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Abstract
Introduction
Protocol
Results
Discussion
Disclosures
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Medicine

経皮的僧帽弁修復時のエコー誘導のステップワイズアプローチ

Published: October 16, 2021
doi:
10.3791/62053
, , , ,
1Department of Internal Medicine/Cardiology,BG Klinikum Unfallkrankenhaus Berlin

Summary

このプロトコルは経カテーテル僧帽弁修理の間にリアルタイムの心エコーの指導を行う方法を詳しく示す。基本的な見解と必要な測定値は、手順の各段階について説明されています。

Abstract

僧帽弁の経皮経皮的な経カテーテルの端から端への再建は、外科的リスクの高い患者における重度の症候性僧帽弁逆流に対する安全で確立された治療法である。透視法に加えて心エコーのガイダンスは、標準であり、標準化された技術を使用して行われるべきである。

この記事では、ビュー、測定、および手順中に発生する可能性のある困難を強調するステップエコーカルディオガイドによる再現可能なステップを説明します。

この記事では、手順の各ステップ、特に2Dと3Dイメージングの間の好みについて、詳細で時系列の心エコービューを提供します。必要に応じて、脈波、連続波および色ドップラー測定が記載される。さらに、経皮的エッジツーエッジ修復手順の間に僧帽弁逆流の定量化に関する公式な勧告がないため、僧帽リーフレットとデバイス展開後の心エコー定量のためのアドバイスも含まれています。さらに、この記事では、処置中に合併症の可能性を予防し、対処するための重要な心エコービューを扱っています。

経カテーテル僧帽弁修復中の心エコーガイダンスは必須です。構造化されたアプローチは、介入者とイメージャーのコラボレーションを改善し、安全で効果的な手順のために不可欠です。

Introduction

僧帽弁逆流(MR)は、ヨーロッパで弁の手術のための2番目に頻繁な適応症である 1.治療を受けていないと、重度の心不全や生活の質が低下する可能性があります2,3,4.経皮的僧帽弁修復(PMVR)はカテーテルベースの技術であり、A2とP2ホタテ5を接続して僧帽修復するアルフィエリステッチの外科方法を模倣する。高い外科的リスクを有する患者に対して、この技術は、重度のMR.いくつかのレジストリからのデータを治療するための低侵襲的アプローチを提供し、試験は、MitraClip手順、経カテーテル僧帽弁修復療法、効果的かつ安全な方法6、7、8、9であることを示している。2019年には、同様の装置であるPASCAL経カテーテル弁修理システムが市場に導入されました。これは、重症MR10患者の治療における実現可能性と許容可能な安全性を示している。PMVRの持続時間と成功は、個々のオペレータのスキルと経験11に依存します。透視検査のみで行うことができる経皮的経弁置換術(TAVR)のような他の経皮的技術とは対照的に、PMVRは心エコーガイダンス12、13を必要とする。

この記事では、測定、MRの手続き内定量化の提案、手順ごとの合併症を防ぐための重要な見解など、PMVR中の心エコーのアプローチを段階的に説明します。

Protocol

このプロトコルは、当社の機関の人間研究倫理委員会のガイドラインに従っています。 1. 介入前の評価 経中隔穿刺前の心膜滲出を除外する。小さい心膜滲出液が存在する場合、右心室(RV)、中食右心室流出図、および長軸(LAX)ビューに焦点を当てた4チャンバー(4Ch)ビューの最大エンド拡張期エコールセント空間を測定する。 左上肺静脈(LUPV)の脈波ドップラ?…

Representative Results

経皮的な端から端への弁の修理は、症候性の重篤なMRを有する手術の対象外の患者における外科弁の修復または置換に代わるものである。MitraClipの最初の臨床応用は、血管内弁エッジツーエッジ修復研究I(EVERESTI)14試験で調査された。他の多くの試験は、症状の改善だけでなく、病院の死亡率および有害事象(アクセスEU、TRAMI、EVERESTII)15、16、17<sup cla…

Discussion

PMVRのエコーガイダンスは安全な方法です。心エコー検査による合併症は起こり得るが、重大な損傷を引き起こすことはほとんどない。それにもかかわらず、食道病変は経食道心エコー検査を行った後に可能である。この発生率は、介入34の短い期間で減少する。それどころか、経カテーテルのエッジツーエッジ僧帽弁修復に関連するいくつかの合併症は、35,36</…

Disclosures

The authors have nothing to disclose.

