体外膜肺氧合辅助经导管主动脉瓣植入治疗极低射血分数值的重度主动脉瓣狭窄
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摘要
目的探讨体外膜肺氧合(ECMO)辅助经导管主动脉瓣植入(TAVI)治疗极低左室射血分数(LVEF)值重度主动脉瓣狭窄患者的临床应用疗效。方法 2018年1月至2018年10月,71例高龄主动脉瓣狭窄患者接受TAVI术,其中4例极低LVEF值患者在ECMO辅助下完成TAVI手术。男性3例,女性1例,年龄60～74(68.5±3.2)岁,体质量47～76(65.4±6.4)kg。患者术前均为主动脉瓣重度狭窄,术前NYHA分级均为IV级。所有患者术前均行经胸超声及CT血管成像(CTA)检查,LVEF值分别为14%,20%,17%,22%。术中全麻及静脉-动脉ECMO(V-A ECMO)置管辅助下,3例行经股动脉TAVI,1例行经心尖TAVI。术后3例在手术室脱离ECMO辅助,1例ECMO辅助下转入ICU。结果 4例患者均手术成功,ECMO转流时间分别为116 min,60 min,38 min,84 h。瓣膜植入并撤离ECMO辅助后,3例LVEF值回升,1例无明显变化。瓣膜植入后最大压差(PGmax)降至3～7 mm Hg。瓣周返流为0～4 ml,4例患者均无Ⅲ度房室传导阻滞。术后患者胸闷气短等心功能不全表现均明显改善,无死亡及重要并发症。随访3～6个月,患者症状较前明显改善,B超提示LVEF均有所恢复,分别为40%,42%,48%及38%。与同期常规TAVI手术患者相比,术前LVEF值明显较低,但住院时间、随访3个月LVEF值无明显差异。结论 ECMO辅助TAVI手术治疗极低LVEF值重度主动脉瓣狭窄患者,能够提高手术安全性,且预后近期疗效满意。
Objective To investigate the clinical efficacy of TAVI with extracorporeal membrane oxygenation( ECMO) support in the treatment of severe aortic stenosis with extremely low left ventricular ejection fraction( LVEF). Methods From January 2018 to October 2018,71 cases of patients with aortic stenosis underwent transcatheter aortic valve implantation( TAVI) in our hospital. Of those patients,four with very low EF underwent TAVI with ECMO support. There were 3 males and 1 female,aged 60-74( 68.5±3.2)years old,weighting 47-76( 65.4± 6. 4) kg. All patients had severe aortic stenosis. Their heart function grades were all NYHA IV class. All patients underwent transthoracic echocardiography and CTA before procedures,and the EF values were 14%,20%,17% and22%,respectively. With general anesthesia and V-A ECMO through femoral approach,three patients underwent transfemoral TAVI,and one patient underwent transapical TAVI. ECMO was removed in three cases in the operating room,while one patient was transferred to the ICU with ECMO. Results All patients discharged from the hospital successfully. The duration of ECMO support was 116 min,60 min,38 min,and 84 h,respectively. After valve implantation and withdrawal from ECMO,the maximum pressure gradient( PGmax) decreased to 3-7 mm Hg,with the paravalvular regurgitation of 0 to 4 ml. No atrioventricular block was detected. No mortality or severe complications occurred. During 3-6 months' follow-up,the patients' physical conditions improved significantly. The LVEF increased to 40%,42%,48% and 38%,respectively at 3-month follow-up. Compared with patients underwent TAVI without ECMO support,their preoperative EF was significantly lower,but there was no significant difference in EF at 3-month follow-up.Conclusion TAVI with ECMO support could improve safety of the procedure and the short-term outcome was reliable in patients with severe aortic stenosis and extremely low EF.
Objective To investigate the clinical efficacy of TAVI with extracorporeal membrane oxygenation( ECMO) support in the treatment of severe aortic stenosis with extremely low left ventricular ejection fraction( LVEF). Methods From January 2018 to October 2018,71 cases of patients with aortic stenosis underwent transcatheter aortic valve implantation( TAVI) in our hospital. Of those patients,four with very low EF underwent TAVI with ECMO support. There were 3 males and 1 female,aged 60-74( 68.5±3.2)years old,weighting 47-76( 65.4± 6. 4) kg. All patients had severe aortic stenosis. Their heart function grades were all NYHA IV class. All patients underwent transthoracic echocardiography and CTA before procedures,and the EF values were 14%,20%,17% and22%,respectively. With general anesthesia and V-A ECMO through femoral approach,three patients underwent transfemoral TAVI,and one patient underwent transapical TAVI. ECMO was removed in three cases in the operating room,while one patient was transferred to the ICU with ECMO. Results All patients discharged from the hospital successfully. The duration of ECMO support was 116 min,60 min,38 min,and 84 h,respectively. After valve implantation and withdrawal from ECMO,the maximum pressure gradient( PGmax) decreased to 3-7 mm Hg,with the paravalvular regurgitation of 0 to 4 ml. No atrioventricular block was detected. No mortality or severe complications occurred. During 3-6 months' follow-up,the patients' physical conditions improved significantly. The LVEF increased to 40%,42%,48% and 38%,respectively at 3-month follow-up. Compared with patients underwent TAVI without ECMO support,their preoperative EF was significantly lower,but there was no significant difference in EF at 3-month follow-up.Conclusion TAVI with ECMO support could improve safety of the procedure and the short-term outcome was reliable in patients with severe aortic stenosis and extremely low EF.
