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中华心脏与心律电子杂志 ›› 2025, Vol. 13 ›› Issue (01) : 1 -28. doi: 10.3877/cma.j.issn.2095-6568.2025.01.001

标准与规范

中国经导管左心耳封堵术临床路径专家共识(2025版)
中国医师协会心血管内科医师分会结构性心脏病学组;苏州工业园区东方华夏心血管健康研究院   
  • 收稿日期:2024-12-07 出版日期:2025-03-25
  • 基金资助:
    上海市创新医疗器械应用示范(23SHS00700)上海市科技创新行动计划(24SF1906600)上海市临床医学研究中心(19MC1910300)国家自然科学基金(82470377、82200457)

Expert consensus on clinical pathway of transcatheter left atrial appendage closure in China(2025)

Heart Disease Group, Chinese College of Cardiovascular Structural   

  • Received:2024-12-07 Published:2025-03-25
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学组;苏州工业园区东方华夏心血管健康研究院. 中国经导管左心耳封堵术临床路径专家共识(2025版)[J/OL]. 中华心脏与心律电子杂志, 2025, 13(01): 1-28.

Heart Disease Group, Chinese College of Cardiovascular Structural. Expert consensus on clinical pathway of transcatheter left atrial appendage closure in China(2025)[J/OL]. Chinese Journal of Heart and Heart Rhythm(Electronic Edition), 2025, 13(01): 1-28.

本共识聚焦左心耳封堵术(LAAC),鉴于心房颤动(房颤)患者增多及LAAC技术进展与临床需求变化,中国医师协会心血管内科医师分会结构性心脏病学组对此进行了更新。房颤发病率随人口老龄化而攀升,房颤引发的脑卒中风险高,而LAAC则是有效预防途径。共识详细阐述LAAC的发展脉络,包括在房颤综合管理中的关键意义、我国的里程碑事件及丰富的循证依据。在团队构建上,明确了涵盖多科室专业人员的配置及精细分工。明确适应证为高脑卒中风险且特定评分达标的非瓣膜性房颤患者,同时列出禁忌证。全面解析方法学,从影像评估[如(经胸超声心动图(TTE)、经食管超声心动图(TEE)、心脏CT血管造影(CTA)作用及要点]、不同封堵器操作(塞式或盘式封堵器的选择、置入、评估及调整流程)到围手术期管理各环节均有涉及。梳理围手术期并发症,涵盖心包积液、脑卒中、封堵器脱落等,分析成因并给出处理策略。术后抗栓治疗依阶段(强化、巩固及特殊患者情形)制订策略,同时详述随访计划(节点、方式、内容及结果判定)。术式选择介绍“一站式”与简化式特点及适用场景,展望未来聚焦适用人群拓展、技术完善、器械创新、联合治疗深化及用药策略优化,为LAAC临床实践与发展提供全方位、精准且具前瞻性的指引,有力推动其规范化、精准化及持续创新。

