# Case Review
# Discussion
PASP 右心导管
The importance of performing left and right heart catheterization in all patients undergoing mitral interventions is stressed, demonstrating the comprehensive diagnostic approach.
It is crucial to assess if there is any reversibility in pulmonary hypertension and the patient's suitability for surgery.
Right heart catheterization is a practical approach to evaluating patients with high surgical risk and pulmonary hypertension.
The debate on the use of right heart catheterization in mitral patients as a standard practice is ongoing, considering the advancements in imaging with echo and indirect assessment of left atrial function.
Patient selection for right heart catheterization should consider the presence and severity of pulmonary hypertension, as well as the potential precapillary component.
Performing left and right heart catheterization is important in mitral valve interventions to assess reversibility in pulmonary hypertension and patient suitability for surgery. The use of right heart catheterization as a standard practice is debated due to advancements in imaging, but it is a practical approach for evaluating high-risk patients with pulmonary hypertension.
进行左右心导管插管在二尖瓣干预中非常重要，可评估肺动脉高压的可逆性和患者是否适合手术。由于影像技术的进步，是否将右心导管插管作为标准实践仍存在争议，但对于评估肺动脉高压高风险患者来说，这是一种实用的方法。
部分专家说在他们中心，所有的 MR 都在术前行右心导管（看 PASP）左心导管（看 LA 压）
有的专家认为不需要全部都做，比如 PMR 可能很多都有 PASP 升高（到 50 左右；目前指南认为到 50 以上就推荐干预）；但如果高到 70 以上，就心导管看，有没有潜在的毛细血管前原因。
该中心做右心导管，不是为了看是否排除外科，根据患者并发症（due to the comorbidities zone）已经可以排除外科了。
讨论主要是继续药物治疗 medical therapy 还是 TEER，因为涉及到麻醉医生 anesthetician 提出症状到底是与 MR 相关还是和肺动脉疾病 pulmonary disease 相关的，因此进一步做了右心导管
这个患者的肺动脉高压 主要是毛细血管后 Pulmonary hypertension was mainly post-capillary
根据 TTE 的更多分析
双心房扩张 Bi atrial dilatation，但左房又没有 huge 时，后叶有限制 restricted，但是看起来并不短（does not look prohibitively short，比如 7-10mm）
这也不是瓣环钙化（mitral annulus calcification），但可以看到间隔（septum）活动度很大（hyperdynamic），而游离壁（free /lateral）则运动减弱（hypokinetic）
这些都提示患者可能之前患有冠心病，且提示如果做外科手术可能不会有很好的修复效果，因为游离壁的收缩能力（because of contractility of free wall）
# TEE
as you can see the leaflets are well represented with the central and the huge jet on all the central parts of the valve
without calcification with the leaflets well-represented
# Discussion 器械选择
which kind of device would you choose and which strategy do you propose
瓣膜成形术 an annuloplasty device
不选，因为后瓣有些拴系，瓣环成形术失败风险很高
there is some tethering of the posterior leaflet so this is a high risk for failure of annuloplasty
The feasibility of the TEER procedure for a patient with a history of radiation and potential leaflet calcification, emphasizes the need to measure the gradient as a challenge in such cases.
这是一个放疗后的病人 a patient underwent radiations
and so if you have an irradiated patient you might have leaflets that are not completely pliable
这类患者的瓣叶可能不柔软
the posterior leaflet is not as much restricted as is retracted
后叶不是那么的受到限制
This sentence discusses the posterior leaflet of a structure, which is not as restricted in movement as it is retracted or pulled back.
there is some infiltration of that leaflet which is related to calcification which makes it unable to co-opt to the anterior leaflet as well
有钙化相关的渗透，影响瓣叶对合
I don't think he's a patient which is absolutely contraindicated for TEER, but the first question I will ask in the procedure is to measure the gradient. this is the first challenge we have in such cases
不是绝对禁忌，但是第一个问题是术前要测一下跨瓣压差
Regarding the Mac, we performed the CT. but there was no Mac, not so much calcium. And also the mean gradient was two millimeters of mercury.
