体外膜肺氧合辅助下经导管主动脉瓣置换术的临床应用研究
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摘要
目的探讨体外膜肺氧合(ECMO)辅助下经导管主动脉瓣置换术(TAVR)治疗极高危主动脉瓣狭窄临床效果。方法 2018年于西京医院接受TAVR治疗极高危主动脉瓣狭窄病人2例,病人心脏射血分数(EF)<20%,手术过程中病人采用ECMO支持,观察ECMO辅助下TAVR的临床安全性和有效性。结果 2例ECMO辅助极高危病人均进行了TAVR手术,围手术期病人血流动力学稳定,于TAVR手术结束前撤除ECMO,手术时间分别为220、190min,DSA照射时间分别为38、26min,ECMO辅助时间分别为150、38min,随访中2例病人心脏功能明显改善,EF值明显提高。结论对于极高危主动脉瓣狭窄的病人在行TAVR时,ECMO辅助可保证病人围手术期的血流动力学稳定,避免恶性心率失常和循环崩溃的发生,提供有效心肺功能支持,应成为此类病人的首选治疗方式。
Objective To investigate the clinical effect of extracorporeal membrane oxygenation(ECMO)-assisted transcatheter aortic valve replacement(TAVR)in the treatment of patients with extremely high-risk aortic valve stenosis. Methods Two patients with extremely high-risk aortic valve stenosis who were treated in Xijing Hospital in 2018 were enrolled,with an ejection fraction(EF)of<20%.Both patients were given ECMO during surgery to observe the clinical effect and safety of ECMO-assisted TAVR. Results Both patients underwent ECMO-assisted TAVR had stable hemodynamic parameters during the perioperative period.ECMO was removed before TAVR ended.The time of operation for these two patients was 220,190 min respectively,the duration of digital subtraction angiography was 38,26 min respectively,and the duration of ECMO was 150,38 min respectively.Both patients had significant improvements in cardiac function and EF during follow-up.Conclusion In patients with extremely high-risk aortic valve stenosis,ECMO during TAVR can maintain stable hemodynamic parameters during the perioperative period,avoid malignant arrhythmia and circulatory collapse,and provide effective cardiopulmonary support.Therefore,it can be used as the preferred treatment for such patients.
Objective To investigate the clinical effect of extracorporeal membrane oxygenation(ECMO)-assisted transcatheter aortic valve replacement(TAVR)in the treatment of patients with extremely high-risk aortic valve stenosis. Methods Two patients with extremely high-risk aortic valve stenosis who were treated in Xijing Hospital in 2018 were enrolled,with an ejection fraction(EF)of<20%.Both patients were given ECMO during surgery to observe the clinical effect and safety of ECMO-assisted TAVR. Results Both patients underwent ECMO-assisted TAVR had stable hemodynamic parameters during the perioperative period.ECMO was removed before TAVR ended.The time of operation for these two patients was 220,190 min respectively,the duration of digital subtraction angiography was 38,26 min respectively,and the duration of ECMO was 150,38 min respectively.Both patients had significant improvements in cardiac function and EF during follow-up.Conclusion In patients with extremely high-risk aortic valve stenosis,ECMO during TAVR can maintain stable hemodynamic parameters during the perioperative period,avoid malignant arrhythmia and circulatory collapse,and provide effective cardiopulmonary support.Therefore,it can be used as the preferred treatment for such patients.
引文
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[2]VAHANIAN A,OTTO C M.Risk stratification of patients with aortic stenosis[J].Eur Heart J,2010,31(4):416-423.
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[7]刘庆荣,吴永健.经导管主动脉瓣膜置换心脏团队建设[J].心电与循环,2016,35(6):401-402,406
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[9]SCHYMIK G,SCHROFEL H,SCHYMIK J S,et al.Acute and late outcomes of Transcatheter Aortic Valve Implantation(TAVI)for the treatment of severe symptomatic aortic stenosis in patients at high-and low-surgical risk[J].J Interv Cardiol,2012,25(4):364-374.
[10]NISHIMURA R A,OTTO C M,BONOW R O,et al.2014AHA/ACC guideline for the management of patients with valvular heart disease:A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines[J].J Thorac Cardiovasc Surg,2014,148(1):e1-e132.
[11]PIAZZA N,KALESAN B,VAN MIEGHEM N,et al.A3-center comparison of 1-year mortality outcomes between transcatheter aortic valve implantation and surgical aortic valve replacement on the basis of propensity score matching among intermediate-risk surgical patients[J].JACC Cardiovasc Interv,2013,6(5):443-451.
[12]PATRICIO L.Comment on“1-year outcomes after transfemoraltranscatheter or surgical aortic valve replacement.Results from the Italian OBSERVANT study”[J].Rev Port Cardiol,2015,34(11):711-712.
