经导管主动脉瓣植入术的麻醉管理

背景 对于有临床症状的严重主动脉瓣狭窄患者而言,实施标准主动脉瓣置换术(surgical aortic valve replacement,SAVR)可能有禁忌或高风险.经导管主动脉瓣植入术(transcatheter aortic valve implantation,TAVI)是一种可供选择的治疗方式. 目的 阐述TAVI围手术期的麻醉管理与监测. 内容 实施TAVI患者的术前评估、风险分级、麻醉的准备和麻醉方法的选择以及行TAVI术中和术后监测管理. 趋向 设备更新与开发、进一步的研究和经验的积累将促使TAVI成为一种在心脏导管室开展的经皮入路微创手术,以后可以更加广泛地应用于有手术禁忌、合并并发症以及严重、不稳定心脏病的危重主动脉瓣狭窄患者.     

A difficult case of retrieval of an aortic valve and balloon during a transcatheter aortic valve implantation

INTRODUCTIONTranscatheter aortic valve implantation (TAVI) represents an emerging therapy for valve replacement in patients not suitable for traditional open repair. As awareness of the procedure grows, case numbers are increasing worldwide. Though this procedure represents a less invasive approach to aortic valve replacement, it is not without complications.PRESENTATION OF CASEThis case presentation describes a serious, previously unreported, complication incurred in an 83-year-old male in whom TAVI was attempted. During deployment of the valve at the aortic annulus, both the valve and accompanying balloon embolised into the thoracic aorta and this was further complicated by migration of the balloon into the abdominal aorta and an aortic dissection. The false lumen of the dissection at the level of the infrarenal aorta was tacked to the aortic adventitial wall using interrupted sutures through a laparotomy. A completion angiogram demonstrated that a flow limited dissection did extend up to both common iliac arteries. This was managed with balloon-expandable covered stents deployed in both common iliac arteries with satisfactory outcome.DISCUSSIONThis case occurred as a combination of multiple factors that include lack of burst pacing and poor timing of the balloon inflation. The aortic balloon and the valve had to be removed urgently to avoid ventricular embolization of these structures that can result in a fatal situation.CONCLUSIONThis case presentation describes the management of these complications using a combined open and endovascular approach in a well-equipped hybrid operating theatre, resulting in the patient survival.     

Peripartum anesthetic management of patients with aortic valve stenosis: a retrospective study and literature review

BackgroundAnesthetic management of parturients with aortic stenosis is controversial. Early studies suggest maternal mortality was related to cardiac condition and anesthetic care. In this report, management of parturients with moderate or severe aortic stenosis in two institutions is compared, and published cases are reviewed.MethodsPeripartum anesthetic management of all parturients with moderate or severe aortic stenosis who gave birth between 1990 and 2005 at our institutions, is described. Patients with mild or non-valvular aortic stenosis were excluded.ResultsThere were 12 parturients, six with moderate and six with severe aortic stenosis. Two patients with moderate aortic stenosis were New York Heart Association (NYHA) classification II, the others were asymptomatic. Five patients with severe aortic stenosis were symptomatic (NYHA classification II or III). Two patients with moderate and three with severe aortic stenosis underwent cesarean delivery; epidural anesthesia was used for two. Two patients with moderate and all with serious aortic stenosis were observed postpartum for 24 to 48 h in a high-dependency unit. There were no severe maternal or neonatal complications.ConclusionsCarefully titrated regional analgesia is usually well tolerated in patients undergoing vaginal or cesarean delivery even in the presence of severe aortic stenosis. Standard monitoring is usually adequate for vaginal delivery, but invasive monitoring may facilitate management in some patients. An arterial line allows close monitoring of systemic blood pressure. Facilities for close 24-48-h post-partum observation should be available. A multidisciplinary approach is needed.     

Aortic valve replacement for aortic regurgitation in a patient with antiphospholipid antibody syndrome

Cardiac manifestations of antiphospholipid antibody syndrome (APLS) comprise a major complication. Herein we report our surgical treatment of aortic regurgitation in a patient with APLS. A 61-year-old woman was referred to our hospital with symptoms of congestive heart failure. Systemic lupus erythematosus had been diagnosed at the age of 36, and immunosuppressive therapy has been continuously performed. APLS was also diagnosed at the age of 55, after which cardiomegaly was noted on chest radiographs and aortic regurgitation was evident on echocardiography. Although immunosuppressive therapy had been continued, cardiac symptoms began to develop. With a presumed diagnosis of valvular disease associated with autoimmune disease, the aortic valve was replaced with a bioprosthesis. Noninfective endocarditis was confirmed in the excised specimen and was likely involved in APLS. The patient was discharged on postoperative day 26 without complications.     

