经导管主动脉瓣置换术中瓣环破裂的三步手术管理算法
Three-step surgical management algorithm for annular rupture in transcatheter aortic valve replacement.
作者信息
Yamashita Kizuku, Shimamura Kazuo, Maeda Koichi, Kawamura Ai, Taira Masaki, Yoshioka Daisuke, Miyagawa Shigeru
机构信息
Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan.
Department of Minimally Invasive Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan.
出版信息
JTCVS Tech. 2023 Aug 22;22:169-177. doi: 10.1016/j.xjtc.2023.08.012. eCollection 2023 Dec.
OBJECTIVE
Whereas transcatheter aortic valve replacement is widely implemented, annular rupture is a devastating complication and could be highly mortal. However, owing to its rare incidence, the optimal treatment algorithm has not been established. Thus, we evaluated the feasibility and effectiveness of a 3-step algorithm to treat annulus rupture.
METHODS
From 2009 to 2022, 8 patients of 1083 transcatheter aortic valve implantation (0.8%) developed annulus rupture and were treated with the three-step algorithm. The algorithm was composed of a first step (pericardial drainage and protamine neutralization with blood pressure control), second step (manual hemostatic compression via full/partial sternotomy), and a third step (conservative treatment or radical surgical correction).
RESULTS
The median age at the procedure was 85 (78-88) years and 7 female patients were included in this study. Two (25%) patients had end-stage renal failure under hemodialysis, and median Society of Thoracic Surgeons score was 8.9% (2.1%-23.2%). The implanted transcatheter heart valves (THVs) were 7 balloon-expandable THVs and 1 self-expandable THV with balloon postdilatation. Under this strategy, 8 (100%) patients underwent pericardial drainage as first step and 5 patients achieved hemostasis. Of these, patient 1 demonstrated bleeding from left sinus of Valsalva and required a Bentall procedure. Although the etiology of this phenomenon was not investigated by contrast-enhanced computed tomography, it might be derived from pseudoaneurysm rupture or delayed annular rupture. In 2 patients, the second step treatment was needed for hemostasis. Third-step treatment was conducted in 1 patient. Postoperatively, 6 patients could be discharged without critical complications whereas 2 patients died during the hospitalization. There were no other complications during the followed-up (584 [7-1614]) days.
CONCLUSIONS
In accordance with the three-step algorithm, 6 patients, including those with high-risk or inoperative status, survived.
目的
虽然经导管主动脉瓣置换术已广泛开展，但瓣环破裂是一种灾难性并发症，死亡率可能很高。然而，由于其发病率低，尚未确立最佳治疗方案。因此，我们评估了一种三步治疗方案治疗瓣环破裂的可行性和有效性。
方法
2009年至2022年，1083例经导管主动脉瓣植入患者中有8例（0.8%）发生瓣环破裂，并采用三步治疗方案进行治疗。该方案包括第一步（心包引流、鱼精蛋白中和及血压控制）、第二步（通过全/部分胸骨切开术进行手动止血压迫）和第三步（保守治疗或根治性手术矫正）。
结果
手术时的中位年龄为85（78-88）岁，本研究纳入7例女性患者。2例（25%）患者在接受血液透析，处于终末期肾衰竭，胸外科医师协会评分中位数为8.9%（2.1%-23.2%）。植入的经导管心脏瓣膜（THV）为7个球囊扩张式THV和1个自膨胀式THV并进行了球囊后扩张。在此策略下，8例（100%）患者作为第一步接受了心包引流，5例患者实现止血。其中，患者1表现为主动脉瓣窦左窦出血，需要进行Bentall手术。虽然未通过增强CT检查该现象的病因，但可能源于假性动脉瘤破裂或延迟性瓣环破裂。2例患者需要第二步治疗来止血。1例患者接受了第三步治疗。术后，6例患者无严重并发症出院，2例患者在住院期间死亡。随访（584[7-1614]）天期间无其他并发症。
结论
按照三步治疗方案，6例患者存活，包括高危或无法手术的患者。
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