经食管实时三维超声在人工二尖瓣瓣周漏诊治中的作用

Use of real-time 3-dimensional transesophageal echocardiography in evaluation of paraprosthetic mitral leakage and guidance of Its management

目的:探讨经食管实时三维超声(RT3D-TEE)技术在人工二尖瓣瓣周漏(PVL)诊断及治疗中的应用价值。方法:共10例中度及以上的二尖瓣PVL患者接受治疗,在内科介入术前、后择期及外科术前、后即刻均行二维经食管超声(2D-TEE)及RT3D-TEE检查,明确PVL的病理解剖改变,并了解纠治的效果;镶嵌介入封堵术则全程在2D-TEE及RT3D-TEE并配合X-射线的监护与引导下完成。结果:7例PVL患者行介入封堵术,其中6例成功,1例需要做第2次封堵术;另3例行外科手术。在所有患者中,RT3D-TEE均能准确地显示漏口的位置、形态、数目并测量漏口最大径及面积,1例还能清晰地显示出导致PVL的原因。2例外科手术患者因为RT3D-TEE的干预,使外科医生于术前进一步修正了手术方案。介入封堵术中RT3D-TEE能准确地鉴别导引钢丝是通过瓣周缺损还是瓣叶对合处。1例在介入术后复查显示封堵器部分阻碍了人工瓣叶的启闭活动。结论:RT3D-TEE所提供的二尖瓣PVL解剖及功能等的诊断信息,能最大限度帮助临床医生于术前选择并制定最佳的治疗手段及具体的方案,对二尖瓣PVL介入封堵术而言,RT3D-TEE的作用不可或缺。

Objective：To assess the use of real-time 3-dimensional transesophageal echocardiography（RT3D-TEE） in evaluation the severity of paraprosthetic mitral leakage and guidance of its management.Method：Ten patients with moderate to severe paravalvular mitral regurgitation,in whom either percutaneous leak closure or surgery would be appropriated,were studied.Two-dimensional transesophageal echocardiography（2D-TEE） and RT3D-TEE were performed before and after procedure both surgery and percutaneous closure to identify anatomic characteristics of the paraprosthetic defects and to determine the final outcome of the procedure.Hybrid repair of mitral paravavular leak using occluder device were done under radiographic,2D and RT3D-TEE guidance.Result：Seven patients had received percutaneous closure of the defect,in whom six had successful procedures and another needed to second percutaneous closure of residual dehiscence.The other three patients underwent re-operations.RT3D-TEE could accurately evaluate the location,shape,number and size of the leakage in all patients,and identify the etiology in one patient.The corresponding operative protocol had been changed because of the pre-operative RT3D-TEE results in 2 patients.RT3D-TEE monitoring during Hybrid procedure facilitated the introduction of the guide wire through the paravalular defect and correct delivery of the device.Post-procedural RT3D-TEE detected partial blockage of the prosthetic valve leaflet in one patient.Conclusion：RT3D-TEE can provide more accurate information about anatomic characteristics of paraprosthetic mitral leakage and may help the operators in planning an appropriate intervention strategy.It plays a key role for the percutaneous closure of peraprosthetic dehiscence.