经导管缘对缘修复的操作原理、基本原则及预后影响因素

Transcatheter edge-to-edge repair:Operating theories,basic principles,and predictors of prognosis

二尖瓣反流是最常见的心脏瓣膜病之一。经导管缘对缘修复(transcatheter edge-to-edge repair,TEER)是目前发展最成熟、应用最广泛的二尖瓣反流介入治疗技术,被最新欧美指南推荐用于外科手术高风险患者。TEER器械通常由夹合装置和输送系统组成。夹合装置的运动轨迹为弹道,其建立离不开输送系统5个维度的运动:左右摆动、前后摆动、整体平行移动、夹合装置自身钟向旋转以及垂直上下运动。其中输送系统的前后及左右摆动是围绕虚拟穿刺点进行,房间隔穿刺点位置对于弹道建立有决定性影响。TEER手术的成功需评估3个变量,且符合“4M法则”。其中3个变量分别是夹子位置在反流中心、夹子钟向垂直于瓣膜开放线、夹合量适宜;“4M法则”包括瓣膜形态良好、残余反流在2+以下、平均跨瓣压差≤5 mm Hg、前后叶瓣膜夹合量适宜。TEER预后的影响因素包括患者基础情况、二尖瓣反流和心室重构比例以及瓣膜解剖和手术相关情况。

Mitral regurgitation is one of the most common heart valve diseases.Transcatheter edge-to-edge repair(TEER)is currently the most developed and commonly used interventional technique for mitral regurgitation and is recommended by the latest European and American guidelines for patients who are at high surgical risk.TEER device usually consists of a clamping device and a delivery system.The trajectory of the clamping device is called the trajectory,and the trajectory can be well established with the five dimensions movement of the delivery system:left-right oscillation,anterior-posterior oscillation,overall parallel movement,the clamping device's own clockwise rotation,and vertical upand-down movement.The delivery system's anteroposterior and lateral oscillations are concentrated on the virtual puncture site.Furthermore,the location of the septal puncture site has a significant impact on the establishemnt of the trajectory.The evulation of three variables and adherence to the"4M principles"are necessary for the successful TEER.The three variables are:the position of the clip in the center of the regurgitation,the arm orientation of the clip perpendicular to the boundary of anterior and posterior leaflets,as well as the appropriate length of clamping.The"4M principles"include favorable valve morphology,residual mitral regurgitation below grade 2+,mean transvalvular pressure≤5 mm Hg,and an appropriate amount of leaflets clamping.Patients'baseline situation,the degree of mitral regurgitation and ventricular remodeling,as well as the valve morphology and the outcome of the procedure,are the factors determining the prognosis of patients after TEER.