三维经食管超声心动图在经导管主动脉瓣植入术中的应用研究

The application value of real-time 3-dimensional transesophageal echocardiography in aortic valve implantation

目的探讨三维经食管超声心动图在经导管主动脉瓣植入术中的应用价值。方法对16例严重主动脉瓣病变患者分别经由两种不同手术入径行经导管主动脉瓣植入术(transcatheter aortic valve implantation,TAVI),其中7例重度主动脉瓣狭窄(主动脉瓣狭窄面积<1.0 cm2,主动脉瓣口最大流速≥4 m/s,平均跨瓣压差≥40 mm Hg)和1例人工生物主动脉瓣中重度反流患者行经股动脉TAVI,另外4例重度主动脉瓣狭窄和4例重度主动脉瓣反流患者行经心尖TAVI,术前均行常规经胸超声心动图检查及三维经食管超声心动图检查,术中三维经食管超声心动图监测,术后常规经胸超声心动图随访。结果经股动脉TAVI组:所有患者均成功经导管植入人工生物主动脉瓣,其中1例患者术中发现心包填塞合并升主动脉夹层分离。经心尖TAVI组:所有患者均成功植入人工生物主动脉瓣,无并发症发生。CT和经食管三维超声心动图测量主动脉瓣环最大径、最小径、瓣环面积及狭窄瓣口数据的比较,二者相关性良好,r值分别为0.99(瓣环最大径)、0.97(瓣环最小径)、0.98(瓣环面积)、0.99(狭窄瓣口面积);术前连续性方程测量的狭窄瓣口面积与CT及3D-TEE比较,二者相关性良好,r值均为0.99。结论三维经食管超声心动图能快速、准确地测量主动脉瓣环的大小及评价主动脉的解剖结构,并且能实时引导、监测经导管人工生物主动脉瓣的植入。

Objective To investigate the application value of 3-dimensional transesophageal echocardiography in aortic valve implantation. Methods We performed transcathet aortic valve implantations （TAVI） to 16 patients with severe aortic stenosis through two different surgical accesses. Of these patients, 7 severe aortic stenosis （ AVA 〈 1.0 cm2 , peak aortic valve velocity ≥4.0m/s, and mean aortic valve pressure gradient ≥ 40mmHg） and one patient with moderate to severe prosthetic valve regurgitation were enrolled in transfemoral TAVI group. Four patients with severe aortic stenosis and four patients with severe aortic regurgitation were enrolled in transapical TAVI group. All patients received 2- and 3-dimensional transthoracic and transesophageal echocardiographic examination before, during and after surgery using Philips IE33 with S5-1 and X7-2 probe. Results In the transfemoral TAVI group, procedural success was achieved in all 8 patients, but one patient died due to pericardial tamponade and aortic dissection three days after TCTA- VI. In the transapical TAVI group, all patients were implanted successfully aortic valve and had no complication. The maximum and minimum diameter of aortic annulus, the area of aortic annulus and aortic valve were measured by CT and 3D TEE. All parameters had a strong correlation between CT and 3D TEE： r values were 0.99 （ maximum diameter）, 0.97 （ minimum diameter）, 0.98 （ the area of aortic annulus） and 0.99 （ the area of aortic valve） , respectively. There were a good correlation for the area of aortic valve among CT, 3DTEE and equation of continuity （all r= 0.99）. Conclusion 3-dimensional transesophageal echocardiography can quantify the size of aortic annular and comprehensively evaluate the anatomical structure of aorta rapidly and accurately. It can be used in guiding the implantation of aortic valve and monitoring its complications in real time.