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    Home > Active Ingredient News > Anesthesia Topics > Anesthetic treatment of aortic valve replacement by the tip of the heart through catheterized aortic valve replacement

    Anesthetic treatment of aortic valve replacement by the tip of the heart through catheterized aortic valve replacement

    • Last Update: 2020-06-21
    • Source: Internet
    • Author: User
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    The traditional surgical method of aortic valve replacement is an in vitro circulation assisted by a mid-middle incision of the sternumFor patients withdiabetes, renal insufficiency, patients with advanced age and/ordiabetes, kidney insufficiency, often because of poor overall health, traditional surgery is not availableIt is reported that up to 30% to 40% of patients with aortic valve lesions receive medication because they cannot tolerate surgery, seriously affecting their quality of lifethrough catheter aortic valve replacement(TAVI) as a novel surgical method that has emerged in recent years, mainly through the aorta (femoral artery, collarbone artery, artery) approach, because of small trauma, rapid postoperative recovery by surgeons and elderly patientsis more direct than the aortic artery route, and can overcome the peripheralvascularpoor conditions and other obstacles, with the advantages not available through the aortic artery pathHowever, due to the need to induce pulseless ventricular tachycardia, theof anaestheticmanagement is higherZhejiang University Medical College affiliated first hospital recently completed 3 cases of heart-to-heart TAVI, the anaesthetic experience is summarized below1 Clinical Data 1.1 Case Information Cases 1, female, 74 years old, weight 43 kg, diagnosis the main arterial valve closure incomplete, hypertension disease, second-tip valve reflux (mild) Ultrasound examination of the chest heart: aortic internal diameter (AO) 33 mm, chamber space thickness (IVSd) 8mm, left ventricle diastopathy (LVDd) 52mm, left ventricular shortening fraction (FS) 0.27, heart rate 92 times/min, left ventricular diameter (LA) 24mm, left ventricular wall thickness (LVWd) 8mm, left Ventricular shrinkage (LVDs) 38mm, left ventricular blood fraction (LVEF) 0.52, right ventricular diameter (RV) 11mm, contraction period by aortic valve peak flow rate of 2.0m/s, peak pressure difference of 16mmHg (1mmHg x 0.133kPa), valve area 1.47cm2, 24mm diameter ring electrocardiogram examination: sinus tachycardia, I degree chamber conduction block, frequent room early fight, when the short burst chamber tachycardia; NYHA Cardiofunction Grade III, American Society of Anesthesiologists (ASA) Grade III No obvious abnormalities were observed in blood routine, liver and kidney function, and blood clotting function To be undergoing a heart tip TAVI under general anaesthetic cases 2, male, 70 years old, weight 68 kg, diagnosis main arterial valve stenosis with closure incomplete, mild reflux of the two-tip valve Chest heart ultrasound examination: AO33mm, IVSd 16mm, LVDd 49mm, heart rate 65 times/min, FS0.40, LA 38mm, LVPWd 14mm, LVDs 30mm, LVEF001, aortic valve multiple calcification, two-lod aortic valve not excluded, severe stenosis medium-sized closed, left ventricular larger ventricle, left ventricle Back wall reverse movement, hypertension heart disease combined with the possibility of thickening of cardiomyopathy, left ventricle diastolic function decreased, two and three tip valves mild reflux; coronary artery CT vascular angiography examination (CTA) reconstruction: coronary artery multiple calcification plaque forming with the corresponding tube cavity with varying degrees of stenosis, aortic and arch part branch, aortic valve region multiple calcification, left ventricular enlargement Coronary artery angiography examination: right coronary artery whole tube wall irregular, near 30% stenosis, middle section more than 30% stenosis, local tumor-like expansion, remote section 40% stenosis; The near section is 30% narrow, the middle section is 50% narrow, the far section is 30% narrow, the second diagonal branch opening is 50% narrow, the left swing branch opening is 60% narrow, the middle section is 30% narrow, and the near middle section is 80% narrow MRI examination: side ventricular side, half-egg center and the frontal foalcortex on both sides of the frontal cortex multiple ischemia, geriatric brain changes electrocardiogram examination: sinus heart rate, high left ventricle voltage, occasional ventricular early fight, ST-T wave change NYHA Heart Function Rating LEVEL III, ASA Rating IV Blood routine, liver function, blood clotting function test did not show abnormal, urea 7.47mmol/L, creatinine 105 mmol/L To be undergoing a heart tip TAVI under general anaesthetic cases 3, male, 