜面积1.5平方厘米；3+级二尖瓣反流[MR]），且有药物难治性心力衰竭症状，被纳入APOLLO（使用美敦力Intrepid TMVR系统对严重症状性二尖瓣反流患者进行经导管二尖瓣置换术）试验，接受Intrepid瓣膜TMVR治疗。在植入前，通过两个横跨二尖瓣环放置的8.0×60毫米M5+球囊输送冲击波IVL，以辅助48毫米Intrepid瓣膜的经间隔植入。在IVL和瓣膜植入过程中，通过Sentinel装置和左锁骨下球囊闭塞提供脑栓塞保护。
尽管植入后初期瓣膜框架变形且存在中度中心性MR，但球囊扩张后实现了瓣膜框架扩张并减少了MR。出院前及30天时进行的超声心动图和计算机断层扫描显示，瓣膜框架在前后径上逐渐扩张，瓣膜面积增加，MR消失。
在自膨胀TMVR之前对严重MAC进行血管内碎石术可能会增强瓣环顺应性，减轻纤维弹性回缩，并使TMVR瓣膜框架变形最小化。尽管前景乐观，但在IVL被视为严重MAC中TMVR的常规辅助手段之前，还需要进一步研究。
