1 case of sudden stop at the TAVI Surgery Center.

1. Clinical data patient male, 83 years old.
hospital on December 11, 2018 due to "short chest tightness after the event for 3 years, aggravated dizziness for 10 plus days".
history of hypertension for more than 3 years, pyrenine blood pressure 150 plus /90 plus mmHg.
November 30, 2018 Heart Color Oversized: aortic valve calcification, narrow (severe) valve area of approximately 0.5 cm, two-tip valve throlobe (moderate), moderate-severe pulmonary hypertension, LVEF: 67%, LV55mm, LA40mm; CTA shows: aortic valve thickening, calcification, aortic bow wall and left and right coronary artery wall calcification, slow entitis, emphysema; electrocentric illustration: sinus heart rhythm. the
-minute walking test was 197 meters, heart function III, STS rating 2.764 percent, Logistic Euro SCORE score 7.18 percent, 5 meters walking test 7.4s, grip test 24.3 kg, Katz life scale 4 points.
preoperative BNP: 2836pg/mL, biochemical, liver function, blood routine, clotting routine, etc. did not see obvious abnormalities.
Preliminary diagnosis is: 1) heart valve disease: aortic valve severe stenosis with mild throes, left room enlargement; 2) two-tip valve moderate throes; 3) three-tip valve moderate throes; 4) moderate-severe pulmonary hypertension.
after multi-tropic discussion, it is considered that the patient's drug treatment is poor and the risk of surgery is high, and it is recommended to conduct catheter aortic valve implantation (Implant Aortic Valve, TAVI) under monitoring anesthesia management (MAC).
procedure: routine monitoring of patients after entering the room and monitoring of the bispectral index (BIS), placement of in vitro defibrillation electrodes, placement of end-of-life monitoring tubes and masks to give oxygen.
the bureau hemp down the piercing tube of the artery.
intravenously pumped propofol 1.5 mg/(kg.h), rifentanyl 0.05 ?g/(kg?min), right-hand metomination 0.4?g/(kg?h), Lidokain 1mg/(kg?h).
the central venous pressure parameter after the intravenous puncture tube in the right side of the hemp linen.
blood pressure gradually decreased and remained at 90 to 100/60 to 70 mmHg, and BIS remained at 50 to 80.
, before the operation began, the patient's heart rate was kept at a low level by giving commonly used vascular active drugs such as interserosamine, and the MAP was maintained at a rate of 75mmHg.
monitors patients' heart function using transthoracic echo cardiography (TTE) intermittently.
the operation began with a static injection of heparin, the ACT met the standard, punctured the venous veins, implanted the pacing electrode, tested the pacing parameters and continued to puncture the right ethrogen, placed in the 14F arterial tube.
In the case of maintaining the patient's MAP of 75mmHg, the temporary pacemaker overspeeds to 180 times/min, the aortic valve balloon dilates, stops the overspeed after successful expansion, the patient gradually resumes the autonomic heart rhythm, blood pressure at 50 to 60/60/2 30 to 35mmHg, heart rate 50 to 60 times / min fluctuations, immediately give interhydroxyamine, epinephrine, blood pressure rose to 70 s/35mmHg, at this time suddenly turned to chamber fibrillation heart rhythm, blood pressure can not be measured, immediately inform the surgery doctor.
line 200J heart electrodetic fibrillation, while continuous heart pressure, repeatedly push adrenaline a total of 3mg, de-adrenaline a total of 0.4mg, atropine a total of 4mg, Lidoccain 0.5mg, A strong dragon 80mg, omeprazole 40mg; Sodium hydroxide 250mL droplets, pumping epinephrine, epinephrine to maintain the patient's blood pressure, while emergency tube intrinsic, mechanical breathing, ventilator pressure maintained at 30mmHg or so, placed in the transesophage echoal cardiography (transesophage echoal cardiography, TEE).
to ice cap and other brain protection measures, intermittent 4 cardiac defibrillation did not restore sinus heart rhythm, after the addition of heparin by cyclovenous emergency establishment of in vitro circulation, the average arterial pressure in patients at 80mmHg up and down fluctuations, continuous chamber fibrillation heart rhythm.
the surgical doctor again through the right eso artery through the catheter aortic valve, TEE showed that its position effect is good.