Acknowledgements

ドロテア・シューレン氏の技術ビデオサポートに感謝します。

Materials

EPIQ 7 Ultrasound System Philips US218B0542 Cardiac Ultrasound Machine
X8-2t xMATRIX 3D-TEE probe Philips B34YYK TEE-probe
Sheath 6F 25 cm Merit Medical B60N25AQ Sheath
Dilator 16 F Abbott 405544 Dilator
BRK-1 transseptal needle 71 cm St. Jude Medical ABVA407201 Transseptal Needle
Swartz Lamp 90° St. Jude Medical 407356 Transseptal Guiding Introducer Sheath
Amplatz super stiff Kook Medical 46509 Wire
Steerable Guide Catheter Abbott SGC0302 Steerable Guide Catheter
MitraClip NTR Delivery System Abbott CDS0602-NTR Clip Delivery System
MitraClip NTR Bundle Abbott MSK0602-NTR Device
DOWNLOAD MATERIALS LIST

References

  1. Iung, B., et al. A prospective survey of patients with valvular heart disease in Europe: The Euro Heart Survey on Valvular Heart Disease. European Heart Journal. 24 (13), 1231-1243 (2003).
  2. Hauptman, P. J., Rector, T. S., Wentworth, D., Kubo, S. Quality of life in advanced heart failure: role of mitral regurgitation. American Heart Journal. 151 (1), 213-218 (2006).
  3. Lewis, E. F. Assessing the impact of heart failure therapeutics on quality of life and functional capacity. Current Treatment Options in Cardiovascular Medicine. 15 (4), 425-436 (2013).
  4. Vaishnava, P., Lewis, E. F. Assessment of quality of life in severe heart failure. Current Heart Failure Reports. 4 (3), 170-177 (2007).
  5. Feldman, T., et al. Percutaneous repair or surgery for mitral regurgitation. New England Journal of Medicine. 364 (15), 1395-1406 (2011).
  6. Feldman, T., et al. Percutaneous mitral repair with the MitraClip system: safety and midterm durability in the initial EVEREST (Endovascular Valve Edge-to-Edge REpair Study) cohort. Journal of the American College of Cardiology. 54 (8), 686-694 (2009).
  7. Whitlow, P. L., et al. Acute and 12-month results with catheter-based mitral valve leaflet repair: the EVEREST II (Endovascular Valve Edge-to-Edge Repair) High Risk Study. Journal of the American College of Cardiology. 59 (2), 130-139 (2012).
  8. Baldus, S., et al. MitraClip therapy in daily clinical practice: initial results from the German transcatheter mitral valve interventions (TRAMI) registry. European Journal of Heart Failure. 14 (9), 1050-1055 (2012).
  9. Stone, G. W., et al. Transcatheter Mitral-Valve Repair in Patients with Heart Failure. New England Journal of Medicine. 379 (24), 2307-2318 (2018).
  10. Lim, D. S., et al. Transcatheter Valve Repair for Patients With Mitral Regurgitation: 30-Day Results of the CLASP Study. JACC: Cardiovascular Interventions. 12 (14), 1369-1378 (2019).
  11. Schillinger, W., et al. Impact of the learning curve on outcomes after percutaneous mitral valve repair with MitraClip and lessons learned after the first 75 consecutive patients. European Journal of Heart Failure. 13 (12), 1331-1339 (2011).
  12. Katz, W. E., Conrad Smith, A. J., Crock, F. W., Cavalcante, J. L. Echocardiographic evaluation and guidance for MitraClip procedure. Cardiovascular Diagnosis and Therapy. 7 (6), 616-632 (2017).
  13. Altiok, E., et al. Optimized guidance of percutaneous edge-to edge repair of the mitral valve using real-time 3-D transesophageal echocardiography. Clinical Research in Cardiology. 100 (8), 675-681 (2011).
  14. Feldman, T., et al. Percutaneous mitral valve repair using the edge-to-edge technique: six-month results of the EVEREST Phase I Clinical Trial. Journal of the American College of Cardiology. 46 (11), 2134-2140 (2005).
  15. Maisano, F., et al. Percutaneous mitral valve interventions in the real world: early and 1-year results from the ACCESS-EU, a prospective, multicenter, nonrandomized post-approval study of the MitraClip therapy in Europe. Journal of the American College of Cardiology. 62 (12), 1052-1061 (2013).
  16. Kalbacher, D., et al. Long-term outcome, survival and predictors of mortality after MitraClip therapy: Results from the German Transcatheter Mitral Valve Interventions (TRAMI) registry. International Journal of Cardiology. 277, 35-41 (2019).
