中低温停循环取出经导管主动脉瓣植入术中脱落移位瓣膜的体外循环管理  

Cardiopulmonary bypass management of removal of the migrated prosthetic valve during transcatheter aortic valve implantation under moderate hypothermic circulatory arrest

作　　者：彭勤宝 孟维朋 官莉[1] 刘亚湘[1] 郑少忆[1] Peng Qinbao;Meng Weipeng;Guan Li;Liu Yaxiang;Zheng Shaoyi(Department of Cardiovascular surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515,China)

机构地区：[1]南方医科大学南方医院心血管外科,广州510515

出　　处：《中国体外循环杂志》2019年第2期95-97,共3页Chinese Journal of Extracorporeal Circulation

基　　金：广州市科技计划项目(201804010067)

摘　　要：目的回顾并总结中低温停循环取出经导管主动脉瓣植入术(TAVI)术中脱落瓣膜1例的体外循环管理经验。方法采用股动脉插管,心肺转流开始后快速降温至鼻咽温25℃,负压辅助快速超滤,用Delnido冷停搏液灌注升主动脉使膨胀支架部分回缩,停循环下切开升主动脉取出移位瓣膜同时经冠状静脉窦逆行灌注心脏停搏液保护心肌,阻断主动脉后恢复循环并重新灌注HTK液后行外科主动脉瓣置换。结果手术顺利,体外循环时间126 min,主动脉阻断时间61 min,停循环时间5 min,术后9 h清醒,呼吸机时间25 h,ICU停留时间5 d,术后14 d康复出院。结论 TAVI术中瓣膜脱落且瓣膜支架存留于升主动脉导致无法阻断者可行短暂低温停循环取出,采用灵活的超滤、心肌保护等体外循环技术,做好各种应对方案有利于手术安全实施。Objective To review and summarize the experience of cardiopulmonary bypass( CPB) management in one case of emergency removal of migrated prosthetic valve on a failed transcatheter aortic valve implantation( TAVI). Methods CPB was established by femoral artery cannulation. The patient was rapidly cooled to a nasopharyngeal temperature of 25 ℃ as soon as CPB initiated.Efficient ultrafiltration assisted by negative pressure was also applied. Cold Del Nido cardioplegic solution was used to irrigate the ascending aorta in order to make the stent contract to some degree,then the ascending aorta was cut under circulatory arrest and the migrated valve was removed. The cardioplegia was administered via retrograde perfusion via coronary sinus. The circulation restarted when the ascending aorta was clamped and surgical aortic valve replacement was performed after redosing cardioplegia with HTK solution. Results The operation was successfully performed. CPB time was 126 min,and aortic cross clamp time was 61 min,and circulatory arrest time 5 min. The patient woke up 9 h postoperatively. The ventilation time was 25 h and the ICU stay was 5 d. The patient was fully recovered and discharged 14 days later.Conclusion The migrated valve and stent can be removed under moderate hypothermic circulatory arrest in a short time while the aortic cross clamp procedure can not be implemented. Applying CPB techniques such as rapid ultrafiltration,cardioprotection in a flexible manner and making the skillful counter measures with preparation are beneficial to the safety of the patients in emergency cases.

关 键 词：经导管主动脉瓣置换 体外循环 瓣膜脱落 中低温 停循环 主动脉瓣置换 

分 类 号：R654.2[医药卫生—外科学]