At this time the patient's trachea intrinsic tube has a large number of pink foam sputum overflow, ventilator pressure increased to 50mmHg, considering the occurrence of acute pulmonary edema, then sputum, static push urination and other measures to maintain ventilator pressure below 40mmHg.
circulation appropriately reduce blood flow, pink foam sputum gradually reduced, ventilator pressure dropped to about 30mmHg.
150 mg of amine iodide ketones in the veins, the in vitro heart defibrillation was again resumed, and the patient resumed sinus heart rhythm.
increased the amount of urine to 650mL after the acceleration of the pursuit of urine, during which the input of red suspension 3U, plasma 600mL, self-blood 1000mL.
after the patient's circulation is slightly stable, the in vitro circulation is replaced with extra-in vitro membrane oxygenation (ECMO) support and sent to the Cardiac Care Unit (CCU).
patients after surgery: CCU to strong heart, anti-infection and other symptoms of support treatment, the patient in 2 days after the operation of the whole hemp down ECMO evacuation, the patient's vital signs are stable.
continued further treatment at CCU after surgery, removed the trachea catheter after 9 days, the patient ate a fluid diet after 14 days, and was transferred to the department of internal medicine 16 days later to continue anti-infection, rehydration and other treatment.
was discharged from the hospital on 15 January 2019 and was able to respond normally when discharged with no other discomfort.
2. Discussing traditional surgical valve replacement can significantly improve the quality of life and prognosis of patients, but surgical open chest surgery due to greater trauma, for such older, preoperative conjunctivism patients tend to lead to higher mortality.
Transcatheter aortic valve implantation (TAVI) is currently recognized as a low-traumatic aortic valve stenosis treatment, but due to surgical operation and the patient's own reasons, breathing, circulation and other serious complications may occur during surgery.
Although some studies in recent years have shown that cardiovascular events can be reduced by maintaining stable pre-fast ventricular pacing (RVP) and early intravenous booster drugs, complications associated with balloon expansion and valve position, as well as the necessary rapid ventricular pacing, remain a challenge for an anesthesiologists, with central sudden stops being more common complications.
The causes of cardiac arrest in patients in this case were analyzed as follows: patients with old age, suffering from circulatory diseases and COPD for many years, 5 meters walking test, BNP and other results show that patients have heart failure, generally worse; The left atrium leads to an increase in the front load and work of the left atrium, an increase in diastoid pressure in the left atrium causes increased pressure in the left atrium, acute congestion heart failure occurs, blood pressure drops significantly when pacing quickly, and the perfusion of the coronary artery decreases during the diastosis period, resulting in acute coronary ischemicemia, which causes chamber tremors.
patient's balloon dilation due to a large number of th fluid malignant heart rate abnormality, should start CPR as soon as possible, in the conditions permit the rapid placement of valves, reduce th fluidity.
patients are still unable to restore sinus rhythm after active treatment, maintaining the smooth flow of blood is the primary consideration, should be decisive emergency in vitro circulation support.
Active CPR, intnel intation, maintenance of internal environmental stability, the use of brain protection strategies, and other recommended medications for cardiac arrest prior to the on-body cycle can also benefit patients.
The most common complications in TAVI surgery are: chamber rupture, coronary artery damage, chamber arrhythmic disorder, severe aortic throbbing, aortic valve ring rupture and aortic mezzanine, all of which are adaptations to the emergency use of in vitro circulation during surgery.
from January 2010 to December 2015, there were 1,810 patients in Department of Cardiology, Deutsches Herzentrum Munchen, Munich, Germany (n-841) and Uneversity Hospital, according to Teresa Trenkwalder, among others Of Regensburg, Regensburg, Germany (n-969) received TAVI treatment, of which 1.8% of the patients (33 cases: 22 cases through the atherosclerosis and 11 cases through the tip of the heart) were supported by in vitro circulation, of which 6% had arrhythmic arrhythm.
several studies have shown that the use of emergency in vitro circulation improves the safety of TAVI surgery.