[13]ROTMAN O M,KOVAROVIC B,SADASIVAN C,et al.Realistic vascular replicator for TAVR procedures[J].Cardiovasc Eng Technol,2018.
[14]BUCHANAN K D,ROGERS T,SHULTS C,et al.Successful transcatheter aortic valve replacement in an oversized 800mm(2)annulus and bicuspid aortic valve[J].Cardiovasc Revasc Med,2018.
[15]PFISTER R,WAHLERS T,BAER F M,et al.Utility of NT-pro-BNP in patients undergoing transapical aortic valve replacement[J].Clin Res Cardiol,2010,99(5):301-307.
[16]REHMAN H,KLEIMAN N S,KALRA A.Transcathetervalvular interventions in 2017:Some things old,some things new[J]!Curr Opin Cardiol,2018.
[17]ANNABI M S,CLISSON M,CLAVEL M A,et al.Workup and management of patients with paradoxical low-flow,lowgradient aortic stenosis[J].Curr Treat Options Cardiovasc Med,2018,20(6):49.
[18]HUI S,GOOLEY R,RASHID H N,et al.Transcatheteraortic valve replacement and atrial fibrillation:Impact of antithrombotic strategy on clinical outcomes[J].Heart Lung Circ,2018.
[19]MONDAL S,ASHISH K,BANDYOPADHYAY D,et al.Role of TAVR in pure native valvular aortic regurgitation:A new paradigm[J].Int J Cardiol,2018.
[20]LAZAR H L.One-year outcomes in TAVR patients:Dying from versus dying with aortic stenosis[J].J Card Surg,2018,33(5):250-251.
[21]DOLMATOVA E,MOAZZAMI K,COCKE T P,et al.Extracorporeal membrane oxygenation in transcatheter aortic valve replacement[J].Asian Cardiovasc Thorac Ann,2017,25(1):31-34.
[22]CRIBIER A,ELTCHANINOFF H,BASH A,et al.Percutaneous transcatheter implantation of an aortic valve prosthesis for calcific aortic stenosis:First human case description[J].Circulation,2002,106(24):3006-3008.
[23]BAVARIA J E,SZETO W Y,ROCHE L A,et al.The progression of a transcatheter aortic valve program:Adecision analysis of more than 680patient referrals[J].Ann ThoracSurg,2011,92(6):2072-2077.
[24]LANGE R,SCHREIBER C,GOTZ W,et al.First successful transapical aortic valve implantation with the CorevalveReval-ving system:A case report[J].Heart Surg Forum,2007,10(6):e478-479.
[25]WILLSON A,TOGGWEILER S,WEBB J G.Transfemoral aortic valve replacement with the SAPIEN XT valve:Step-bystep[J].Semin Thorac Cardiovasc Surg,2011,23(1):51-54.
[26]BANJAC I,PETROVIC M,AKAY M H,et al.Extracorporeal membrane oxygenation as a procedural rescue strategy for transcatheteraortic valve replacement cardiac complications[J].ASAIO J,2016,62(1):e1-4.
[27]MAKDISI G,MAKDISI P B,WANG I W.New horizons of non-emergent use of extracorporeal membranous oxygenator support[J].Ann Transl Med,2016,4(4):76.
[28]UEHARA K,MINAKATA K,SAITO N,et al.Use of extracorporeal membrane oxygenation in complicated transcatheter aortic valve replacement[J].Gen Thorac Cardiovasc Surg,2017,65(6):329-336.
[2]VAHANIAN A,OTTO C M.Risk stratification of patients with aortic stenosis[J].Eur Heart J,2010,31(4):416-423.
[3]IUNG B,BARON G,BUTCHART E G,et al.A prospective survey of patients with valvular heart disease in Europe:The Euro heart survey on valvular heart disease[J].Eur Heart J,2003,24(13):1231-1243.
[4]IUNG B,CACHIER A,BARON G,et al.Decision-making in elderly patients with severe aortic stenosis:Why are so many denied surgery[J]?Eur Heart J,2005,26(24):2714-2720.
[5]VAHANIAN A,ALFIERI O,ANDREOTTI F,et al.Guidelines on the management of valvular heart disease(version2012):The joint task force on the management of valvular heart disease of the European Society of Cardiology(ESC)and the European Association for Cardio-Thoracic Surgery(EACTS)[J].Eur J Cardiothorac Surg,2012,42(4):S1-S44.
[6]D'ERRIGO P,BARBANTI M,RANUCCI M,et al.Transcatheter aortic valve implantation versus surgical aortic valve replacement for severe aortic stenosis:Results from an intermediate risk propensity-matched population of the Italian OBSERVANT study[J].Int J Cardiol,2013,167(5):1945-1952.
