Roselli Eric E, Idrees Jay, Mick Stephanie, Kapadia Samir, Tuzcu Murat, Svensson Lars G, Lytle Bruce W
Departments of Thoracic and Cardiovascular Surgery and Interventional Cardiology, Heart and Vascular Institute, The Cleveland Clinic, Cleveland, Ohio.
Departments of Thoracic and Cardiovascular Surgery and Interventional Cardiology, Heart and Vascular Institute, The Cleveland Clinic, Cleveland, Ohio.
J Thorac Cardiovasc Surg. 2014 Oct;148(4):1413-6. doi: 10.1016/j.jtcvs.2013.12.052. Epub 2014 Jan 15.
Transcatheter aortic valve replacement (TAVR) expands options for high-risk patients with aortic stenosis but is complex with life-threatening complications. We describe indications for use of salvage cardiopulmonary bypass (CPB) and assess outcomes.
From 2006 to 2011, 303 patients underwent TAVR, and 12 (4%) required emergency CPB. Approach was transapical (9) and transfemoral (3). Mean age was 82±9 years, median Society of Thoracic Surgeons score was 11 and mean gradient was 46±9 mm Hg. Access for CPB was femoral under fluoroscopy. Principal indication for CPB was hemodynamic instability with or without ischemic changes. These resulted from aortic insufficiency (n=5), valve embolization (n=3), coronary malperfusion (n=2), bleeding requiring pericardiocentesis (n=1), and bleeding from ventricular apex (n=1). Additional procedures included valve-in-valve TAVR (n=5), surgical valve replacement (n=3), and coronary intervention (n=2). Additional circulatory support was used in 7 cases: intra-aortic balloon pump (5) and extracorporeal membrane oxygenation (3).
There were 2 hospital deaths. Mean postoperative gradient was 12±9 mm Hg, and median stay was 16 days. There were no myocardial infarctions or renal failure. One patient had stroke with arm weakness, 2 required tracheostomy, and 2 underwent reoperations for bleeding. Median follow-up was 19 months, and there were 5 late deaths.
Complications during TAVR can be life threatening and may necessitate additional procedures. Expeditious use of CPB support provided by a multidisciplinary heart team optimizes rescue after myocardial collapse.
经导管主动脉瓣置换术（TAVR）为高危主动脉瓣狭窄患者拓宽了治疗选择，但该手术操作复杂，存在危及生命的并发症。我们描述了挽救性体外循环（CPB）的使用指征并评估了治疗结果。
2006年至2011年，303例患者接受了TAVR，其中12例（4%）需要紧急CPB。手术途径为经心尖（9例）和经股动脉（3例）。平均年龄为82±9岁，胸外科医师协会评分中位数为11分，平均压力阶差为46±9 mmHg。CPB的通路为在透视引导下经股动脉建立。CPB的主要指征是血流动力学不稳定伴或不伴有缺血改变。这些情况由主动脉瓣关闭不全（n = 5）、瓣膜栓塞（n = 3）、冠状动脉灌注不良（n = 2）、需要心包穿刺引流的出血（n = 1）以及心尖部出血（n = 1）引起。额外的手术包括瓣中瓣TAVR（n = 5）、外科瓣膜置换术（n = 3）和冠状动脉介入治疗（n = 2）。7例患者使用了额外的循环支持：主动脉内球囊反搏（5例）和体外膜肺氧合（3例）。
有2例患者在医院死亡。术后平均压力阶差为12±9 mmHg，中位住院时间为16天。没有发生心肌梗死或肾衰竭。1例患者发生卒中并伴有手臂无力，2例患者需要气管切开，2例患者因出血接受了再次手术。中位随访时间为19个月，有5例患者晚期死亡。
TAVR术中的并发症可能危及生命，可能需要额外的手术。由多学科心脏团队迅速提供CPB支持可优化心肌功能衰竭后的抢救效果。
