Trenkwalder Teresa, Pellegrini Costanza, Holzamer Andreas, Philipp Alois, Rheude Tobias, Michel Jonathan, Reinhard Wibke, Joner Michael, Kasel Albert M, Kastrati Adnan, Schunkert Heribert, Endemann Dierk, Debl Kurt, Mayr N Patrick, Hilker Michael, Hengstenberg Christian, Husser Oliver
Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technical University Munich, Munich, Germany.
Klinik und Poliklinik für Herz-, Thorax- und herznahe Gefäßchirurgie, University of Regensburg Medical Center, Regensburg, Germany.
Catheter Cardiovasc Interv. 2018 Jul;92(1):149-156. doi: 10.1002/ccd.27385. Epub 2017 Nov 11.
Although the incidence of periprocedural complications has decreased in transcatheter aortic valve implantation (TAVI), life-threatening complications occur and emergency veno-arterial extracorporeal membrane oxygenation (vaECMO) can provide immediate circulatory stabilization. We report our two-center experience of vaECMO during life-threatening complications in TAVI.
From January 2010 to December 2015, 1,810 consecutive patients underwent TAVI at two centers. Clinical characteristics, type of complication, outcome and temporal trends in the requirement of emergency vaECMO were evaluated.
Life-threatening complications requiring vaECMO occurred in 1.8% of cases (33 patients; 22 transfemoral, 11 transapical). Indications for vaECMO were ventricular rupture (30%, 10/33), low output (15%, 5/33), bleeding (12%, 4/33), coronary artery impairment (9%, 3/33), ventricular arrhythmias (6%, 2/33), severe aortic regurgitation (6%, 2/33), aortic annular rupture (6%, 2/33), and aortic dissection (3%, 1/33). In 4 cases, no definite cause for hemodynamic instability was identified. Conversion to open heart surgery was necessary in 42% of patients (14/33). Percutaneous coronary intervention was performed in all cases with coronary artery impairment (9%, 3/33). Patients with severe aortic regurgitation (6%, 2/33) underwent emergency valve-in-valve implantation. Other patients received, in addition to vaECMO support conservative treatment (42%, 14/33). In-hospital mortality and 30-day mortality were 46% (15/33). Of patients discharged, 67% (12/18) had no neurological impairment, whereas mild and severe neurological impairment was found in 11% (2/18) and 22% (4/18), respectively. From 2010 to 2015, with increasing procedures (from n = 43 to n = 553) requirement of vaECMO decreased from 9.3% to 0.9% (P for the trend <0.001).
Over a 6-year period, need for emergency vaECMO during TAVI significantly decreased over time. Despite high in-hospital mortality, vaECMO represents a feasible strategy for hemodynamic support in case of life-threatening complications.
尽管经导管主动脉瓣植入术（TAVI）围手术期并发症的发生率有所下降，但仍会发生危及生命的并发症，而紧急静脉-动脉体外膜肺氧合（vaECMO）可提供即时循环稳定。我们报告了我们两个中心在TAVI危及生命并发症期间使用vaECMO的经验。
2010年1月至2015年12月，两个中心连续1810例患者接受了TAVI。评估了临床特征、并发症类型、结局以及紧急vaECMO需求的时间趋势。
1.8%的病例（33例患者；22例经股动脉，11例经心尖）发生了需要vaECMO的危及生命并发症。vaECMO的适应证包括心室破裂（30%，10/33）、低心排血量（15%，5/33）、出血（12%，4/33）、冠状动脉损伤（9%，3/33）、室性心律失常（6%，2/33）、严重主动脉瓣反流（6%，2/33）、主动脉环破裂（6%，2/33）和主动脉夹层（3%，1/33）。4例患者未发现明确的血流动力学不稳定原因。42%的患者（14/33）需要转为心脏直视手术。所有冠状动脉损伤的病例（9%，3/33）均进行了经皮冠状动脉介入治疗。严重主动脉瓣反流的患者（6%，2/33）接受了紧急瓣中瓣植入术。其他患者除vaECMO支持外还接受了保守治疗（42%，14/33）。住院死亡率和30天死亡率为46%（15/33）。出院的患者中，67%（12/18）无神经功能障碍，而轻度和重度神经功能障碍分别见于11%（2/18）和22%（4/18）的患者。从2010年到2015年，随着手术例数的增加（从n = 43增至n = 553），vaECMO的需求从9.3%降至0.9%（趋势P<0.001）。
在6年期间，TAVI期间紧急vaECMO的需求随时间显著下降。尽管住院死亡率高，但vaECMO是在发生危及生命并发症时进行血流动力学支持的可行策略。