引文
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[11]Husser O,Holzamer A,Philipp A,et al.Emergency and prophylactic use of miniaturized veno-arterial extracorporeal membrane oxygenation in transcatheter aortic valve implantation[J].Catheter Cardiovasc Interv,2013,82(4):E542-E551.
[12]Drews T,Pasic M,Buz S,et al.Elective femoro-femoral cardiopulmonary bypass during transcatheter aortic valve implantation:a useful tool[J].J Thorac Cardiovasc Surg,2013,145(3):757-763.
[13]Makdisi G,Makdisi PB,Wang IW.New horizons of non-emergent use of extracorporeal membranous oxygenator support[J].Ann Transl Med,2016,4(4):76.
[14]Trenkwalder T,Pellegrini C,Holzamer A,et al.Prophylactic ECMO during TAVI in patients with depressed left ventricular ejection fraction[J].Clin Res Cardiol,2018.[Epub ahead of print]
[15]Seco M,Forrest P,Jackson SA,et al.Extracorporeal membrane oxygenation for very high-risk transcatheter aortic valve implantation[J].Heart Lung Circ,2014,23(10):957-962.
[16]Singh V,Damluji AA,Mendirichaga R,et al.Elective or Emergency Use of Mechanical Circulatory Support Devices During Transcatheter Aortic Valve Replacement[J].J Interv Cardiol,2016,29(5):513-522.
[17]Ribeiro HB,Lerakis S,Gilard M,et al.Transcatheter aortic valve replacement in patients with low-flow,low-gradient aortic stenosis:the TOPAS-TAVI registry[J].J Am Coll Cardiol,2018,71(12):1297-1308.
[2]Smith CR,Leon MB,Mack MJ,et al.Transcatheter versus surgical aortic-valve replacement in high-risk patients[J].N Engl JMed,2011,364(23):2187-2198.
[3]Nishimura RA,Otto CM,Bonow RO,et al.2017 AHA/ACC focused update of the 2014 AHA/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 clinical practice guidelines[J].J Am Coll Cardiol,2017,70(2):252-289.
[4]Kapadia SR,Leon MB,Makkar RR,et al.5-year outcomes of transcatheter aortic valve replacement compared with standard treatment for patients with inoperable aortic stenosis(PARTNER1):a randomised controlled trial[J].Lancet,2015,385(9986):2485-2491.
[5]Vahanian A,Alfieri O,Andreotti F,et al.Guidelines on the management of valvular heart disease(version 2012):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]Kim EH,Lee SM,Lee JH,et al.Unexpected and fatal hemodynamic collapse during transapical transcatheter aortic valve implantation-a case report[J].Korean J Anesthesiol,2013,64(4):360-362.
[7]Huang J,Chen P,Hu X,et al.Aortic stenosis complicated by cardiogenic shock treated by transcatheter aortic valve replacement with extracorporeal membrane oxygenation:a case report[J].Medicine(Baltimore),2018,97(33):e11900.
[8]Makdisi G,Makdisi PB,Wang IW.Use of extracorporeal membranous oxygenator in transcatheter aortic valve replacement[J].Ann Transl Med,2016,4(16):306.
[9]Trenkwalder T,Pellegrini C,Holzamer A,et al.Emergency extracorporeal membrane oxygenation in transcatheter aortic valve implantation:a two-center experience of incidence,outcome and temporal trends from 2010 to 2015[J].Catheter Cardiovasc Interv,2017.[Epub ahead of print]
[10]Higuchi R,Tobaru T,Hagiya K,et al.Outcomes of patients requiring extracorporeal membrane oxygenation in transcatheter aortic valve implantation:a clinical case series[J].Heart Vessels,2018,33(11):1343-1349.
[11]Husser O,Holzamer A,Philipp A,et al.Emergency and prophylactic use of miniaturized veno-arterial extracorporeal membrane oxygenation in transcatheter aortic valve implantation[J].Catheter Cardiovasc Interv,2013,82(4):E542-E551.
[12]Drews T,Pasic M,Buz S,et al.Elective femoro-femoral cardiopulmonary bypass during transcatheter aortic valve implantation:a useful tool[J].J Thorac Cardiovasc Surg,2013,145(3):757-763.
[13]Makdisi G,Makdisi PB,Wang IW.New horizons of non-emergent use of extracorporeal membranous oxygenator support[J].Ann Transl Med,2016,4(4):76.
[14]Trenkwalder T,Pellegrini C,Holzamer A,et al.Prophylactic ECMO during TAVI in patients with depressed left ventricular ejection fraction[J].Clin Res Cardiol,2018.[Epub ahead of print]
[15]Seco M,Forrest P,Jackson SA,et al.Extracorporeal membrane oxygenation for very high-risk transcatheter aortic valve implantation[J].Heart Lung Circ,2014,23(10):957-962.
[16]Singh V,Damluji AA,Mendirichaga R,et al.Elective or Emergency Use of Mechanical Circulatory Support Devices During Transcatheter Aortic Valve Replacement[J].J Interv Cardiol,2016,29(5):513-522.
[17]Ribeiro HB,Lerakis S,Gilard M,et al.Transcatheter aortic valve replacement in patients with low-flow,low-gradient aortic stenosis:the TOPAS-TAVI registry[J].J Am Coll Cardiol,2018,71(12):1297-1308.