少见的介入瓣膜手术肺动脉瓣

少见的介入瓣膜手术少见的介入瓣膜手术 肺动脉瓣肺动脉瓣 Samir Kapadia, MD, FACCSamir Kapadia, MD, FACC Associate Professor of MedicineAssociate Professor of Medicine Director, Interventional Cardiology FellowshipDirector, Interventional Cardiology Fellowship Cleveland ClinicCleveland Clinic Disclosures: NoneDisclosures: None 肺动脉瓣返流 (右室流出道功能障碍) 先心病手术右室流出道功能障碍需行手术治疗比例升高 长期肺动脉瓣返流导致活动耐量下降，右心功能障碍和 心律失常 (房性/室性) 早期纠正肺动脉瓣返流可以改善右心功能 介入治疗适应症 返流百分比30% 和持续多普勒监测右室流出道功能障 碍峰速 16 mm 管道 功能障碍 纳入标准 NYHA II,III,IV 平均右室流出道功能障碍压差 35 mmHg, 或 中重度肺动脉返流 NYHA I 平均右室流出道功能障碍 40 mmHg, 或 重度 肺动脉返流合并右室扩张或功能障碍 *右心室扩张的定义是三尖瓣瓣环直径 2.0 *右心室功能障碍的定义是 右室面积变化 35 kg 管道 16mm 重度 肺动脉返流 3+ 或40%返流分数 有症状( 心肺活动测试) 绝大多数患者进行随访 Z. Hijazi, TCT 2008 Edward-Sapien 瓣膜 患者 年龄: 15-71 岁 诊断: 2 例为 Ross术后; 5 例为法四术后; 1例为 Rastelli术后 术前压差为 30-75mmHg 肺动脉瓣关闭不全: 重度 7 名患者既往行支架植入术;1名患者同时行支架植 入 NYHA 分级: 2-3 Z. Hijazi, TCT 2008 Edward-Sapien 瓣膜 最初结果 8名患者中，7名成功经皮输送 1名患者，瓣膜位置不理想，瓣膜移位；手术取出和 非体外循环下经心室瓣膜植入 急性压差下降 术前10-40 mm Hg 术后10-25 mm Hg 未出现肺动脉关闭不全 Z. Hijazi, TCT 2008 总结 目前，经皮肺动脉瓣置换术 效果令人鼓舞。 经皮肺动脉置换术的成功取决于患者的选择、影像学和 密切随访. Less Common Interventional ValvesLess Common Interventional Valves Pulmonary ValvePulmonary Valve Samir Kapadia, MD, FACCSamir Kapadia, MD, FACC Associate Professor of MedicineAssociate Professor of Medicine Director, Interventional Cardiology FellowshipDirector, Interventional Cardiology Fellowship Cleveland ClinicCleveland Clinic Disclosures: NoneDisclosures: None Pulmonary Regurgitation (RVOT dysfunction) Need for intervention in RVOT dysfunction following congenital heart disease repair is increasing Long standing pulmonary regurgitation leads to decreased exercise tolerance, RV dysfunction and arrhythmia (atrial/ventricular) Earlier correction of PR may preserve RV function Indications for Intervention Regurgitation Fraction 30% and RVOT peak velocity on continuous Doppler wave 16 mm Conduit dysfunction Study Inclusion Criteria NYHA II,III,IV Mean RVOT gradient 35 mmHg, or Moderate or Severe PR NYHA I Mean RVOT gradient 40 mmHg, or Severe PR with RV dilation* or dysfunction* *RV dilatation defined as z-score for tricuspid annular diameter 2.0 *RV dysfunction defined as RV fractional area change 35 kg Conduit 16mm Severe PR 3+ or 40% regurgitant fraction Subject is symptomatic ( CP exercise testing ) Must comply with F/U Z. Hijazi, TCT 2008 Edward-Sapien Valve Experience Patient Population Age: 15-71 years DX: 2 post Ross; 5 post Tet; 1 post Rastelli Pre Gradient 30-75mmHg PI: severe 7 patients had pre stenting; one had the stenting at the same time of the procedure NYHA class: 2-3 Z. Hijazi, TCT 2008 Edward-Sapien Valve Experience Initial Results 7/8 Successful percutaneous delivery 1/8: valve position was not ideal; valve migrated; surgical retrieval and “perventricular valve implantation” off bypass Acute Reduction of Gradients pre 10-40 mm Hg post 10-25 mm Hg No PI Z. Hijazi, TCT 2008 Summary Initial Experience from percutaneous PV replacement is very encoura