59 years old, weight 64 kg, diagnosed with main arterial valve stenosis with closure incomplete, two-tip valve reflux (mild) Chest heart ultrasound examination: AO38mm, IVSd 13mm, LVD76mm, heart rate 80 times/min, FS0.26, LA 45mm, LVPWd 13.5mm, LVDs 56mm, LVEF0.49, aortic valve trilobites, calcification, right crown The valve is obvious, the valve ring is also tired, the aortic valve ring area is 4.77 cm2, the contraction period is 4.5m/s, the peak pressure difference is 79mmHg, the three-tip valve right ventrrium side can detect the turbulent spectrum, the peak flow rate is 3.67m/s, and the pulmonary artery shrinkpressure pressure is calculated at 59mmHg Diagnosis: Aortic valve calcification with stenosis (moderate and severe), with closure incomplete (severe), left atrium, left ventricle enlargement, ventricle enlargement, room interval and left ventricular back wall reverse movement, left ventricular contraction function decreased, trilateral valve reflux (mild), pulmonary artery pressure increased, two-tip valve mild reflux electrocardiogram check: sinus heart rate, complete right beam conduction block, left front branch conduction block, left ventricular high voltage, ST-T change NYHA Heart Function Rating LEVEL III, ASA Rating III No abnormalities were observed in blood routine, liver and kidney function, and blood clotting function To be undergoing a heart tip TAVI under general anaesthetic 1.2 Anaesthetic after in vitro circulation preparation and then into the operating room to monitor electrocardiograms and pulse oxygen saturation Open peripheral veins, in local anesthesia downstream artery tube monitoring arterial blood pressure General anaesthetic induction drugs: relying on mite 0.2 to 0.3mg/kg, roculpentum 0.8 to 1.0mg/kg, Schuffintani 0.5 to 1.0 mg/kg After the trachea tube control breathing, continuous pump propofol 6 to 8 mg / (kg-h), Riffentani 0.1 to 0.3 sg / (kg-min), maintain the electroencephalic double frequency index (BIS) 45 to 60, after anesthesia continuous pump injection of epinephrine 0.04 to 0.20 sg / kg (kg) ( kg) , maintain the arterial pressure (MAP) 70 to 75 mmHg average After the trachea intubation is completed, the esophageal ultrasound electrocardiogram (TEE) is examined Activate the autologous blood transfusion device Monitor urine volume Intravenous pressure at the intra-cervical venous tube monitoring center and temporary bipolar pacing catheter (Fast-Cath TM, USA) by vascular implantation, digital contrast angiography (DSA) test confirmed that the pacing catheter is located at the tip of the right ventricle In order to debug to ensure that the pace wire works properly, the pacemaker frequency will be adjusted to 180 times / min, the rapid ventricular rate makes blood pressure baseline level, the pressure drops to about 50mmHg is considered satisfactory, stop the pacing properly fixed the pace wire cases 2 and cases 3 patients main artery stenosis, balloon expansion induced ventricular tachycardia, systolic pressure dropped to about 50mmHg, expansion is completed to stop pacing, pump norepinephrine to restore systolic pressure to about 90mmHg After the valve stent is placed in the TEE examination confirms that the aortic valve is open and no significant reflux is seen Case 2 valve stent after the injection of blood pressure significantly higher than before, intravenous pump injection of nitrate glycerin 0.3 to 0.6 sg / (kg .min), deepening anesthesia to maintain MAP 70 to 75mmHg intravenous fluid infusion, case 1 surgery time is 215min, infusion 3 750 mL, are sodium lactate, urine volume 350mL/h; Protein 300mL, self-blood 500mL, urine volume 45mL/h; case 3 surgery time is 219min, urine volume 120 mL/h, infusion 2,000 mL, of which sodium lactate fluid 1,500mL, self-blood 500mL In all three patients, there were uncontrollable hemodynamic fluctuations case 1 and case 2 with tube into the ICU, case 3 is sober, after pulling the tube into the ICU Case 1 and case 2 both recovered from the hospital after surgery 7d, case 3 after 6d formed aortic mezzanine, emergency upgrade aortic replacement, after the occurrence of acute renal failure, continuous renal replacement treatment after the recovery of kidney function, 40d discharge after surgery 2 Discussion although the trauma is small, quick after surgery, but through the left ventricle placement conveyor device, mechanical stimulation of the heart may induce arrhythmia and low blood pressure, and even the occurrence of ventricular tachycardia, atrial fibrillation and other life-threatening complications, due to the lack of in vitro circulation assistance, the of anesthesia management put forward higher requirements During the operation, two central veins are prepared, one for rapid infusion and pumping of vascular active drugs, and the other for the placement of temporary