Transcatheter Mitral Valve Repair Effective and Safe for Refractory Eclipsed Mitral Regurgitation-Induced Cardiogenic Shock: A Case Report
Transcatheter Mitral Valve Repair Effective and Safe for Refractory Eclipsed Mitral Regurgitation-Induced Cardiogenic Shock: A Case Report
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经导管二尖瓣修复术对于顽固性二尖瓣反流引起的心源性休克有效且安全：病例报告
DOI：
10.1161/circimaging.121.012641
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发表时间：
2021
期刊：
影响因子：
--
通讯作者：
Fukuda Keiichi
中科院分区：
文献类型：
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作者：
Umei Tomohiko C.;Shiraishi Yasuyuki;Tsuruta Hikaru;Hayashida Kentaro;Imaeda Shohei;Ryuzaki Toshinobu;Myojin Sosuke;Kobari Yusuke;Saito Tetsuya;Yoshijima Nobuhiro;Itabashi Yuji;Kishino Yoshikazu;Katsumata Yoshinori;Yuasa Shinsuke;Fukuda Keiichi
一名90岁男性因急性失代偿性心力衰竭反复住院入院。入院时，他血流动力学不稳定，意识障碍，提示心源性休克（SCAI 分类 C 期）。他的初始血压为 76/49 mm Hg，脉搏为 60 次/分钟，呼吸频率为 28 次/分钟，室内空气氧饱和度为 85%。心肺听诊可见不规则不规则、第三心音及双侧粗爆裂音。实验室测试结果表明组织灌注受损，乳酸（2.0 mmol/L）、B 型利钠肽（1983 pg/mL）、血清肌酐（2.69 mg/dL）和总胆红素（1.6 mg/dL）水平升高。心电图 (ECG) 显示房颤并伴有 V4-V6 导联 ST-T 压低（图 1）。经胸超声心动图显示左心室动力性收缩（射血分数 70%），伴有前侧壁节段性运动功能减退和大量二尖瓣反流 (MR)，继发于严重栓系导致二尖瓣小叶无法接合（图 2；数据补充中的影片 I）。通过强化治疗，包括常规氧疗以及静脉注射多巴酚丁胺和去甲肾上腺素联合利尿剂，他的血流动力学稳定下来。值得注意的是，入院后第二天，随着 MR 的减少，二尖瓣的接合得以恢复。冠状动脉造影未发现任何明显狭窄（图 3A 和 3B）。 123I-β-甲基碘苯基十五烷酸（123I-BMIPP）闪烁扫描显示侧乳头肌周围的 123I-BMIPP 摄取减少（图 3C），这可能归因于短暂的冠状血管痉挛和/或微血管功能障碍。即使在给予足够的冠状血管扩张剂的情况下，使用测力计进行的运动负荷超声心动图也证实，由于低负荷运动期间二尖瓣的贴合不良，MR 突然恶化（从轻度到重度分级），导致收缩压降低至 60 mm Hg。运动终止后几分钟后，二尖瓣的接合突然恢复，MR 显着下降（图 4A 至 4D；数据补充中的电影 II），随后收缩压恢复至 > 90 mm Hg。这些发现表明存在短暂的大量 MR；这种现象通常称为重叠 MR。在我们的心脏团队讨论围手术期手术风险（包括功能能力和虚弱程度）后，我们随后使用 MitraClip 装置（在 A2/A2 处有 2 个夹子）进行了经导管二尖瓣修复术。
A 90-year-old man with recurrent episodes of hos-pitalization due to acute decompensated heart failure was admitted to our hospital. Upon admission, he was hemodynamically unstable with disordered consciousness suggestive of cardiogenic shock (SCAI classification stage C). His initial blood pressure was 76/49 mm Hg, pulse 60 beats/minute, and respiratory rate 28 breaths/minute with an oxygen saturation of 85% on room air. Cardiopulmonary auscultation revealed irregularly irregular, third heart sound and bilateral coarse crackles. Laboratory test results suggested impaired tissue perfusion with elevated levels of lactate (2.0 mmol/L), B-type natriuretic peptide (1983 pg/mL), serum creatinine (2.69 mg/dL), and total bilirubin (1.6 mg/dL). Electrocardiography (ECG) revealed atrial fibrillation with ST-T depression in leads V4–V6 (Figure 1). Transthoracic echocardiography revealed hyperdynamic left ventricular contraction (ejection fraction 70%) with segmental hypokinesis of the anterolateral wall and massive mitral regurgitation (MR) with lack of coaptation of the mitral leaflets secondary to severe tethering (Figure 2; Movie I in the Data Supplement). He was hemodynamically stabilized by intensive treatment, including conventional oxygen therapy and the intravenous administration of dobutamine and norepinephrine combined with diuretics. Notably, coaptation of the mitral valve was restored with reduction in MR the day after admission. Coronary angiography did not reveal any significant stenosis (Figure 3A and 3B). The 123I-β-methyliodophenylpentadecanoic acid (123I-BMIPP) scintigraphy revealed decreased 123I-BMIPP uptake localized around the lateral papillary muscle (Figure 3C), which was perhaps attributable to transient coronary vasospasm and/or microvascular dysfunction. Even under sufficient administration of coronary vasodilators, exercise stress echocardiography using an ergometer confirmed sudden exacerbation of MR (from mild to severe grading) due to malcoaptation of the mitral valve during low-load exercise, leading to a reduction in systolic blood pressure to 60 mm Hg. Several minutes later after termination of exercise, coaptation of the mitral leaflets was abruptly restored and MR markedly decreased (Figure 4A through 4D; Movie II in the Data Supplement), followed by the recovery of his systolic blood pressure to> 90 mm Hg. These findings suggested transient massive MR; this phenomenon is commonly referred to as eclipsed MR. After our heart-team discussions on perioperative surgical risk, including functional capacity and frailty, we consequently performed transcatheter mitral valve repair using the MitraClip device (with 2 clips at the A2/