如果是 MAC 的病人，会常规做 CT，但本例钙化并不多，所以没有做。术前平均跨瓣压差是 2mmHg。
the infiltrate leaflets may be thick. 不仅仅是钙化，放疗病人的浸润瓣叶可能很脆弱 And we have no imaging, to be honest, which is giving us information about leaflets. 且没有可靠的检查可以明确瓣叶的情况。
The coaptation gap is quite long 对合间隙非常长，认为并不是绿区的病人 so I probably would not have put him as a green. It is not a straightforward P2 prolapse. 这不简单的 P2 脱垂
This is more complicated but the anatomy on the three-chamber view did look like it would potentially be suitable for TEER. 这是更复杂的情况，但是三腔心的解剖来看，他还是潜在的适合 TEER 的。
the previous radiation involvement of the leaflets. And really, the necessity to get a really good tissue bridge on this patient might not be as predictable as you would think.
而且还有放疗对瓣叶的影响。要在这个病例上得到一个非常好的组织桥可能并不像想象的那样可预测。
The feasibility of transcatheter edge-to-edge repair (TEER) procedure for a patient with a history of radiation and potential leaflet calcification presents challenges, particularly in measuring the gradient. The posterior leaflet may be retracted and infiltrated with calcification, affecting coaptation with the anterior leaflet. While not an absolute contraindication, measuring the gradient is the first step in such cases. The coaptation gap may be long, indicating a more complex situation than a straightforward P2 prolapse. However, the three-chamber view suggests that TEER may still be suitable. The impact of previous radiation on leaflet involvement and the predictability of achieving a good tissue bridge in this patient are uncertain.
对于具有放射疗法历史和潜在叶瓣钙化的患者来说，经导管边缘对边修复（TEER）手术的可行性存在挑战，尤其是在测量压差方面。后叶可能会退缩并且被钙化物浸润，影响与前叶的对合。虽然并非绝对禁忌症，但测量压差是这种情况下的第一步。对合间隙可能较长，表明比简单的 P2 脱垂更复杂。然而，三腔视图表明 TEER 可能仍然适用。以前的放射治疗对瓣叶受累的影响以及在该患者中实现良好组织桥梁的可预测性尚不确定。
The importance of analyzing the patient's anatomy
返流来自两侧的 indentations，这里是 areas with maximum color convergence，但同时也是不应该下夹子的地方 areas where you should not go with your device.
有一个非常宽的对合间隙， there is a pretty wide coaptation gap.
this is a typical mistake. 反流束 the maximum jet 来自 indentation，这个区域测瓣叶长度明显不够
由于 MV 是一个 3D structure，所以在 2D dimension 测的时候，需要小心会错失一些东西 You have to be careful you're missing something.
you can have it short only if you have mitral annular calcification retracting the leaflet if it's retracted. Otherwise, it's just wrongly measured. It's oblique.
只有在瓣环钙化导致瓣叶回缩时瓣叶才短。否则，那只是错误的测量。它是斜的。
the mistake of turning down patients for a procedure based on incorrect measurements
# 主题 - 如何保证手术安全
最重要的是 The importance of clear communication and interaction within the medical team during the procedure
了解 3D enface view； understanding the 3D structure of the mitral valve for accurate assessment.
the mitral valve sits at the back of the chest with the aorta just anterior to it.
where is the leak 反流来自哪里
what is the grasping view
because you've got a P2 prolapse doesn't mean that it's a straightforward case,
it's very, very long. It's very broad. you'll need more than one device to treat this anatomy equally.
not only has the patient got a cordal prolapse or flail towards the lateral side of the valve but there are possibly some indentations on either side of the prolapse.
in this particular case, there's a P2 prolapse, but the underlying anatomy is very complex with indentations and clefts and difficult anatomy on the anterior leaflet.
在 en face 或者底部，或者 mpr，描绘瓣口面积，确认没有狭窄
a medial commissure prolapse. You can get very tangled up in the cords, the more lateral and medial you go.