Larsen syndrome and its anaesthetic considerations

Larsen syndrome is a complex syndrome with genetic heterogeneity, and with both autosomal dominant and autosomal recessive patterns of inheritance. It is characterized by congenital dislocation of joints, flat faces and complicated by issues relating to respiratory, cardiac, musculoskeletal and central nervous systems. This report describes the anaesthetic management of two patients with Larsen syndrome. The first case is a 4-year-old patient who had cervical cord compression secondary to cervical instability and who was scheduled for anterior corpectomy with fusion of cervical vertebrae and placement of halo frame. This patient had transient loss of evoked potentials during positioning and a stormy postoperative course requiring reintubation and a prolonged stay in the intensive care unit. The second case is a 22-month-old child who was scheduled for a repeat posterior cervical spinal fusion due to failure of her initial fusion procedure. This patient had an uneventful perioperative course. Relevant anaesthetic issues in patients with Larsen syndrome are discussed.     

Transapical minimally invasive aortic valve implantation; the initial 50 patients

OBJECTIVE: To evaluate the feasibility of minimally invasive transapical beating heart aortic valve implantation (TAP-AVI) for high-risk patients with aortic stenosis. METHODS: TAP-AVI was performed via a small anterolateral minithoracotomy in 50 patients from February 2006 to March 2007. A balloon expandable transcatheter xenograft (Edwards SAPIEN THV, Edwards Lifesciences, Irvine, CA, USA) was used. Mean age was 82.4+/-5 years and 39 (78%) were female. Implantation was performed in a hybrid operative theatre using fluoroscopic and echocardiographic visualization. Average EuroSCORE predicted risk for mortality was 27.6+/-12%. Seven (14%) patients were re-operations with patent bypass grafts. RESULTS: TAP-AVI (13 patients 23 mm and 37 patients 26 mm) was successfully performed on the beating heart under temporary rapid ventricular pacing in 47 (94%) patients, and implantation was performed completely off-pump in 34 (68%) patients. Three patients required early conversion; two of them were successfully discharged. There was no prosthesis migration or embolization observed. Echocardiography revealed good hemodynamic function in all and minor incompetence in 23 patients, mostly paravalvular, without any signs of hemolysis. Mortality was due to the overall health condition and non-valve related in all patients. Actuarial survival at 1 month, 6 months and 1 year was 92+/-3.8%, 73.9+/-6.2% and 71.4+/-6.5%, respectively. CONCLUSIONS: Transapical minimally invasive aortic valve implantation is feasible using an off-pump technique. Good results have been achieved in the initial 50 patients, especially when considering the overall high-risk profile of these patients.     

Health-related quality-of-life after transapical transcatheter aortic valve implantation

Abstract

Purpose. Transcatheter aortic valve implantation (TA-TAVI) is a well-established treatment for aortic valve stenosis in high-risk patients and indications have been continuously expanding to also include intermediate-risk patients. However, in low-risk patients, experiences are still sparse and although clinical outcomes have been shown favorable results, HRQoL has remained unexplored. The aim of this report was to describe the long-term health-related quality-of-life (HRQoL) in low-risk patients randomized to TA-TAVI or surgical aortic valve replacement (SAVR). Methods. In a prospective, randomized trial, patients with aortic valve stenosis were randomized to either TA-TAVI or SAVR. TA-TAVI was performed through a mini thoracotomy with the introduction of prosthesis via the apex of the heart and antegradely advancement over the pre-dilated native valve. SAVR was performed during cardiopulmonary bypass with resection of the native valve and replacement with a prosthesis valve through a median sternotomy. Afterwards, patients were followed yearly with echocardiography and HRQoL assessment. Results. A total of 58 patients were included; 29 patients for TA-TAVI and 29 patients for SAVR. The only difference in HRQoL was found in the physical component summary after 1 year; 44?±?9 in the TA-TAVI group compared with 36?±?9 in the SAVR group, p?=?.03. There were no differences in any of the remaining timepoints in neither physical nor mental component summary, p?=?.19 and p?=?.98, respectively, and there were no differences in survival during the 5 years. Conclusions. In low-risk patients with aortic valve stenosis undergoing TA-TAVI, no differences appeared in HRQoL compared with SAVR during a 5-year follow-up period.     

