背景:肺动脉瓣狭窄决定了对右心室尺寸和功能的多重影响。经皮球囊瓣膜成形术是所有年龄段患者严重肺动脉瓣狭窄的首选治疗方法。然而,关于经皮球囊扩张后右心室功能的即刻变化知之甚少。孤立性肺动脉瓣狭窄的小儿患者代表了慢性RV压力超负荷的纯临床模型,不受其他混杂因素或合并症的影响。
目的:本研究旨在探讨经皮球囊肺动脉瓣成形术(BPV)治疗肺动脉瓣狭窄(PS)后早期小儿右心室(RV)力学。
方法:43例儿科患者(19例男性),平均年龄3.2±4.9岁,纳入重度肺动脉瓣狭窄患者和经皮球囊瓣膜成形术的适应证.所有患者均行标准经胸超声心动图(TTE),和斑点追踪超声心动图(STE),并在手术前一天和术后一天分析右心室游离壁纵向应变(RVFWLS)。对于每个病人来说,我们在BPV之前和之后的介入过程中收集了侵入性参数。
结果:手术后,峰-峰跨肺梯度(峰-峰PG)和右心室收缩压与主动脉收缩压之比(RV/AoP)均立即显著降低,分别下降Δ29.3±14.67mmHg和Δ0.43±0.03.术后超声心动图显示峰值和平均跨瓣压力梯度下降(分别为Δ50±32.23和Δ31±17.97)。手术前8%的患者肺动脉瓣反流程度较轻,影响29%的患者在BPV后(p=0.007)。右心室力学分析显示,BPV后即刻分数面积变化(FAC)显着改善(40.11%vs.44.42%,p=0.01)。另一方面,右心室纵向收缩功能参数,TAPSE和全球RVFWLS,干预后没有明显改善。RVFWLS的节段分析表明,心尖段的心肌变形有明显的区域性增加。
结论:经皮BPV是缓解重度肺动脉瓣狭窄的一种有效和安全的方法。超声心动图对右心室功能的分析显示了立即的整体收缩功能改善,而纵向收缩功能在干预后24小时持续受损,可能是由于需要更长的恢复时间。
BACKGROUND: Pulmonary valve stenosis determines multiple effects on the right ventricular dimension and function. Percutaneous balloon valvuloplasty is the treatment of choice in severe pulmonary valve stenosis in patients of all ages. However, little is known regarding right ventricular function immediate changes after percutaneous balloon dilation. Pediatric patients with isolated pulmonary valve stenosis represent a pure clinical model of chronic RV pressure overload not affected by other confounders or comorbidities.
OBJECTIVE: This
study seeks to explore right ventricle (RV) mechanics in pediatric patients early after percutaneous balloon pulmonary valvuloplasty (BPV) for valvar pulmonary stenosis (PS).
METHODS: Forty-three pediatric patients (19 males), mean age 3.2 ± 4.9 years old, with severe pulmonary valve stenosis and indication for percutaneous balloon valvuloplasty were recruited. All patients underwent standard transthoracic echocardiography (TTE), and speckle-tracking echocardiography (STE) with an analysis of right ventricle free-wall longitudinal strain (RVFWLS) one day before and one day after the procedure. For each patient, we collected invasive parameters during the interventional procedure before and after BPV.
RESULTS: After the procedure, there was an immediate significant reduction in both peak-to-peak transpulmonary gradient (peak-to-peak PG) and ratio between the right ventricle and aortic systolic pressure (RV/AoP) with a drop of ∆29.3 ± 14.67 mmHg and ∆0.43 ± 0.03, respectively. Post-procedural echocardiography showed peak and mean transvalvar pressure gradient drop (∆50 ± 32.23 and ∆31 ± 17.97, respectively). The degree of pulmonary valve regurgitation was mild in 8% of patients before the procedure, affecting 29% of our patients post-BPV (p = 0.007). The analysis of right ventricular mechanics showed a significant improvement of fractional area change (FAC) immediately after BPV (40.11% vs. 44.42%, p = 0.01). On the other hand, right ventricular longitudinal systolic function parameters, TAPSE and global RVFWLS, did not improve significantly after intervention. The segmental analysis of the RVFWLS showed a significant regional increase in the myocardial deformation of the apical segments.
CONCLUSIONS: Percutaneous BPV represents an efficient and safe procedure to relieve severe pulmonary valve stenosis. The analysis of the right ventricular function on echocardiography demonstrated an immediate global systolic function improvement, while longitudinal systolic function was persistently impaired 24 h after intervention, possibly due to the necessity of a longer recovery time.