And equally, sometimes the imaging can be a little bit more challenging out in the commissures.
although hopefully, you can see a cordal rupture here with a prolapse going across, it can be quite challenging to see these
We don't like to have patients who've got prolapsing lesions with other areas of calcification. Because this can induce mitral stenosis
neither do we like patients whose starting mitral valve area is less than four centimeters squared.
there was a broad jet of mitral regurgitation along the coaptation line.
But looking at this, the leaflets themselves are not thickened. The posterior leaflet is not retracted, it's not restricted, and it's also not short.
there's a very short surface of coaptation, which might make you think carefully about which device to use because you don't want to pull too hard on the leaflets as you're creating an apposition, particularly in cases like this where the annulus is super dilated, where the patient's had longstanding atrial fibrillation.
This is secondary mitral regurgitation due to annular dilatation and atrial fibrillation.
there's a very broad coaptation gap, but the leaflets themselves are very horizontal and are very short opposition.
anatomical suitability for secondary mitral regurgitation.
It can be helpful to measure the tenting area and the tenting height.
The more that the valves are tented, the harder and more complicated the procedure will be.
it's important to confirm any indentations or clefts.
in this patient with secondary mitral regurgitation, the posterior leaflet is over one centimeter, but it's very verticalized and restricted.
That doesn't mean that you can't perform the procedure, just means you might have a job to get the device underneath the posterior leaflet when it's been pulled down so tightly against the lateral wall.
the patient's got some subvalvular thickening
This might increase the potential for subvalvular increased grads at the end of the procedure.
- is the inter-atrial septum crossable?
if a patient sometimes presents with a PFO it's quite useful if you can, to avoid that area.
Some patients will have presented with previous closing of the interatrial septum.
# Discussion
this patient is a wide jet. The jet, as we have seen the jet has is all over, but there are two areas where there is more jet, the area of the indentations.
the jet indentation was due to the tethering of the chordal.
对于 DMR，一般夹持在返流最多的地方
we were guided by the jet, which is a good idea in primary MR, you need to go at the maximum jet velocity.
但是这点对于 FMR 来说似乎不是最优解
It is not always a good idea to functional MR
because as we have seen today, the main jet is coming from these areas where there is less tissue available.
对于 FMR 来说， the strategy was to work on the A 2 P 2 zone.
the jet was very wide. So we thought about it, two clip or two device strategy.
because as you say, there are indentations, each size of P 2, it'll look like there are two jets of a there depending at the level you cross the jet, you can find it truly going across the coaptation line.
if you reduce the amount, the volume of overload, and the amount of regurgitation, in general, trying to do with your strategy in the center, these two jets, each side of P 2 will go away if eventually, you improve the hemodynamics of this valve.
if you do go right in the center of the valve, of course, this is where a chordal free zone exists, and therefore you are unlikely to become trapped in any subvalvular apparatus.
when the panel mentions indentations even if they are there, there's a real role. It is very unpredictable what will happen to those indentations when you put an edge-to-edge device in because sometimes they will close, but sometimes you will open them and make the situation worse.
This document discusses key questions and considerations for transcatheter edge-to-edge repair in mitral valve intervention. It highlights the importance of identifying the areas with the most significant regurgitant jet and the potential impact of tethering of the chordal. The document also mentions the strategy for functional MR and the use of two clip or two device strategy for wide jets. It emphasizes the need to improve hemodynamics and reduce regurgitation volume. Additionally, it cautions about the unpredictability of indentations when using an edge-to-edge device.
本文讨论了二尖瓣经导管缘对缘修复术的关键问题和考虑因素。它强调了识别最显著的反流区域以及腱索拴系的潜在影响的重要性。文中还提到了功能性二尖瓣关闭不全的策略以及广泛反流的两个夹子或两个装置策略的使用。它强调了改善血流动力学和减少反流量的需求。此外，它提醒在使用缘对缘装置时，压痕的不可预测性。
why do we go in the middle, let's recap all that you said.
First of all, because in this area, there is no tissue to grasp very short number two, because these areas, if I show you what is behind, below this clefts whatever, you have a lot of chords, you get entangled number three
because if you go in the A 2 P 2 region is the longest portion of the leaf. This is where the leaflets are the longest because leaflets are triangular. So the center is very long and you're not stealing leaflet surface for coaptation.
