Paprotny Matthias, Ruschitzka Frank, Lüders Bernd, Wilhelm Markus J, Aser Raed, Bettex Dominique, Flammer Andreas J, Rudiger Alain, Winnik Stephan
University Heart Center Zurich, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland.
J Cardiothorac Surg. 2019 Dec 18;14(1):219. doi: 10.1186/s13019-019-1039-z.
Left ventricular assist devices (LVAD) have become a common treatment option in advanced heart failure. Lack of aortic valve opening during left ventricular unloading is a common complication and associated with a worse outcome. Maintaining a minimum pulse pressure is an important goal during the early postoperative period after LVAD implantation since it is commonly seen as secure sign of aortic valve opening.
AIMS/OBJECTIVE: We report a case of an LVAD-supported patient with early permanent closure of the aortic valve despite a pulse pressure > 15 mmHg at all times following LVAD implantation. We demonstrate how careful assessment of the invasive arterial blood pressure curve can indicate aortic valve closure irrespective of pulsatile blood flow.
A 69-year old male patient with terminal ischemic cardiomyopathy was referred for long-term mechanical circulatory support. Due to mild aortic regurgitation both an aortic bioprosthesis and a continuous-flow left ventricular assist device were implanted. Postoperative echocardiography documented a patent aortic bioprosthesis and an acceptable residual systolic left ventricular contractility. During invasive arterial blood pressure monitoring repetitive transient slight blood pressure decreases followed by slight blood pressure increases coincided with programmed LVAD flushing cycles. Permanent pulsatile flow with a pulse pressure of ≥15 mmHg conveyed systolic opening of the aortic valve. Echocardiography, however, proved early permanent aortic valve closure. In retrospect, transformation of the automated LVAD flushing cycles into visible changes of the arterial blood pressure curve during invasive blood pressure monitoring is indicative of ejection of the complete cardiac output through LVAD itself, and therefore an early clinical sign of aortic valve closure.
DISCUSSION/CONCLUSION: We present this interesting didactic case to highlight caveats during the early postoperative period after LVAD implantation. Moreover, this case demonstrates that careful and differentiated observation of the arterial blood pressure waveform provides crucial information in this unique and growing patient population of continuous-flow LVAD support.
左心室辅助装置（LVAD）已成为晚期心力衰竭的常见治疗选择。左心室卸载期间主动脉瓣不开口是一种常见并发症，且与较差的预后相关。在LVAD植入术后早期，维持最低脉压是一个重要目标，因为它通常被视为主动脉瓣开口的可靠迹象。
我们报告一例LVAD支持的患者，尽管LVAD植入后脉压始终>15 mmHg，但主动脉瓣仍早期永久性关闭。我们展示了如何通过对有创动脉血压曲线的仔细评估来提示主动脉瓣关闭，而不论搏动性血流情况如何。
一名69岁终末期缺血性心肌病男性患者被转诊接受长期机械循环支持。由于轻度主动脉瓣反流，同时植入了主动脉生物瓣和连续流左心室辅助装置。术后超声心动图显示主动脉生物瓣通畅，左心室残余收缩期收缩功能可接受。在有创动脉血压监测期间，与LVAD程控冲洗周期一致，反复出现短暂的轻微血压下降，随后是轻微血压升高。脉压≥15 mmHg的永久性搏动血流提示主动脉瓣收缩期开放。然而，超声心动图证实主动脉瓣早期永久性关闭。回顾来看，在有创血压监测期间，自动LVAD冲洗周期转变为动脉血压曲线的可见变化，提示全部心输出量通过LVAD自身射出，因此是主动脉瓣关闭的早期临床征象。
讨论/结论：我们展示这个有趣的典型病例，以强调LVAD植入术后早期的注意事项。此外，该病例表明，对动脉血压波形进行仔细且有区别的观察，可为这一独特且不断增加的接受连续流LVAD支持的患者群体提供关键信息。
