先天性心脏病封堵治疗基础超声影像课件

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1、先天性心脏病封堵治疗 基础超声影像,福建医科大学附属协和医院心内科 福建省冠心病研究所 陈良龙 MD PhD FACC,导管室彩色多普勒超声的作用 术前诊断/术中监测/术后评价,介入治疗引导监测 先天性心脏病封堵治疗 瓣膜性心脏病扩张成形 肥厚型心肌病消融治疗 扩张型心肌病同步治疗 急诊胸痛病因鉴别 急性冠脉综合征 主动脉夹层血肿 急性肺动脉栓塞 重症心肌心包炎 严重张力性气胸,导管并发症早发现 心包填塞 心脏破裂 接触血栓 腔内气栓 术后疗效评价优化 影像形态学评估 血流动力学评估 器械是否需更换 术式是否需改变 术后治疗关注点,S1 术中引导监测,1.导管房间隔缺损封堵术,术前 ASD超声

2、评估,ASD位置/形态/数目 选择合适ADO,2019/4/28,LL CHEN MD PhD FACC,6,心尖四腔观,房间隔全长 最大ADO 缺损直径 解剖 扩张 缺损边缘 有无 厚薄 周围结构 PV CS SVCIVC MVTV,A,B,2019/4/28,LL CHEN MD PhD FACC,7,剑下四腔观,A,B,房间隔全长 最大ADO 缺损直径 解剖 扩张 缺损边缘 有无 厚薄 周围结构 PV CS SVCIVC MVTV,2019/4/28,LL CHEN MD PhD FACC,8,心底短轴观,主动脉对侧房缺边缘长度 主动脉侧房缺边缘长度 周围结构 主动脉根部 SVC MV,

3、A,B,2019/4/28,LL CHEN MD PhD FACC,9,剑下下腔观,A,B,房间隔缺损在IVC侧边缘残端 有无 厚薄 IVC侧边缘无残端容易导致封堵失败,术中 封堵器能否释放,夹住房间隔残端的超声影像观察 排除封堵器占位的超声影像观察,2019/4/28,LL CHEN MD PhD FACC,11,心尖四腔观:通过牵/拉输送系统,确定房间隔前下/后上是否被封堵器夹住 确定封堵器是否正常、移位。,A,B,2019/4/28,LL CHEN MD PhD FACC,12,剑下四腔观:通过牵/拉输送系统,A,B,确定房间隔前下/后上是否被封堵器夹住 确定封堵器是否移位,2019/4

4、/28,LL CHEN MD PhD FACC,13,心底短轴观:通过牵/拉输送系统,A,B,确定封堵器是否夹住主动脉侧房缺残端或抱住主A根部 确定封堵器是否夹住主动脉对侧房缺残端,2019/4/28,LL CHEN MD PhD FACC,14,各切面观:排除封堵器占位,二三尖瓣 肺静脉 冠状窦 上下腔静脉,A,B,封堵效果好的超声影像观察,术后 ASD封堵效果观察,2019/4/28,LL CHEN MD PhD FACC,16,心尖四腔及大动脉短轴观,补片位置和形态良好 对二、三尖瓣无影响 对肺静脉回流无影响 良好环抱主动脉,A,B,2.经导管VSD封堵术,术前 VSD超声评估,VSD位

5、置/形态/数目 选择合适ADO,2019/4/28,LL CHEN MD PhD FACC,19,室间隔缺损的形态分类,管状,窗状,囊袋型,漏斗型,2019/4/28,LL CHEN MD PhD FACC,20,心尖五(四)腔心切面,室间隔缺损边缘距主动脉瓣距离 与瓣环的距离 与窦的距离 窦脱垂 室间隔缺损的形态 长管状 短窗型 漏斗状 囊袋状：多漏口，基底宽 室间隔缺损与三尖瓣的关系 囊袋状缺损与三尖瓣粘连 三尖瓣粘连封闭缺损,2019/4/28,LL CHEN MD PhD FACC,21,左心室长轴切面,室间隔缺损边缘距主动脉瓣距离 与瓣环的距离 与窦的距离 窦脱垂 室间隔缺损与三尖瓣

