Xu Zhao, Yu Hong, Liang Peng
Department of Anesthesiology, West China Hospital, Sichuan University and The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu 610041, Sichuan Province, China.
World J Clin Cases. 2020 Feb 26;8(4):815-819. doi: 10.12998/wjcc.v8.i4.815.
Aortic stenosis is the most common valve disease in adults. Transcatheter aortic valve implantation (TAVI) is being increasingly applied for intermediate- to low-risk patients. Here, we describe an uncommon complication of delayed right coronary obstruction in a transapical TAVI case.
A 73-year-old woman with a EuroSCORE II of 1.21% underwent transapical TAVI because of severe aortic stenosis. The surgical procedure was uneventful. However, during routine monitoring after valve placement, the patient had a sudden onset of slow heart rate, the systolic blood pressure dropped sharply from 115 to 60 mmHg, and the central venous pressure abruptly increased from 10 to 33 cmHO. The patient had a poor response to vasoactive agents. Transesophageal echocardiography revealed poor myocardial contractility, and electrocardiography showed a significant depression of ST-segment. Another angiography was performed immediately, which suggested complete obstruction of the right coronary artery. An emergency protocol was initiated. Cardiopulmonary bypass was established immediately. An aortic biological valve replacement under cardiopulmonary bypass was performed.
Perioperative monitoring, early recognition, and diagnosis of obstruction of coronary arteries in TAVI are important. Transesophageal echocardiography is a useful diagnostic and monitoring tool in this situation. Emergency protocols should be established during TAVI.
主动脉瓣狭窄是成人中最常见的瓣膜疾病。经导管主动脉瓣植入术（TAVI）正越来越多地应用于中低风险患者。在此，我们描述了一例经心尖TAVI病例中罕见的延迟性右冠状动脉阻塞并发症。
一名欧洲心脏手术风险评估系统（EuroSCORE）II评分为1.21%的73岁女性因严重主动脉瓣狭窄接受了经心尖TAVI。手术过程顺利。然而，在瓣膜置入后的常规监测期间，患者突然出现心率减慢，收缩压从115 mmHg急剧降至60 mmHg，中心静脉压从10 cmH₂O突然升至33 cmH₂O。患者对血管活性药物反应不佳。经食管超声心动图显示心肌收缩力差，心电图显示ST段明显压低。立即进行了另一项血管造影，结果提示右冠状动脉完全阻塞。启动了紧急预案。立即建立体外循环。在体外循环下进行了主动脉生物瓣膜置换术。
TAVI围手术期的监测、冠状动脉阻塞的早期识别和诊断很重要。在这种情况下，经食管超声心动图是一种有用的诊断和监测工具。TAVI期间应建立紧急预案。
