在二尖瓣环钙化的情况下经导管二尖瓣置换术后可能发生左心室流出道阻塞。
我们提供了一个病例系列,其中4例尽管有酒精间隔消融术,但仍有左心室流出道阻塞风险的患者使用超前间隔射频消融术(RADIO-TMVR)来增加左心室流出道,用于经导管二尖瓣置换术。
所有患者均为女性,平均年龄74.9(68.8-80.4)岁。基线射血分数为71%(63%-75%)。平均二尖瓣面积为1.28(范围,1.0-1.59)cm2。休息时的平均二尖瓣梯度为9.5(范围,7-11)mmHg。纽约心脏协会的症状在基线时为III至IV。患者在酒精间隔消融术后69至154天接受了超前间隔射频消融术,以防止经导管二尖瓣置换术的左心室流出道阻塞。手术时间为384(337-424)分钟,透视时间为31(14-71)分钟。射频消融时间为132(100-175)分钟。如预期,3例患者出现完全心脏传导阻滞,并接受起搏器植入,而1个有预先存在的起搏器。一名患者出现腹股沟血肿和心力衰竭加重。没有围手术期死亡。经导管二尖瓣置换术预防左心室流出道梗阻的超前间隔射频消融导致间隔舒张末期壁厚度与基线相比减少(28.6%,30.4%,30.3%,和11.1%)和酒精间隔消融术(23.1%,12%,8.5%)。所有患者在二尖瓣环钙化的情况下进行了瓣膜置换89(范围,在先发制人的间隔射频消融术后38-45天,通过经导管二尖瓣置换术防止左心室流出道阻塞。两名患者伴有二尖瓣前小叶裂伤,以进一步扩大新左心室流出道。手术后,纽约心脏协会的症状改善为I级(3例)和II级(1例)。
在有风险的个人中,抢先性间隔射频消融可能是经导管二尖瓣置换术预防左心室流出道阻塞的有效策略。
Left ventricular outflow tract obstruction may occur following transcatheter mitral valve replacement in the setting of mitral annular calcification.
We present a
case series whereby preemptive septal radiofrequency ablation (RADIO-TMVR) was used to augment the left ventricular outflow tract for transcatheter mitral valve replacement in 4 patients at risk for left ventricular outflow tract obstruction despite alcohol septal ablation.
All patients were female, average age of 74.9 (68.8-80.4) years. Baseline ejection fraction was 71% (63%-75%). Mean mitral valve area was 1.28 (range, 1.0-1.59) cm2. Mean mitral valve gradient at rest was 9.5 (range, 7-11) mm Hg. New York Heart Association symptoms were III to IV at baseline. Patients underwent preemptive septal radiofrequency ablation to prevent left ventricular outflow tract obstruction with transcatheter mitral valve replacement a range between 69 and 154 days after alcohol septal ablation. Procedural time was 384 (337-424) minutes with a fluoroscopic time of 31 (14-71) minutes. Radiofrequency ablation time was 132 (100-175) minutes. As anticipated, 3 patients developed complete heart block and underwent pacemaker implantation, whereas 1 had a preexisting pacemaker. One patient developed groin hematoma and heart failure exacerbation. There were no peri-procedural deaths. Preemptive septal radiofrequency ablation to prevent left ventricular outflow tract obstruction with transcatheter mitral valve replacement resulted in septal end-diastolic wall thickness reduction compared with baseline (28.6%, 30.4%, 30.3%, and 11.1%) and following alcohol septal ablation (23.1%, 12%, 8.5%). Valve replacement in the setting of mitral annular calcification was performed in all patients 89 (range, 38-45) days after preemptive septal radiofrequency ablation to prevent left ventricular outflow tract obstruction with transcatheter mitral valve replacement. Two patients had concomitant laceration of the anterior mitral leaflet to further augment the neo-left ventricular outflow tract. Postprocedure, New York Heart Association symptoms improved to class I (3 patients) and class II (1 patient).
In at-risk individuals, preemptive septal radiofrequency ablation may be an effective strategy at preventing left ventricular outflow tract obstruction with transcatheter mitral valve replacement.