# Summary
Type: Essay
Publishing/Release Date: 2011/07/11
Publisher: BMJ-Heart
Link: https://heart.bmj.com/content/97/20/1717.1
通过减少潮气量和增加通气频率，降低抓捕难度。吸气时心脏朝外侧移动，呼气时朝内侧移动。
腺苷诱导停搏，但无法预测瓣叶所停留的位置。（原作者认为腺苷诱导 AVB，心房收缩而心室不动，瓣叶通常停在瓣环水平）
快速起搏不推荐，因为心房心室同时都在收缩，对瓣叶位置的影响不那么确定
诱导性胸内压升高（PEEP），减少回心血量，减小心腔大小，促进前后瓣对合（原作者没试过）
适合 TEER 的解剖，不需要使用这些 "技巧" 来安全地抓住二尖瓣叶；需要用到这些技巧的，可能不是一个很好的 TEER 病例
# Detail
# To the Editor
It was with great interest that we read the article by Borgia et al1 on their experience with an adenosine-induced asystole to facilitate the grasping of the mitral valve leaflets during a MitraClip procedure.
腺苷诱导的心脏停搏
We would like to comment on our experience with an adenosine-induced asystole and describe an alternative method using ventilation manoeuvres to ease the grasping of the mitral valve leaflets.
Borgia et al described their method in a situation where the first clip had already been placed and grasping of the leaflets for the second clip appeared to be difficult.
别人用在了第二枚夹子的捕获
We have also attempted to facilitate leaflet grasping using an adenosine-induced asystole when the positioning of the first clip proved difficult.
我们在第一枚夹子捕获时用这个方法
Unfortunately, this method did not lead to the desired outcome because, in our experience, the position of the valve leaflets during the induced asystole cannot be predicted and may not be appropriate for grasping.
发现效果不佳，因为无法预测（腺苷）停搏时瓣叶的位置
This appears to be different in the case described by Borgia et al, where the first clip may have limited leaflet movement during the induced asystole.
这一不同可能是因为在第二枚时应用，已经有第一枚对瓣叶的限制的话，情况会好一些
Currently, we anaesthetists facilitate the grasping of the leaflets by implementing various ventilation manoeuvres. Because all patients undergoing a MitraClip procedure are intubated and ventilated, the position of the heart is highly dependent on the actual ventilation phase.
目前，我们的麻醉师通过实施各种通气操作来促进瓣叶捕获。由于所有接受 MitraClip 手术的患者都进行了插管和通气，因此心脏的位置在很大程度上取决于实际的通气阶段。
A lateral shift of the heart can be observed in the transoesophageal echocardiography during inspiration and a corresponding medial shift during expiration.
吸气时经食道超声心动图可观察到心脏的外向移位，呼气时可观察到相应的内向移位。
By decreasing the tidal volume and increasing the ventilation frequency, these movements can be considerably reduced.
通过减少潮气量和增加通气频率，可以大大减少这些运动。
If grasping proves more difficult, manual ventilation is applied to achieve the desired heart position.
如果抓取比较困难，则采用手动通气来达到理想的心脏位置。
Pressure is carefully applied to the manual ventilation bag to achieve a superior position in which the leaflets can be grasped.
小心地对手动通气袋施加压力，以达到可以抓住传单的优越位置。
We believe that extremely close cooperation between interventional cardiologists and cardiac anaesthetists is crucial for the successful execution of MitraClip procedures.
# The Authors’ reply
We would like to thank N Patrick Mayr et al for their insightful comments.1
MitraClip implantation certainly requires an exciting team work with a key role for the anaesthetist who was in fact administering adenosine via a central line in the case we reported.
通过中心静脉注射腺苷
We agree with our colleagues that there are other manoeuvres which can be used to modify the spatial relation of the clip and the leaflets.
确实有其他操作可以优化夹子和瓣叶的空间关系
As adenosine induces an atrioventricular block, the atria are contracting while the ventricles are not contracting.
当腺苷诱发房室传导阻滞时，心房收缩而心室不收缩。
As a result, the leaflets usually come to rest at the height of the mitral annulus.
因此，瓣叶通常会停在二尖瓣环水平。
This can help to grasp mitral leaflets if they tend to slip off the clip arms due to, for instance, ruptured secondary chords.
如果二尖瓣叶因次级腱索断裂等原因容易从夹臂上滑落，这将有助于抓住二尖瓣叶。
This was the case in the patient we reported. 2
Rapid pacing seems to have less reproducible influence on the position of the leaflets because the atrium and ventricle may contract.
由于心房和心室可能会收缩，因此快速起搏对瓣叶位置的影响似乎不那么具有可重复性。
We share the experience of our colleagues that ventilation influences the spatial relation too. The clip is moving during respiration, mostly in the laterale medial direction.
通气会影响空间关系，夹子在呼吸过程中移动，主要是内外移动
A stop of the ventilation in the appropriate phase can help first to position the clip correctly and thereafter to grasp the leaflets at this location.
在适当的阶段停止通气有助于首先正确定位夹子，然后在此位置抓住瓣叶。
We hope that our report made clear that a lateralemedial movement of the clip was not the problem in our patient.
Additionally, an induced raise of the intrathoracic pressure can reduce the venous return to the heart and therefore reduce the size of the left ventricular cavity, thus helping the posterior and anterior mitral leaflet to come closer together.
此外，诱导性胸内压升高可减少心脏的静脉回流，从而缩小左心室腔的大小，从而帮助二尖瓣后叶和前叶靠拢。
This manoeuvre theoretically may have helped in this case. We do not have specific experience with this manoeuvre during MitraClip implantation but certainly appreciate the positive experience reported in this letter 1 with ventilation manoeuvres.
从理论上讲，这种做法可能对本案有所帮助。
我们没有在 MitraClip 植入术中使用这种方法的具体经验，但对本信 中报告的通气方法的积极经验表示赞赏。
We feel it is important to mention that in the vast majority of patients with suitable mitral valve anatomy, none of these ‘tricks’ is required to safely grasp the mitral leaflets
我们认为有必要提及的是，在绝大多数具有合适二尖瓣解剖结构的患者中，不需要使用这些 "技巧" 来安全地抓住二尖瓣叶
