Chou Wei-Han, Wang Yi-Chia, Huang Hsing-Hao, Cheng Hsiao-Liang, Lin Yi-Shiuan, Wang Ming-Jiuh, Huang Chi-Hsiang
Department of Anesthesiology, National Taiwan University College of Medicine and National Taiwan University Hospital, Taipei, Taiwan.
Department of Anesthesiology, National Taiwan University College of Medicine and National Taiwan University Hospital, Taipei, Taiwan.
Acta Anaesthesiol Taiwan. 2014 Mar;52(1):2-5. doi: 10.1016/j.aat.2014.05.002. Epub 2014 Jun 18.
Valvular aortic stenosis (AS) is a major cardiac valvular disease in geriatric people. Conventional treatment for severe AS is aortic valve replacement through surgery. However, many geriatric patients are considered inoperable due to higher risks for surgery and anesthesia. Transcatheter aortic valve implantation (TAVI), a less invasive procedure, has rapidly developed in recent years as an alternative management option for high-risk AS patients. Herein, we describe our anesthetic experience in the TAVI procedure.
We included 11 patients who consecutively received transfemoral TAVI in the period from September 2010 to January 2011. All patients received general anesthesia with endotracheal intubation; arterial line placement and central venous catheter insertion were carried out for monitoring hemodynamics. Transesophageal echocardiography was applied for valve evaluation, hemodynamic monitoring, and intraoperative guidance. Patients were transferred to the intensive care unit for further care after surgery. The periprocedural events were recorded.
The mean age of these patients was 82 years. Morphology of the aortic valve in all patients was tricuspid, and the etiology of AS was degenerative calcification. During TAVI, all patients received bolus injections of 5-10 μg norepinephrine just before the rapid pacing stage in order to increase the mean arterial pressure. Only one patient needed continuous infusion of dopamine because of severe preoperative congestive heart failure, and another patient needed continuous infusion of norepinephrine due to relatively old age and suspected low systemic vascular resistance. After TAVI, all patients had the endotracheal tube extubated within 7 hours, except one because of preoperative ventilator dependence. Another male patient stayed in the intensive care unit for 8 days due to postoperative complete atrioventricular block, and he received permanent pacemaker implantation. There was no early mortality.
TAVI is another choice for AS patients who have a high perioperative risk. General anesthesia with endotracheal intubation and application of transesophageal echocardiography can facilitate the use of this new technique by cardiologists. Complete preprocedural evaluation and good intraprocedural cooperation are still the gold standards to achieve successful TAVI and patient safety.
瓣膜性主动脉狭窄（AS）是老年人群中的一种主要心脏瓣膜疾病。重度AS的传统治疗方法是通过手术进行主动脉瓣置换。然而，由于手术和麻醉风险较高，许多老年患者被认为无法进行手术。经导管主动脉瓣植入术（TAVI）是一种侵入性较小的手术，近年来作为高危AS患者的替代治疗选择迅速发展。在此，我们描述我们在TAVI手术中的麻醉经验。
我们纳入了2010年9月至2011年1月期间连续接受经股动脉TAVI的11例患者。所有患者均接受气管插管全身麻醉；放置动脉导管和插入中心静脉导管以监测血流动力学。应用经食管超声心动图进行瓣膜评估、血流动力学监测和术中指导。术后患者被转至重症监护病房进行进一步护理。记录围手术期事件。
这些患者的平均年龄为82岁。所有患者的主动脉瓣形态均为三尖瓣，AS的病因是退行性钙化。在TAVI期间，所有患者在快速起搏阶段前均接受了5 - 10μg去甲肾上腺素的静脉推注，以提高平均动脉压。仅1例患者因术前严重充血性心力衰竭需要持续输注多巴胺，另1例患者因年龄较大且怀疑体循环血管阻力较低需要持续输注去甲肾上腺素。TAVI术后，除1例因术前依赖呼吸机外，所有患者均在7小时内拔除气管导管。另1例男性患者因术后完全性房室传导阻滞在重症监护病房停留8天，并接受了永久性起搏器植入。无早期死亡病例。
TAVI是围手术期风险较高的AS患者的另一种选择。气管插管全身麻醉和经食管超声心动图的应用可便于心脏病专家使用这项新技术。完整的术前评估和良好的术中配合仍然是成功进行TAVI和确保患者安全的金标准。
