• 经导管主动脉瓣置换术中循环崩溃单中心经验分析
  • 方毅.经导管主动脉瓣置换术中循环崩溃单中心经验分析[J].内科急危重症杂志,2021,27(6):453-456
    DOI:10.11768/nkjwzzzz20210603
    中文关键词:  主动脉瓣狭窄  经导管主动脉瓣置换术  循环崩溃
    英文关键词:
    基金项目:
    作者单位E-mail
    方毅 中国人民解放军北部战区总医院心内科 xukai2001@sina.com 
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    中文摘要:
          摘要 目的:总结经导管主动脉瓣置换术(TAVR)治疗的主动脉瓣狭窄(AS)患者术中发生循环崩溃可能的原因、危险因素及有效的处理方法。方法:本研究为单中心回顾性研究,选取2016年5月 2021年8月北部战区总医院心内科住院行TAVR术中发生循环崩溃的AS患者。记录患者术中循环崩溃的发生情况、处理方式及随访结果,并逐一分析病例特点。结果:完成TAVR手术200例,术中发生循环崩溃10例(5%),预扩张前(2例,20%)、预扩张后(3例,30%)、瓣膜植入中及植入后(5例,50%)均有发生;其中5例(50%)左室射血分数(LVEF)≤40%,最低达23%;左室舒张末期内径(LVDD)≤42mm合并室间隔(IVS)≥13mm共3例(30%);陈旧性心肌梗死2例(20%)。分析发生循环崩溃可能的原因:冠状动脉闭塞2例(20%),自杀左心室2例(20%),预扩后大量反流2例(20%),对瓣膜释放时冠脉缺血无法耐受2例(20%),心功能过差无法耐受麻醉2例(20%);其中转外科开胸1例(10%),心肺复苏(CPR)5例(50%),应用体外循环或体外膜肺氧合(ECMO)3例(30%),快速球囊扩张或植入瓣膜6例(60%),单纯大量血管活性药1例(10%)。住院期间死亡1例(10%);随访1、3及6个月(8例入窗),9例均存活。结论:循环崩溃的发生率并不低,低LVEF、小心室并心肌肥厚、心肌梗死病史可能是术中发生循环崩溃的高危因素;冠脉堵塞、球囊扩张后大量反流、自杀左心室、心功能过差无法耐受麻醉可能是循环崩溃的原因;持续有效的心肺复苏,迅速置入瓣膜及循环辅助装置是使血流动力学恢复的主要措施;出现循环崩溃的患者经积极处理预后较好。
    英文摘要:
          Abstract Objective: To summarize the possible causes, risk factors and effective management of circulatory collapse in patients with aortic stenosis (AS) treated by transcatheter aortic valve replacement (TAVR). Methods: This study was a single center retrospective study. From May 2016 to August 2021, As patients with circulatory collapse during TAVR operation hospitalized in the Department of Cardiology of the General Hospital of Northern Theater Command were selected. The occurrence, treatment and follow-up results of intraoperative circulatory collapse were recorded, and the characteristics of cases were analyzed. Results: A total of 200 cases of TAVR were completed, and 10 cases (5%) had circulatory collapse during operation, which occurred before predilation (2 cases, 20%), after predilation (3 cases, 30%), during and after valve implantation (5 cases, 50%); among them, 5 cases (50%) had left ventricular ejection fraction (LVEF) ≤40%, and the lowest was 23%; there were 3 patients (30%) with left ventricular end diastolic diameter ≤42mm and ventricular septum ≥13mm; old myocardial infarction occurred in 2 cases (20%). The possible causes of circulatory collapse were analyzed: coronary artery occlusion in 2 cases (20%), suicidal left ventricle in 2 cases (20%), massive regurgitation after predilation in 2 cases (20%), coronary ischemia during valve release in 2 cases (20%), and poor cardiac function in 2 cases (20%); among them, 1 case (10%) was converted to surgical thoracotomy, 5 cases (50%) were given CPR, 3 cases (30%) were treated with cardiopulmonary bypass or ECMO, 6 cases (60%) were treated with rapid balloon dilatation or valve implantation, and 1 case (10%) was treated with a large amount of vasoactive drugs. During hospitalization, 1 case (10%) died; after follow-up, 9 cases survived at 1st month, 3rd month and 6th month (8 cases entering the time window). Conclusion: The incidence of circulatory collapse is not low. Low LVEF, small left ventricle with hypertrophy and history of myocardial infarction are the possible high risk factors of circulatory collapse during operation. Coronary artery occlusion, massive regurgitation after balloon dilatation, suicidal left ventricle, poor cardiac function and intolerable anesthesia are the possible causes of circulatory collapse. Continuous and effective cardiopulmonary resuscitation, rapid implantation of valves and circulation auxiliary devices are the main measures to restore hemodynamics. The prognosis of patients with circulatory collapse is better after active treatment.