使用J-ValveTM系统经心尖导管主动脉瓣置换术治疗高危主动脉瓣关闭不全患者:1年随访中期结果

目的分析使用J-Valve^TM系统行经心尖主动脉瓣置换术(transapical aortic valve implantation,TA-TAVI)治疗高危主动脉瓣关闭不全患者的中期临床预后。方法回顾性收集2016年9月至2020年6月在浙江大学医学院附属第二医院连续收治的25例使用J-Valve^TM系统经心尖TAVI治疗的主动脉瓣关闭不全患者资料,分析总结术后全因病死率,不良事件发生率及心功能改善情况。结果25例中男19例,年龄范围为59~83岁,平均年龄(72.3±27.11)岁。经胸超声心动图检查评估重度主动脉瓣反流比例达88%,心功能(NYHA分级)Ⅲ-Ⅳ级占92%。患者最常合并的基础病为高血压(占68%),合并冠心病5例,既往心脏手术史3例,术前胸外科医师协会(the Society of Thoracic Surgeons,STS)评分为1.511%~27.674%,中位STS评分为4.27(2.914~6.033)%。手术均成功置入J-Valve瓣膜,无中转开胸。术后置入永久起搏器2例,CRRT 1例,中度及以上瓣周漏1例。手术早期疗效可观,不良事件发生率低,中期随访心功能及心室逆重构也有持续改善表现。结论对于高危主动脉瓣关闭不全患者使用J-Valve^TM系统行经心尖TAVI可获得较好的围手术期安全性及中期预后。     

The left axillary artery — a new approach for transcatheter aortic valve implantation

Objective: Transcatheter aortic valve implantation (TAVI) is an alternative treatment for aortic stenosis in selected cases, but requires appropriate vascular access. We report our initial clinical experience with a novel endovascular approach for TAVI. Methods: Between 1 April 2007 and 31 August 2008, 48 patients underwent TAVI at our institution. Of these, eight patients (17%) were deemed to be best served through direct surgical exposure of the left axillary artery rather than a trans-femoral or TA approach. Results: Procedural success was achieved in seven of eight cases. In one patient the axillary artery was too small to accept the 18 French sheath. In the remaining seven, the device was implanted without major complication and with only trivial paravalvular aortic regurgitation. The in-hospital mortality was 0%. The 30-day mortality was 12.5% (one patient). There was one localised dissection at the origin of the vertebral artery. There was one late pericardial effusion and a permanent pacemaker was implanted in five patients. Conclusions: TAVI can be performed through a left axillary artery approach. This is a technically simple procedure and, in this small initial clinical experience, was performed with encouraging results. It is a realistic option in patients in whom neither the trans-femoral or trans-apical approaches are optimal.     

The Larsen Syndrome with multiple congenital dislocations and a normal facies

Summary Details of four children with congenital skeletal abnormalities are reported. In one, typical of the Larsen Syndrome, an autosomal dominant pattern of inheritance is demonstrated. The three others show marked skeletal abnormalities similar to those seen in the Larsen Syndrome but without the usual characteristic facial features.

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Résumé Observations détaillées de quatre enfants porteurs d'anomalies squelettiques congénitales. Chez l'un d'entre eux, présentant un syndrome de Larsen typique, on a pu faire la preuve d'une transmission héréditaire autosomique dominante. Les trois autres étaient atteints d'anomalies squelettiques semblables à celles du syndrome de Larsen, mais sans les habituelles modifications caractéristiques du faciès.

     

Aortic endarterectomy: a useful technique to utilize for aortic valve replacements in hostile aorta

Calcified aorta poses a significant technical challenge in the performance of surgical aortic valve replacement (AVR). Aortic endarterectomy is a less utilized approach and is suitable in select cases for aortic decalcification during AVR. Here, we report a case of calcified ascending aorta who underwent ascending aortic endarterectomy and AVR with the technical details of the procedure.Electronic supplementary materialThe online version of this article (10.1007/s12055-020-01014-y) contains supplementary material, which is available to authorized users.     