And finally, because you work in the chord-free zone.
So if you have no effect, you can easily retrieve and start from scratch.
There are so many reasons to go in the middle.
I think there is only one case in which you will open the indentations, the folds, and each type of P2, and that will be atrial secondary MR rather than ventricular secondary. When the leaflets are already unfolded, stretched thinned pencils delineated, so they barely reach each other and if you put the clips in the center, you might open up the indentations. Otherwise, the regurgitation will just get better.
我认为只有一种情况会打开缝隙、褶皱和各种 P2，那就是心房继发性二尖瓣反流而不是心室继发性。当瓣叶已经展开，拉伸细长时，它们几乎无法彼此接触，如果你把夹子放在中间，你可能会打开压痕。否则，反流只会变得更好。
the papillary muscle can be symmetric or can be asymmetric.
# Transseptal puncture
we all know that the fossa ovalis is the area we want to achieve, is the only safe area, and is the only area where there is nothing other than the right and left atrium. if we puncture the fossa, we are in a safe place to orient ourselves.
Safe introduction of the large delivery system
Coaxial orientation of the delivery system to the long axis of the heart
Appropriate distance of the transeptal GC from the aorta to avoid aortic hugging
Appropriate height to enable efficient handling and grasping
安全引入大型输送系统
将输送系统的同轴方向与心脏的长轴对齐
使穿刺房间隔与主动脉保持一定距离，避免主动脉拥抱
适当的高度以实现有效的操作和抓握能力
Today we have devices that allow us to play around, but the more curves you add to your delivery system, the more complexity you add to your procedure, And the less predictability of the trajectory of devices.
if you are too close to the aorta, you are not at all above the line of coaptation. The line of coaptation is very posterior.
Tailored TS puncture
It is like a helicopter view.
The post-medial commissure is basically at the level of the fossa.
The inferior and superior vena cava comes with an angle of almost 45 degrees to this anatomy.
右图是 a surgical view, Ao 在 12 点位置， the posterior leaflet is on the bottom. （蓝色箭头是）this is the direction of the superior-inferior.
we come with some angulation for those who have been or will go to the simulation lab.
这是左房面观
这是右房面观
这是右房面观和左房面观
What happens if I have a superior puncture?
So now we are watching the mitral valve from above. This is a kind of surgical view
as I go superior, I'm very far from the line of coaptation.
The more inferior I go, the more I get coaxial to the line of coaptation, which means already.
越靠下，越与对合线同轴，越少操作输送系统
The more inferior you go, the more you are going to be in line and the less manipulation on your delivery system you need.
the best example is when you have a commissural lesion, you want to be as close as possible to the posterior medial commissure by having an inferior puncture.
If you do a superior puncture, you have to do a U-turn to go to A3P3.
一个例子，靠近内交界的病变，应该靠下穿刺，这样正好在内交界上方。如果在偏上的位置穿刺，则需要打一个 U 弯才能靠近 3 区。
We understand now a little bit better the three-dimensional anatomy, and we understand also that superior and inferior maneuvers going from superior to inferior have very minimal effect on height. 上下对高度的影响非常小；上下相对于 MV 来说是前后关系
coaxial and height are not affected by superiority and inferiority.
If you go superior, you're going to be impacting the aortic valve.
These are superior posterior, and inferior posterior. we have reasonable height. 上后或者下后，都能保证合理的高度
An anterior superior is gonna be very low, a superior posterior. 上前高度很低
The original Everest paper publication suggested to go here, superior, posterior, we are very high, but also we are very biased towards the anterior commissure. And we are touching the aorta is an aorta hugger. 以前推荐靠上靠后穿刺，结果会有主动脉拥抱
mid fossa posterior is the one that most people are using today for these procedures because it's a good compromise of height and coaxial.
中后是现在更常用的
In my practice, I use all the time the inferior and posterior rather than mid-fossa.
this is where I go usually this is an excellent position because it allows me to enter the room.
