葛均波院士团队完成国内首例一站式TAVR+PTSMA术

2020-04-18 潘文志 周达新 MedSci原创

4月18日,复旦大学附属中山医院葛均波院士团队完成一例“一站式” 经导管主动脉瓣置换+经皮腔内室间隔心肌消融术(TAVR+PTSMA)。通过文献检索证实,国内尚未有同类手术报道

4月18日,复旦大学附属中山医院葛均波院士团队完成一例“一站式” 经导管主动脉瓣置换+经皮腔内室间隔心肌消融术(TAVR+PTSMA)。通过文献检索证实,国内尚未有同类手术报道,全世界也仅有数个同类病例报道。

1. 病例基本情况

接受该手术的是一例77岁女性,术前超声心动图显示:重度主动脉瓣狭窄(平均压差45 mmHg),左心室射血分数65%,左室肥厚(室壁厚度16-25mm),二尖瓣中度反流(图1)。术前CT显示主动脉根部解剖适合TAVR,左心室壁肥厚(图2)。

图 1  患者术前超声心动图

图2 患者术前CT

经右侧股动脉顺利植入26mm启明Venus-A 瓣膜,主动脉根部造影显示瓣膜支架位置合适,轻度瓣周漏,冠脉显影清晰(图3)。

图3 冠脉显影

但患者血压明显降低(70/40mmHg),并出现肺水肿。食道超声显示极重度二尖瓣反流,二尖瓣向室间隔前移(SAM现象),并导致左心室流出道梗阻(导管测压压差60mmHg),见图4。

图4 食道超声

经过仔细评估及反复讨论,决定给患者实施紧急的(经皮腔内室间隔心肌消融术(PTSMA)。

 

2 手术经过

反复尝试,使用XB 3.5导管通过瓣膜支架网孔进入左冠开口进行造影(图5)。之后在第一间隔支注射无水酒精2ml 实施心肌消融术(图6)。消融后2分钟,患者血压升高至160/90mmHg,食道超声显示二尖瓣反流降低为中度,SAM现象缓解(图7)。患者生命体征恢复稳定,正在康复中。该例手术由葛均波院士、周达新教授以及潘文志、陆浩、李伟等医生完成。

图5 使用XB 3.5导管通过瓣膜支架网孔进入左冠开口进行造影

图6 实施心肌消融术

图7 术后食道超声

3 总结

肥厚性梗阻性心肌病(HOMC)被列为TAVR禁忌症,该例手术显示对合并有HOMC的主动脉瓣狭窄患者,一站式TAVR+PTSMA是可行的。对于主动脉瓣狭窄患者,一方面左心室流出道梗阻容易被掩盖,同时,TAVR术后左心室流出道梗阻会即刻加重导致紧急风险,本病例成功处理为类似案例提供很好经验参考。

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    2022-06-17 小小医者

    #葛均波#院士,牛

    0

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    2020-10-09 fusion
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    2020-04-20 江川靖瑶
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    2020-04-18 junJUN

    院士是学术至高点,也是大家必争之地呀

    0

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