Direct transaortic transcather valve-in-valve implantation into a mechanical aortic valve prosthesis during left ventricular assist device implantation: description of a surgical technique

The presence of a mechanical aortic valve prosthesis is considered a relative contraindication for left ventricular assist device implantation (LVAD) due to the occurrence of thromboembolic events. Five patients were operated on for LVAD implantation with status post mechanical aortic valve implantation (n = 3 with status post Bentall procedure). After removal of the leaflets, a transcatheter balloon-expandable valve was placed within the mechanical ring in all patients. Three patients were discharged from hospital with a maximum follow-up of 3.3 years. Transaortic transcatheter valve implantation into a mechanical aortic valve during LVAD implantation is a feasible option. It reduces operative times and might also prevent thromboembolic events.     

Aortic valve replacement in predominant aortic stenosis: What is an appropriate size valve?

Objective This is a retrospective analysis of 94 patients who underwent aortic valve replacement for predominant aortic stenosis between January 1998 and December 2004. Patients and Methods Age ranged from 16 to 70 years (mean 43.2±13.2 years). 73 were male (77.7%). Etiology was rheumatic in 71 (75.5%) and degenerative in 23 (24.5%) patients. On transthoracic echocardiography, the diameter of the aortic annulus ranged from 19 mm to 36mm (mean 28.5±3.0 mm) and the peak systolic gradients ranged from 54 mm to 174 mm of Hg (mean of 109.8±28.8 mmHg). Aortic regurgitation was absent or mild in 76 patients (80.8%) and moderate in rest. A mechanical valve was implanted in 66 patients (70.2%) and a tissue valve in 28 patients (29.8%). Valves of size 23 mm or more were implanted in 75 patients (80%). A valve of 25 mm or larger was implanted in 55 patients (54.3%). Results There were no early deaths. Two patients required permanent pacemaker implantation for complete heart block in the immediate postoperative period. Prosthetic valve thrombosis in one patient was relieved by thrombolysis. Anticoagulant related hemorrhage was seen in two patients. One patient underwent homograft aortic valve replacement for prosthetic valve endocarditis nine months after surgery. Conclusion Isolated aortic valve replacement in patients with predominant aortic stenosis can be performed safely by implanting an adequately large sized prosthesis, without root enlargement in a large majority of patients.     

Endocarditis after transfemoral aortic valve implantation in a patient with Osler-Weber-Rendu syndrome

Transcatheter aortic valve implantation (TAVI) was introduced five years ago (2007) as an alternative treatment for patients with severe aortic stenosis, who are considered at too high a risk for surgical replacement. Few cases of postoperative infection by TAVI device are reported in the literature. We report the case of a patient with Osler-Weber-Rendu (OWR) syndrome, in which the TAVI procedure was preferred at the outset to avoid the risk of bleeding. He was diagnosed with endocarditis on the TAVI device one year later; he then underwent an uneventful surgical aortic valve replacement. In these complex clinical cases it is difficult to determine a 'gold standard' treatment and the possibility of offering patients both the percutaneous treatment and the surgical replacement appears to be desirable. Correction of the valve disease improves the outcome, reducing the episodes of haemorrhage and the need for blood transfusions.     

主动脉瓣置换术后SAM现象机制及相关因素的探讨

目的探讨主动脉瓣置换术后SAM现象的发生机制并对其相关因素进行分析,旨在进一步认识此现象.方法 48例严重主动脉瓣狭窄病人,男26例,女22例;年龄20～58岁.行主动脉瓣置换术后1周内复查超声心动图,以是否出现SAM现象分成两组,对左室舒张末期内径、收缩末期内径、左室流出道内径、室间隔和左室后壁厚度、左室流出道射流速度及压力阶差进行对比.结果无手术死亡.9例左室流出道流速显著增加(大于2.5 m/s),其中6例出现了SAM现象.除左室后壁对比差异无显著性外,其余指标对比差异均具显著性(P＜0.05或0.01).结论主动脉瓣置换术后出现SAM现象与左室流出道流速和压力阶差增大有直接关系,而小左室舒张末期内径、收缩末期内径、流出道内径及增厚的室间隔是SAM现象的主要病理解剖基础.