The left headroom is my room where I want to play. I enter the playroom at the beginning of the room, not in the middle. 可以在房间的起始边缘进入而不是在中间
I start at the very end, at the very entrance of the room, and I can move around the room from here to the lateral wall.
So at this level, if I am posterior, I have enough height. 在这个水平，如果我靠后，我一样能有足够的高度
But imagine if I push the system towards the lateral wall, my height increases.
如果把系统推向 lateral，高度也会增加。
the superior inferior vena cava, they are 45 degrees. So as I move lateral, the height increases. 因为上下腔静脉有个 45 度。
because what means that the main determinant of our maneuvers is not the location of the puncture, is the location of our hinge point where we have the secondary curve of the delivery system, is where we have the the guide catheter at this level. 操作取决于 器械第二层鞘打弯 hinge point 的位置
which means the inferior posterior will let you go wherever you want, always with good height and good maneuverability.
How to reach that one trick increase. 如何达到下后穿刺点的技巧：
The angle of the tip of the needle will push you to the inferior rim of the fossa. and enlarge you can create an additional curve here to additional contact on the pressure on the fossa. 塑形穿刺针，红色 tip 段的弯保证能到达下缘；蓝色段的弯保证适当的力能抵住 FO
4ch view height assessment reliability is reduced in patients with floppy septum. 房间隔松软的病例 4ch 高度测量可靠性降低
总结：
Inferior posterior puncture is the most versatile puncture for structural interventions on the mitral valve （TEER, TMVR, and ViV）
下后穿刺是进行二尖瓣结构性干预（TEER、TMVR 和 ViV）最灵活的穿刺方式。
To achieve an inferior posterior puncture, stay a 6 hrs and bend the tip of the TS needle
为了实现下后穿刺，将 TS 针的尖端弯曲，并且保持 6 点钟方向。
stay as close to the posterior rim of the fossa as possible to avoid loss of height in floppy septum
尽可能靠近卵圆窝后缘以避免松弛间隔高度的损失。
# Step by step
从房间隔穿刺后 show us very precisely
在左上肺静脉放一根支撑导丝，然后倒入 guiding catheter
推送时要看到 tenting
you see the tenting while advancing the guiding catheter And you see the transition between the dilator and the guiding catheter itself. And when you see the tenting that comes back, it means that the tip has crossed.
回撤扩张器，推送入 teer device 进左房
keep their hand brake on, meaning that you advance with your right hand.
手保持刹车，这意味着你用右手前进。
However, due to the varying frictional resistance inside the catheter, your left hand needs to stop what your hand does to avoid any abrupt, abrupt forward movements.
接下来时唯独 Pascal 需要的步骤 （pascal specific）：关闭夹子，和 flex/unflex
因为是以伸长形态进入的，因此需要先打开夹子
First You have to close the implant. The skull comes into the left atrium in an elongated fashion. So you need to rotate, the knob to close it.
其次，由于可操控导管和导引导管未固定在彼此内部，因此您需要进行弯曲和伸直导引导管的操作，以验证弯曲平面的同轴性，该平面需要与二尖瓣环平行。
Since the steerable catheter and the guiding catheter are not fixed one inside the other, you need to do this maneuver of flexing and unflexing the guiding to verify the coaxially of the flexing plane which needs to be parallel with the mitral valve annulus.
如果想做的更快一些， If you want to be quick, you can do it Also Fluoroscopically.
turn your c-arm to 30 CRA so that you see your perpendicular mitral valve plane, and you flex and you verify that you do not lose or gain height with the tip of your device with regard to the mitral valve plane.
将 C 形臂旋转到 30CRA，这样您就可以看到垂直的二尖瓣平面，您可以 flex，并且可以验证尖端不会失去或增加相对于二尖瓣平面的高度。
2ch 下看到（垂直的）二尖瓣平面，在这个体位上 flex，确定不会有高度增加或丧失。
也可以 skip 这个步骤
然后需要 steer towards the MV 转向 MV
主要是在 fluoroscopy 下， It's done by rotating the steerable knob on the Pascal system and retracting a little bit the whole assembly to clear the ridge. Pascal 系通过 steerable knob，以及整体回撤一点，以过华法林脊。
If you are with a mitral clip device you rotate the M knob on this handle over here, and you need to check on echo. 如果是 MC，则旋转 M 旋钮，配合超声。
定位和找方向
you need to identify the location where your clip needs to be placed.
you basically can be above the target jet.