图1 LAAC中国发展史 LAAC为左心耳封堵术,ICE为心腔内超声心动图
图2 应用塞式封堵器经食管超声心动图测量的方法[2A为0°;2B为45°;2C为90°,均以左回旋支为基线到左上肺静脉嵴部远端2 cm以内作为测量开口(标记为1的测量线),深度为着陆区中点至左心耳的远端(标记为2的测量线);2D为135°,以左心耳颈部平行于左回旋支处到左心耳外侧壁作为测量开口(标记为1的测量线),深度为着陆区中点至左心耳的远端(标记为2的测量线)]
图3 不同形态的左心耳穿刺轴向选择(3A为仙人掌型的轴向选择;3B为鸡翅型的轴向选择;3C为反鸡翅型的轴向选择) a、b为轴向选择
图4 LAAC术前心脏CTA检查(4A为延迟扫描鉴别左心耳内血栓和血流淤滞;4B为左心耳与周围结构的关系;4C为左心耳的相对位置;4D为模拟术中工作体位;4E为模拟Watchman FLX封堵器置入的位置;4F为左心耳深度的测量;4G为Watchman FLX封堵器着陆区平面测量最大径、最小径和周长;4H为模拟LACbes封堵器置入的位置;4I为LACbes封堵器径线测量方法) LAAC为左心耳封堵术,CTA为CT血管造影
图5 ICE导管送入左心房后,按“三轴六向法”进行左心耳扫描评估 ICE为心腔内超声心动图,LSPV为左上肺静脉,RPVO为右肺静脉口部,MAO为二尖瓣环口部,LCX为左回旋支,Ao为主动脉,MV为二尖瓣,LA为左心房,PA为肺动脉,Ridge为华法林嵴
图6 X线透视下多体位左心耳造影(6A为RAO 30°+CRA 20°;6B为LAO 0°+CAU 20°;6C为RAO 30°+CAU 20°) RAO为右前斜位,CRA为头位,LAO为左前斜位,CAU为足位
图7 Watchman FLX退鞘四步法
图8 Watchman FLX退鞘四步法DSA影像(8A为左心耳造影;8B为退鞘形成FLX BALL;8C为封堵器肩线对齐封堵线退鞘展开封堵器;8D为顶住释放手柄>10 s;8E为造影确认封堵效果;8F为释放封堵器)
图9 Watchman FLX封堵器进伞四步法
图10 Watchman FLX封堵器进伞四步法DSA影像(10A为左心耳造影;10B为退鞘形成FLX BALL;10C为输送系统远端MARK环对齐封堵线推伞展开封堵器;10D为顶住释放手柄>10 s;10E为造影确认封堵效果;10F释放封堵器)
图11 毛毛虫法示意
图12 Watchman FLX回收手法示意
图13 盘式封堵器常规法展开流程[13A为在数字减影血管造影指导下,沿猪尾导管将外鞘头端送至左心耳开口内约10 mm处(固定盘着陆区位置);13B为固定钢缆,回撤外鞘,使固定盘部分打开呈倒三角形;或呈圆盘形 (13C);13D为固定鞘管,推送钢缆,使固定盘完全展开;13E为固定钢缆、回撤输送鞘,使封堵盘慢慢打开;13F为在封堵盘展开瞬间保持向前推送钢缆力量使封堵盘完全打开]
图14 盘式封堵器三明治策略展开流程(14A~14D为正鸡翅型盘式封堵器三明治策略展开流程;14E~14H为反鸡翅型盘式封堵器三明治策略展开流程)
图15 盘式封堵器硬币法展开流程(15A为封堵器于左心耳口部形成“倒三角”;15B为整体推送,使固定盘盘面与左心耳壁接触,继续缓慢推送,观察固定盘形成“硬币形”;15C为固定鞘管,推送钢缆直至固定盘完全打开;15D为最后同常规法展开外盘)
图16 盘式封堵器PAST原则评估(16A为固定盘至少有2/3在左回旋支内左心耳侧;16B为牵拉封堵盘时,固定盘无位移;16C~16E为分别使用多普勒、三维经食管超声心动图和造影确认封堵效果;16F为固定盘有一定的压缩比例,呈“轮胎状”)
图17 LAmbre封堵器原位展开流程(17A为刚开伞;17B为半打开的状态;17C为全打开;17D为外盘打开)
图18 LAmbre封堵器渐进式展开流程 landing zone为着陆区,LAA为左心耳,TEE为经食管超声心动图
图19 LAmbre封堵器置入及COST原则评价(19A为封堵器固定盘在左回旋支外侧展开;19B为固定盘充分展开,U型勾末端与封堵器的连接键呈一直线;19C为封堵盘展开后贴合左心耳口部,残余分流≤3 mm;19D为固定盘稳定,通过牵拉测试)
图20 LAAC后整体用药方案流程 LAAC为左心耳封堵术,NOAC为新型口服抗凝药物,VKA为维生素K拮抗剂,SAPT为单药抗血小板治疗,TEE为经食管超声心动图,CTA为CT血管造影,DRT为器械相关血栓,PDL为器械残余分流,DAPT为双联抗血小板治疗
图21 心脏CTA检查(21A为Lambre封堵器移位,21B为封堵器下缘存在边缘残余分流,21C为封堵器存在装置内分流,21D为残存左心耳内未见对比剂进入,提示Watchman FLX封堵器表面完全内皮化;21E为残存左心耳内见对比剂进入,提示封堵器表面内皮化不全;21F为封堵器表面左心房侧血栓形成) CTA为CT血管造影
图22 CTA术后判断左心耳封堵内皮化流程 CTA为CT 血管造影,LAA为左心耳,LA为左心房
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