6、的关系 三尖瓣粘连封闭缺损 囊袋状缺损与三尖瓣粘连,2019/4/28,LL CHEN MD PhD FACC,22,心底短轴切面,室间隔缺损的位置 脊下型，膜部，膜周部 脊内型，脊上型，干下型 室间隔缺损的大小 右室流出道情况,术中 VSD封堵超声监测,封堵过程是否影响重要结构 封堵效果及残余分流,2019/4/28,LL CHEN MD PhD FACC,24,心尖五（四）腔心切面,观察输送导管穿过室间隔 观察出鞘的封堵器是否影响二尖瓣腱索引起关闭不全,2019/4/28,LL CHEN MD PhD FACC,25,心尖五（四）腔心切面,观察封堵器位置是否正常 观察封堵器是否完全封堵缺损

7、，是否有残余分流,2019/4/28,LL CHEN MD PhD FACC,26,心尖五（四）腔心切面,观察封堵器是否引起主动脉瓣关闭不全 是否触及主动脉窦 是否影响主动脉瓣关闭 观察封堵器是否引起三尖瓣关闭不全 三尖瓣腱索被夹，断裂 低血压,2019/4/28,LL CHEN MD PhD FACC,27,左室长轴切面,观察封堵器是否引起主动脉瓣关闭不全，是否触及主动脉窦或引起主动脉窦变形,封堵效果与并发症,术后 VSD封堵效果观察,2019/4/28,LL CHEN MD PhD FACC,29,成功封堵,封堵器位置良好 无主动脉瓣返流 无三尖瓣返流 无主动脉窦变形,可释放封堵器,3.超

8、声引导PDA封堵术,2019/4/28,LL CHEN MD PhD FACC,31,测量PDA大小、观察其形态、选择封堵器,Figure 1. The ampulla and the duct connection between the descending aorta and the left pulmonary artery in a patient with a megaphone-like PDA were clearly visualized on the parasternal short axis view, and MDD of 4.3 mm and 4.5 mm was

9、accurately measured in 2DEimage (1A) and CDFI mapping(1B),respectively. The interrogate depth was 15 cm unless otherwise indicated.,2019/4/28,LL CHEN MD PhD FACC,32,准确测量PDA大小,Figure 2. 2DE did not completely reveal the duct morphology in a patient with a small PDA (2A); while CDFI clearly detected a

10、 duct shunting jet entering the pulmonary artery from the descending aorta, producing a vena-contracta phenomenon (2B), and the jet width of 2.3 mm was measured at the point (arrow) of the vena-contracta in this case, which was an alternative to direct 2DE measurement,2019/4/28,LL CHEN MD PhD FACC,3

11、3,准确测量PDA大小及合适选择封堵器,The measurements of SDD and MDD in 60 patients with a first or a second successful occlusion were 7.12.7mm (3.5-17.2mm) and 5.41.4mm (3.1-10.3mm), respectively (P0.001). And there was highly linear relationship (SDD = 1.67 MDD-2.02, r=0.95, SEE=0.58, P0.01) between SDD and MDD,20

12、19/4/28,LL CHEN MD PhD FACC,34,封堵器定位、形态判断、占位效应,Figure 3. During the procedure, when the retention disk was deployed, 2DE could clearly revealed the extended disk against the duct ampulla (3A); and further withdraw the delivery sheath was indicated to deploy the conical segment of the device (3B); a

13、properly positioning occluder usually showed an I-shaped appearance with the retention disk closely against the ampulla (3C) ; there were not any ADO protrusion into the left pulmonary artery(3D),2019/4/28,LL CHEN MD PhD FACC,35,封堵器定位、形态判断、占位效应,Figure 4 On a modified super-sternal long axis view of

14、the aorta arch with the probe tilted leftward, a well-positioning ADO (arrow) was clearly seen with mild occupation of the left pulmonary artery in 2DE image (4A), and CDFI demonstrated local flow turbulence (4B), indicating ADO-produced mild stenosis of the left pulmonary artery. On a super-sternal

15、 long axis view of the aorta arch, an ADO (arrow) was clearly seen with moderate occupation of the descending aorta in 2DE image (4C), and CDFI demonstrated local flow turbulence (4D), indicating ADO-produced moderate stenosis of the descending aorta. The interrogate depth was 9 cm in figure 4C, 4D.

16、,2019/4/28,LL CHEN MD PhD FACC,36,残余分流观察、更换封堵器,Figure 5. On the left panel, CDFI detected a small marginal residual shunt with a width of 0.9 mm immediately after well-position of an ADO (5A), and CDFI continuous monitoring revealed the shunt become smaller at 10 min (5C) and finally vanished at 20 min (5E). Conversely, on the right panel, CDFI detected a large marginal residual shunt with a width of 2.1 mm immediately after well-position of an ADO (5B), and CDFI continuous mo