  17. Glower, D. D., et al. Percutaneous mitral valve repair for mitral regurgitation in high-risk patients: results of the EVEREST II study. Journal of the American College of Cardiology. 64 (2), 172-181 (2014).
  18. Baumgartner, H., et al. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. European Heart Journal. 38 (36), 2739-2791 (2017).
  19. Obadia, J. F., et al. MITRA-FR Investigators. Percutaneous Repair or Medical Treatment for Secondary Mitral Regurgitation. New England Journal of Medicine. 379 (24), 2297-2306 (2018).
  20. Stone, G. W., et al. COAPT Investigators. Transcatheter Mitral-Valve Repair in Patients with Heart Failure. New England Journal of Medicine. 379 (24), 2307-2318 (2018).
  21. Vahanian, A., et al. Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC); European Association for Cardio-Thoracic Surgery (EACTS), Guidelines on the management of valvular heart disease (version 2012). European Heart Journal. 33 (19), 2451-2496 (2012).
  22. American College of Cardiology/American Heart Association Task Force on Practice Guidelines; Society of Cardiovascular Anesthesiologists; Society for Cardiovascular Angiography and Interventions. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 114 (5), 84 (2006).
  23. Praz, F., et al. Compassionate use of the PASCAL transcatheter mitral valve repair system for patients with severe mitral regurgitation: a multicentre, prospective, observational, first-in-man study. Lancet. 390 (10096), 773-780 (2017).
  24. McCarthy, K. P., Ring, L., Rana, B. S. Anatomy of the mitral valve: understanding the mitral valve complex in mitral regurgitation. European Journal of Echocardiography. 11 (10), 3-9 (2010).
  25. Zoghbi, W. A., et al. Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation: A Report from the American Society of Echocardiography Developed in Collaboration with the Society for Cardiovascular Magnetic Resonance. Journal of the American Society of Echocardiography. 30 (4), 303-371 (2017).
  26. Zoghbi, W. A., et al. Guidelines for the Evaluation of Valvular Regurgitation Percutaneous Valve Repair or Replacement: A Report from the American Society of Echocardiography Developed in Collaboration with the Society for Cardiovascular Angiography and Interventions, Japanese Society of Echocardiography, and Society for Cardiovascular Magnetic Resonance. Journal of the American Society of Echocardiography. 32 (4), 431-475 (2019).
  27. Abudiab, M. M., Chao, C. J., Liu, S., Naqvi, T. Z. Quantitation of valve regurgitation severity by three-dimensional vena contracta area is superior to flow convergence method of quantitation on transesophageal echocardiography. Echocardiography. 34 (7), 992-1001 (2017).
  28. Dietl, A., et al. 3D vena contracta area after MitraClip procedure: precise quantification of residual mitral regurgitation and identification of prognostic information. Cardiovasc Ultrasound. 16 (1), 1 (2018).
  29. Ikenaga, H., et al. Usefulness of Intraprocedural Pulmonary Venous Flow for Predicting Recurrent Mitral Regurgitation and Clinical Outcomes After Percutaneous Mitral Valve Repair With the MitraClip. JACC: Cardiovascular Interventions. 12 (2), 140-150 (2019).
  30. Tang, G. H. L., et al. Continuous invasive hemodynamic monitoring using steerable guide catheter to optimize mitraclip transcatheter mitral valve repair: A multicenter, proof-of-concept study. Journal of Interventional Cardiology. 31 (6), 907-915 (2018).
  31. Maor, E., et al. Acute Changes in Left Atrial Pressure After MitraClip Are Associated With Improvement in 6-Minute Walk Distance. Circulation: Cardiovascular Interventions. 10 (4), 004856 (2017).
  32. Kuwata, S., et al. Continuous Direct Left Atrial Pressure: Intraprocedural Measurement Predicts Clinical Response Following MitraClip Therapy. JACC: Cardiovascular Interventions. 12 (2), 127-136 (2019).
  33. Corrigan, F. E., et al. Pulmonary Venous Waveforms Predict Rehospitalization and Mortality After Percutaneous Mitral Valve Repair. JACC Cardiovasc Imaging. 12 (10), 1905-1913 (2019).