Thorsten and others reported that 35 of the 512 patients who underwent TAVI surgery at the same medical center in Germany between April 2008 and August 2011 had an emergency in vitro cycle during surgery, with a success rate of 94%, a 30-day mortality rate of 20% and a one-year survival rate of 46%, significantly reducing the mortality rate of patients with serious complications during surgery.
This case in the patient after a sudden cardiac arrest after multiple defibrillation can not restore sinus heart rhythm in the case of emergency in vitro circulation, not only reflects the importance of in vitro circulation after serious complications in TAVI surgery, but also illustrates the safety of TAVI surgery in the hybrid operating room operation.
"2012 U.S. Expert Consensus on Catheterized Aortic Valve Replacement" recommends that TAVI should be completed in the hybrid operating room, and can meet the simultaneous placement of anesthesia equipment, cardiac ultrasound equipment, aortic balloon receding machine and in vitro circulation machine, in the event of an emergency can be treated as soon as possible to improve patient safety and survival rate.
China's TAVI surgery compared to Europe and the United States to carry out late, according to the doctor's learning curve, in the early stage of operation should pay more attention to the safety of surgery, and anesthesiologists should act as a leader in dealing with emergencies.
tam and other studies show that the treatment of acute complications in TAVI surgery includes CPR, in vitro circulation and stable hemodynamics.
but even larger medical centers have been unsatis-performing in their handling, wasting valuable rescue time.
Therefore, the establishment of emergency CPE team before surgery, and to clarify the respective responsibilities of anesthesiologists, surgery doctors and ultrasound doctors in the event of an emergency, can start to deal with the problem in the first place, cooperate with each other, reduce the emergency due to the process confusion caused by the patient's condition further deterioration.
whether ECMO support will continue after surgery is not conclusive for patients who have serious complications during surgery and who have in vitro circulation during surgery.
a collection of emergency or preventive V-AECMO application studies related to TAVR surgery from November 2012 to November 2017 showed that 102 (2%) of the 5,115 TAVR patients required V-AECMO (preventive 22 cases, 66 emergency cases, 14 cases without adaptive disorders), of which the preventive use of ECMO was mainly due to unstable hemodynamics or poor heart function.
survival rate was 73% (61% in the emergency ECMO group and 100% in the preventive USE ECMO group).
Banjac and others reported that 4.3 percent of the 230 patients who underwent TAVI surgery between 2012 and 2014 needed emergency V-AECMO support, with a survival rate of 70 percent.
cardiovascular complications during or after TAVI surgery are associated with very high mortality rates, ECMO can be used as a prognosticative rescue option for patients with improved breathing or cardiac arrest.
In hospitals where TAVI surgery is performed, patients with serious complications during surgery may consider continuing to use ECMO-assisted treatment after surgery to maintain stability of the patient's vital signs, while for patients with poor foundational conditions and unstable preoperative hemodynamics, TAVI surgery with the support of the preventive use of ECMO may improve patient survival.
, this patient was able to complete TAVI surgery and successfully discharged from the hospital and cardiac arrest after emergency resuscitation, timely CCPB, postoperative ECMO support and other treatment, is the result of multidisciplinary cooperation.
patients with TAVI surgery tend to have poor basic conditions and many preoperative complications, resulting in increased fatal complications during and after surgery.
Anesthesiologists should not only understand the steps of TAVI surgery, do a good job of preoperative risk assessment, closely monitor the flow of blood in surgery, keep patients stable in surgery, in case of emergency, but also in close cooperation with the heart team, quickly and effectively deal with problems, improve the safety of TAVI surgery.
further clinical studies are needed on the adaptation of TAVI surgery supported by the preventive use of ECMO, and it is hoped that the treatment of this case will provide a feasible reference for the treatment of TAVI surgery team after cardiac arrest.
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