[7]刘庆荣,吴永健.经导管主动脉瓣膜置换心脏团队建设[J].心电与循环,2016,35(6):401-402,406
[8]张昊,吴永健.经导管主动脉瓣置换术的进展与未来[J].中国循环杂志,2016,31(7):711-714.
[9]SCHYMIK G,SCHROFEL H,SCHYMIK J S,et al.Acute and late outcomes of Transcatheter Aortic Valve Implantation(TAVI)for the treatment of severe symptomatic aortic stenosis in patients at high-and low-surgical risk[J].J Interv Cardiol,2012,25(4):364-374.
[10]NISHIMURA R A,OTTO C M,BONOW R O,et al.2014AHA/ACC guideline for the management of patients with valvular heart disease:A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines[J].J Thorac Cardiovasc Surg,2014,148(1):e1-e132.
[11]PIAZZA N,KALESAN B,VAN MIEGHEM N,et al.A3-center comparison of 1-year mortality outcomes between transcatheter aortic valve implantation and surgical aortic valve replacement on the basis of propensity score matching among intermediate-risk surgical patients[J].JACC Cardiovasc Interv,2013,6(5):443-451.
[12]PATRICIO L.Comment on“1-year outcomes after transfemoraltranscatheter or surgical aortic valve replacement.Results from the Italian OBSERVANT study”[J].Rev Port Cardiol,2015,34(11):711-712.
[13]ROTMAN O M,KOVAROVIC B,SADASIVAN C,et al.Realistic vascular replicator for TAVR procedures[J].Cardiovasc Eng Technol,2018.
[14]BUCHANAN K D,ROGERS T,SHULTS C,et al.Successful transcatheter aortic valve replacement in an oversized 800mm(2)annulus and bicuspid aortic valve[J].Cardiovasc Revasc Med,2018.
[15]PFISTER R,WAHLERS T,BAER F M,et al.Utility of NT-pro-BNP in patients undergoing transapical aortic valve replacement[J].Clin Res Cardiol,2010,99(5):301-307.
[16]REHMAN H,KLEIMAN N S,KALRA A.Transcathetervalvular interventions in 2017:Some things old,some things new[J]!Curr Opin Cardiol,2018.
[17]ANNABI M S,CLISSON M,CLAVEL M A,et al.Workup and management of patients with paradoxical low-flow,lowgradient aortic stenosis[J].Curr Treat Options Cardiovasc Med,2018,20(6):49.
[18]HUI S,GOOLEY R,RASHID H N,et al.Transcatheteraortic valve replacement and atrial fibrillation:Impact of antithrombotic strategy on clinical outcomes[J].Heart Lung Circ,2018.
[19]MONDAL S,ASHISH K,BANDYOPADHYAY D,et al.Role of TAVR in pure native valvular aortic regurgitation:A new paradigm[J].Int J Cardiol,2018.
[20]LAZAR H L.One-year outcomes in TAVR patients:Dying from versus dying with aortic stenosis[J].J Card Surg,2018,33(5):250-251.
[21]DOLMATOVA E,MOAZZAMI K,COCKE T P,et al.Extracorporeal membrane oxygenation in transcatheter aortic valve replacement[J].Asian Cardiovasc Thorac Ann,2017,25(1):31-34.
[22]CRIBIER A,ELTCHANINOFF H,BASH A,et al.Percutaneous transcatheter implantation of an aortic valve prosthesis for calcific aortic stenosis:First human case description[J].Circulation,2002,106(24):3006-3008.
[23]BAVARIA J E,SZETO W Y,ROCHE L A,et al.The progression of a transcatheter aortic valve program:Adecision analysis of more than 680patient referrals[J].Ann ThoracSurg,2011,92(6):2072-2077.
[24]LANGE R,SCHREIBER C,GOTZ W,et al.First successful transapical aortic valve implantation with the CorevalveReval-ving system:A case report[J].Heart Surg Forum,2007,10(6):e478-479.
[25]WILLSON A,TOGGWEILER S,WEBB J G.Transfemoral aortic valve replacement with the SAPIEN XT valve:Step-bystep[J].Semin Thorac Cardiovasc Surg,2011,23(1):51-54.
[26]BANJAC I,PETROVIC M,AKAY M H,et al.Extracorporeal membrane oxygenation as a procedural rescue strategy for transcatheteraortic valve replacement cardiac complications[J].ASAIO J,2016,62(1):e1-4.
[27]MAKDISI G,MAKDISI P B,WANG I W.New horizons of non-emergent use of extracorporeal membranous oxygenator support[J].Ann Transl Med,2016,4(4):76.
[28]UEHARA K,MINAKATA K,SAITO N,et al.Use of extracorporeal membrane oxygenation in complicated transcatheter aortic valve replacement[J].Gen Thorac Cardiovasc Surg,2017,65(6):329-336.