  34. Ruf, T. F., et al. ELMSTREET (Esophageal Lesions during MitraClip uSing TRansEsophageal Echocardiography Trial. EuroIntervention. 13 (12), 1444-1451 (2017).
  35. Eggebrecht, H., et al. Risk and outcomes of complications during and after MitraClip implantation: Experience in 828 patients from the German TRAnscatheter mitral valve interventions (TRAMI) registry. Catheterization and Cardiovascular Interventions. 86 (4), 728-735 (2015).
  36. von Bardeleben, R. S., et al. Incidence and in-hospital safety outcomes of patients undergoing percutaneous mitral valve edge-to-edge repair using MitraClip: five-year German national patient sample including 13,575 implants. EuroIntervention. 14 (17), 1725-1732 (2019).
  37. Généreux, P., et al. Incidence, predictors, and prognostic impact of late bleeding complications after transcatheter aortic valve replacement. Journal of the American College of Cardiology. 64 (24), 2605-2615 (2014).
  38. Benito-González, T., Estévez-Loureiro, R., Gualis, J. Chordal Rupture Following MitraClip Implantation Resulting in Massive Mitral Regurgitation. Journal of Invasive Cardiology. 27 (10), 224-225 (2015).
  39. Kaneko, H., Neuss, M., Weissenborn, J., Butter, C. Impact of residual mitral regurgitation after MitraClip implantation. International Journal of Cardiology. 227, 813-819 (2017).
  40. Buzzatti, N., et al. What is a “good” result after transcatheter mitral repair? Impact of 2+ residual mitral regurgitation. Journal of Thoracic and Cardiovascular Surgery. 151 (1), 88-96 (2016).
  41. Feldman, T., Guerrero, M. Assessing the Balance Between Less Mitral Regurgitation and More Residual Transmitral Pressure Gradient After MitraClip. JACC: Cardiovascular Interventions. 10 (9), 940-941 (2017).
  42. Neuss, M., et al. Elevated Mitral Valve Pressure Gradient After MitraClip Implantation Deteriorates Long-Term Outcome in Patients With Severe Mitral Regurgitation and Severe Failure. JACC: Cardiovascular Interventions. 10 (9), 931-939 (2017).
  43. Katz, W. E., Conrad Smith, A. J., Crock, F. W., Cavalcante, J. L. Echocardiographic evaluation and guidance for MitraClip procedure. Cardiovascular Diagnosis and Therapy. 7 (6), 616-632 (2017).
  44. Labrousse, L., et al. Guidance of the MitraClip procedure by 2D and 3D imaging. Archives of Cardiovascular Diseases. 111 (6-7), 432-440 (2018).
  45. Khalique, O. K., Hahn, R. T. Percutaneous Mitral Valve Repair: Multi-Modality Cardiac Imaging for Patient Selection and Intra-Procedural Guidance. Frontiers in Cardiovascular Medicine. 6, 142 (2019).
  46. Bushari, L. I., et al. Percutaneous Transcatheter Edge-to-Edge MitraClip Technique: A Practical “Step-by-Step” 3-Dimensional Transesophageal Echocardiography Guide. Mayo Clinic Proceedings. 94 (1), 89-102 (2019).
  47. Sherif, M. A., et al. MitraClip step by step; how to simplify the procedure. Netherlands Heart Journal. 25 (2), 125 (2017).
  48. Guarracino, F., et al. Transesophageal echocardiography during MitraClip procedure. Anesthesia & Analgesia. 118 (6), 1188-1196 (2014).
  49. Avenatti, E., et al. Diagnostic Value of 3-Dimensional Vena Contracta Area for the Quantification of Residual Mitral Regurgitation After MitraClip Procedure. JACC: Cardiovascular Interventions. 12 (6), 582-591 (2019).
  50. Altiok, E., et al. Analysis of procedural effects of percutaneous edge-to-edge mitral valve repair by 2D and 3D echocardiography. Circulation: Cardiovascular Imaging. 5 (6), 748-755 (2012).

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Echo GuidancePercutaneous Mitral Valve RepairEchocardiographic ViewsTransseptal PuncturePericardial EffusionMitral Valve Assessment3D EchocardiographyColor DopplerMitral RegurgitationInterventional Echocardiography
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Gatti, A., Krieger, K., Seidel, M., Röttgen, A., Bruch, L. A Simplified Stepwise Approach to Echo Guidance during Percutaneous Mitral Valve Repair. J. Vis. Exp. (176), e62053, doi:10.3791/62053 (2021).
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