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中华心脏与心律电子杂志 ›› 2022, Vol. 10 ›› Issue (02) : 65 -80. doi: 10.3877/cma.j.issn.2095-6568.2022.02.001

所属专题: 总编推荐 指南共识

标准与规范

简化式左心耳封堵术临床路径中国专家共识(2022)
中国医师协会心血管内科医师分会结构性心脏病专业委员会   
  • 收稿日期:2022-05-27 出版日期:2022-06-25

China/Chinese Expert Consensus Statement on Catheter-based Left Atrial Appendage Occlusion via Minimalistic/Simplified Approach (2022)

Structural Heart Disease Committee of Chinese College of Cardiovascular Physicians   

  • Received:2022-05-27 Published:2022-06-25
引用本文:

中国医师协会心血管内科医师分会结构性心脏病专业委员会. 简化式左心耳封堵术临床路径中国专家共识(2022)[J]. 中华心脏与心律电子杂志, 2022, 10(02): 65-80.

Structural Heart Disease Committee of Chinese College of Cardiovascular Physicians. China/Chinese Expert Consensus Statement on Catheter-based Left Atrial Appendage Occlusion via Minimalistic/Simplified Approach (2022)[J]. Chinese Journal of Heart and Heart Rhythm(Electronic Edition), 2022, 10(02): 65-80.

表1 简化式与经典式LAAO术式对比
图1 X线透视及TTE指导下的房间隔穿刺[1A为心脏后前位(PA)X线透视示意图,左心房影下缘上1个椎体高度(红线之间);1B为心脏右前斜位(RAO)45° X线透视示意图,左心房后缘前0.5~1个椎体,位于标记点2或3(红线之间),进行前后调整;1C为TTE,大动脉短轴切面;1D为TTE,心尖四腔心切面,红圈内为穿刺点]AVG为房室沟,AO为主动脉,RA为右心房,RV为右心室,LA为左心房,LV为左心室,TTE为经胸超声心动图
图2 X线透视下多体位左心耳造影[2A为RAO 30°+CRA 20°;2B为LAO 0°+CAU 20°;2C为RAO 30°+CAU 20°]RAO为右前斜位,LAO为左前斜位,CRA为头位,CAU为足位
图3 封堵器初始位置实物图[3A图示未借深度(封堵器远端与输送系统标记环对齐);3B图示体外借1 mm深度(堵器远端超出输送系统标记环1 mm);3C图示体外借2 mm深度(堵器远端超出输送系统标记环2 mm);箭头示封堵器远端。]
图4 封堵器的露肩测量[4A为X线透视下足位20°,找到封堵器的切线位,测量封堵器的肩部(红色虚线)距离左心耳口的距离(3.5 mm);4B为对应的经食管超声心动图引导下的测量图像,封堵器肩部到心耳口部的距离]
图5 不同切面TEE与X线透视下封堵器压缩比测量值比较。[5A为TEE 135°图像;5B为RAO 30°+CAU 20°的X线透视图像;5C为TEE 45°图像;5D为RAO 30°+CRA 20°的X线透视图像。]TEE为经食管超声心动图;RAO为右前斜位;CAU为足位;CRA为头位
图6 左心耳封堵器(Watchman FLX)球形形态(FLX BALL)示意图
图7 左心耳封堵器(Watchman FLX)展开方式示意图
图8 LACbes封堵器植入及PAST释放原则[8A图示Proper position,封堵器固定盘正确的位置,封堵器固定盘的2/3 在回旋支远侧,红点表示左回旋支的位置;8B 图示Absolute anchor,牵拉封堵盘,固定盘无位移;8C图示Separate and seal,固定盘与封堵盘分离,且封堵盘周围残余漏≤3 mm;8D图示Typical tyre,固定盘呈现轮胎形]
图9 LAmbre封堵器植入及“COST”原则评价[9A图示Circumflex artery,固定盘在心耳内,在左回旋支之后展开。红点表示左回旋支的位置;9B图示Open(展开),固定盘充分打开,使得固定盘末端与连接在密封盘和固定盘之间的显影标志在一条直线,黄线显示了固定盘脚末端;9C图示Sealing(封闭),密封盘达到最佳密封,残余分流≤3 mm;9D图示Tug test(牵拉),牵拉试验确认封堵器固定良好]
图10 简化式左心耳封堵术术中需要转化术式的情况[10A为33 mm WATCHMAN封堵器,压缩比9%(红线处);10B为封堵露肩情况无法准确测量,造影观察约到为1/3(红线处);10C为封堵器下缘疑似较大PDL(红线处);10D为造影不能清晰判断封堵盘与二尖瓣的位置关系(红线处);10E为心耳开口太大,PDL无法精确测量(红线处);10F为固定盘上缘悬空(箭头处),单纯牵拉无法确定封堵器是否稳定]
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