And for this step, again, it's useful to have echo guidance. it's mandatory.
I'd say you need to have an X-plane with an inter-commissural view and an LVOT view, and you can adjust the trajectory and the location of your device accordingly. it's important to have two orthogonal images to identify a precise direction in all directions.
调整 orientation
不同病变位置，不同夹臂方向
对于 MC 来说，抖动释放内管张力， to transmit effectively the movement to the implant you might wanna dissipate the tension by advancing and retracting with very short movements.
对于 PASCAL 系统，内管转 60 度，中管需反向转 15-20 度补偿。if you want to rotate a Pascal system, you need to act on the implant catheter over here, and you need to counteract on the steerable catheter. So if you rotate the implant by 60 degrees, you might wanna rotate the steerable in an opposite direction for 15 to 20 degrees, just to give you an idea of how much the compensation is.
垂直、位置、夹臂方向都 ok 了，推内管，跨二尖瓣
送入心室的深度，基本就是正好在瓣叶下，两个瓣叶都能自由活动 you basically can stop once your device is exactly below both leaflets And you see both leaflets moving.
可以回撤系统，再次之前跨瓣后用 3D 再次检查一下夹臂方向有没有偏转也是很有用的。Now you need to retract your device. it's also useful to check on 3D that you did not lose your clocking after crossing the mitral valve.
you need to retract your clip device until you have both leaflets, which are engaged. And until you see both leaflets nicely bouncing in above the clip arms.
Again here there is a little bit of difference between the two devices. The Pascal device once its arm opens 180 degrees, whereas with the MitraClip, usually we give 120 degrees of opening to both leaflets.
also with the MitraClip, you might wanna have a grasping, which is not as high as you might want with the Pascal system.
After both leaflets are engaged, and the clips or the clasps are down, you're ready to close the implant. And to evaluate for leaflet insertion
you need to evaluate in different echo views.
LVOT view is critical.
You should see both leaflets coming in with a nice v-shape in the clip system.
# Discussion
if I lose clocking as I cross the leaflets. I would almost always recommend starting all over again unless you are A2P2. 下瓣后如果发生偏转，建议全部重来，除非在 2 区。
the problem in echo: We see leaflets, we see papillary muscles, we see the septum, we don't see the chordal. 超声下我们能看见瓣叶、乳头肌、间隔，但是看不到腱索
if you are in the A2 P2 region, you have chordal around yourself.
if you are, let's say five degrees offset and you close like this, you have some residual MR. 二区偏转差个 5 度关夹，可能残余一点返流
But you can easily release, re-clock, re-close, and obtain an improvement. 但可以非常轻松的重新调整方向和关夹，来改善一下
we can do this in different ways. For instance, in case this happens, this happens you can easily just release only one arm and only rotate. and then, use the grippers only on one side. because we have an independent grasp. 还有一些别的方法，比如只松开一边，只旋转，只使用一侧的抓捕片，因为现在可以单边独立抓捕
The problem is different when you are working outside of the A2P2. 但二区以外的地方问题就不同了
如果是非 2 区的，夹子下去后，可能被瓣叶或腱索组织影响，导致夹臂方向偏转，且不好调整。一般 A2P2 的微调，其他区的撤了重来
下瓣时借助 DSA，避免夹臂偏转没被发现
超声切面优化的两点
- bicomm 下心尖放在屏幕正中间， Number one request, gimme the apex at the middle because that creates fewer artifacts.