pacing wires At the same time, prepare the in vitro defibrillation electrode, commissioning to ensure that the pacing wire and in vitro defibrillation electrode is working properly The patient's electrocardiogram and invasive arterial blood pressure need to be closely monitored during the operation, and hemodynamic fluctuations caused by the operation need to be handled in a timely manner pumps nitrate glycerin control pressure during -tip operation, and uses drugs such as Lidocain, Riffentani, and right metormiatod to reduce heart stress Adjust the riffintany pump injection speed as needed to prevent the heart rate from affecting surgical operations too fast Compared with traditional open chest surgery of the sternum, although TAVI surgery has the advantages of small trauma, rapid postoperative recovery and no need for in vitro circulation, there are still some potential complications, including peripheral vascular complications, valve leakage and valve stent displacement, cardiac conduction block, coronary artery closure, aortic mezzanine, valve tearing, stroke , acute kidney injury, etc., which may affect the patient's prognostic studies have found that acute kidney injury is one of the more common complications after TAVI surgery, the possible causes of the kidney perfusion, contrast agent kidney disease and the presence of basic diseases (such as peripheral vascular disease, diabetes ) methods to prevent acute kidney injury are to improve renal perfusion, reduce the use of contrast agents and make timely diuretics In both case 1 and 2 of this group, there was no significant increase in creatinine and urea nitrogen levels after surgery and anesthesia, indicating that the application of transient hypotension and catecholamine during surgery and anesthesia did not produce significant renal function impairment Postoperative acute aortic mezzanine is a serious complication of TAVI, once the aortic endoscosphonal tearing occurs, the disease is dangerous, the fatality rate is high, need to be urgently evaluated and actively treated the case 3 after the 6th day of the case of fainting and left limb weakness, CT examination found the aortic mezzanine (Debakey II), re-surgery to upgrade the aortic replacement, after a long period of treatment to recover The incidence of the aortic mezzanine after TAVI is 0 to 4%, possibly because the placement of the guide wire and the delivery tube during surgery causes mechanical trauma to the aortic endoscosis, and the damaged inner membrane is gradually stripped down under the washofage of blood flow case 3 in the valve stent placement is not smooth, due to valve peripheral leakage and implanted the second valve, commonly known as the valve method, the patient's postoperative aortic mezzanine may be related to the operation of the arterial endomerium damage, the mezzanine and the stem of the head arm, resulting in fainting During the operation, it was found that the inner membrane break is located about 5 cm above the stent valve, peeled to the far end, but did not affect the left and right coronary artery, the original stent valve function is good, so the ascending aorta replacement through this group of cases, get the following experience (1) heart-tip operation in the process of bleeding and circulatory fluctuations, avoid the use of epinephrine, so as to avoid hypercardia hyperstress of myocardial hyperactivity, according to the circulatory conditions to consider the use of norepinephrine, dopapalbutamine and other drugs to raise blood pressure (2) For patients with aortic valve stenosis, the aortic cyostic expansion will induce vasculitary ventricular tachycardia , at which time the ventricular rate is 180 times / min, blood pressure curve is low , the heart is basically in an invalid contraction state; Before pacing, MAP should be maintained at 75mmHg, while controlling the pacing time of the ventricle to avoid excessive low blood pressure time, to prevent coronary artery perfusion, malignant arrhythmia and low kidney perfusion In the process of balloon dilation and valve stent placement, coronary artery blood flow may break down, or even cardiac arrest, so it is still necessary to prepare for emergency in vitro circulation (3) case 3 formed aaortic mezzanine after surgery, indicating that surgery may damage the endoscosis The patient's desmotype and hemodynamic state must be closely monitored after surgery Due to the dangerous condition of the aortic mezzanine, the abnormality should be found in a timely cardiac ultrasound to eliminate the possibility of the mezzanine As patients' tolerance to anesthesia and surgery is further reduced, it is particularly necessary to maintain hemodynamic stability and protect important organ functionduringing during re-surgery
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