- bicomm 下看到两侧乳头肌， Number two, I want to see the two papillary muscles. If I don't see two papillary muscles, if the apex is not in the middle, and sometimes it's impossible, then there is a risk there.
because we are talking about precision, but if we have a wrong image, we don't, we are not precise.
it's incumbent on images to be super strict with themselves to give you this image with the mitral annulus at right angles to an apex
继续 clocking 的问题
3D echo has some degree of parallax. 视差 Distortion. 失真
whenever we do the clocking, make sure you do clocking once your device is touching the leaf just above has to be above leaflets. Should not be far from leaflets. 不管什么时候调整夹臂方向，都最好不要离瓣叶太远
because the 3D that we are using can give you some artifacts of parallax. 因为 3D 可能有一些视差伪影
So the closer you are to the leaflets, the better it is. 离瓣叶越近，调整效果越好
A2P2 病变，那么 6-12 点方向
以往我们都越靠交界，越加大夹臂偏转角度
如果乳头肌位于中间或者比较低，那这个角度是可以的。 this will be correct if the papillary muscle was in the middle of the valve, the papillary muscles are lower.
So the reality is the papillary muscles are biased below the posterior leaflet. 而事实是乳头肌在后瓣下方
For this reason. We don't clock that much, we just keep more straight like this. 由于这个原因，我们没法如此斜，只能保持更直的夹臂方向
减少视差的方法 —— 降低增益，只要看清楚夹子，其他组织不需要
avoid the parallax, You just turn the gains down and anything artificial, whether you're thinking about cords or edge-to-edge devices or anything, you turn the gains down, you see the prosthetic material much, much clearer. So if you are clocking, turn the gains down, you're not necessarily so interested in the tissue.
一般不会在 3D 下做房间隔穿刺
There is only one 3D, which is mandatory, which is the clocking. 只有调整夹臂方向时用到 3D
Everything else can be misleading, particularly TSP.
# 实际处理 - FMR
第二枚夹子 parallel implanted to the first one here.
The fluoro is very useful in positioning the second device
# discussion
now we need to decide on release or not release. 是否释放
I mean, this is always a big dilemma because there are many confounders. 这总是一个很大的困境，因为存在许多混淆因素。
No.1, you might have some distortion, some pressure. You can pull, push, distort. You can do all things while you have the delivery system. 可能有一些失真，有一些压力
No.2, you also have some shadowing. I mean, in the end, you have the old delivery system shadowing the grasping area. 输送系统的伪影投射在抓捕区域
So what few tips?
First of all, before releasing, I also checked last time the orientation, and the clocking, sometimes even by reopening slightly 60 degrees, checking from 3D surgical view, one thing, checking once more prior to this second. 释放前最后检查夹臂方向，甚至会打开到 60 度再检查
I can ask either to pull back retroflex, or I can slightly move my delivery system, just pull back a bit. 解除伪影的方法（探头后屈，或者微调输送系统）
So what is another point?
I think is to have the hemodynamic condition that we had at the beginning of the procedure or at least similar to the patient's weight. I mean with good blood pressure, no 80 millimeters of mercury, but 110 or something like that.
血流动力学状况要与术前相仿，或者至少与病人的体重相符。血压良好，不会低到只有 80，而是 110 左右。
this is important. Because sometimes we can underestimate regurgitation. 因为有时会低估反流。
and if the heart rate, for example, is high, we can overestimate the gradient. 如果心率很高，可能会高估压差
I think the hemodynamics is important. 血流动力学很重要。
And presumably, you've taken the tension off. You're not holding the leaflet up when you are releasing and must, that's really important.
释放时不能把瓣叶拉起来，这也很重要。
we do a Metaraminol challenge. 间羟胺
So instead of improving blood pressure with fluids, I think it's better to increase peripheral resistance. 所以我认为与其用液体来改善血压，不如增加外周阻力。
Because surgeons do that when they do mitral valve repair and they go on the pump again, they do a challenge with Metaraminol.
因为外科医生在做二尖瓣修补术时会这样做，又上了泵，会用间羟胺。
So we do that as well in the cath lab before deploying. because that will increase the mitral regurgitation more significantly than the normal status. 在导管室在释放之前也用，比一般情况下能更增加返流量
It's the same as when we do an isometric exercise cycle to look at mitral regurgitation. 和做运动（增加后负荷？）来观察 MR 一样
二夹之前跨瓣压差 4，二夹之后还是 4。可能是二夹之前残余返流导致压差被高估
术后控制心室率，防止继发狭窄带来的负面效果
