One case of Stanford A aorta mezzanine aneurysm ruptured maternal emergency caesarean section and deep hypothermia stop cycle Bentall surgery

Pregnancy combined with acute aortic mezzanine seriously threatens the life of pregnant women and fetuses, and about 24% of pregnant women are reported to have died as a resultof vascularIf not timely diagnosis and treatment, the risk of maternal mortality is increasing at a rate of 1% to 3% per hourRecently, our hospital successfully treated 1 case of Stanford A aortic mezzanine aneurysm ruptured maternal emergency caesarean section and deep hypothermia cycle Bentall surgery, is reported belowmaternal, 31 years old, 161 cm, 60kg, G1P034, september 28, 2017 after birth test on the way home withno apparent cause of back pain, with chest tightness, shortness of breath, breathing difficulties at 14:00 emergency hospital admissionCheck BP 78/45mmHg, HR 115 times/min, low heart tone, dopamine boost therapy, bedside heart ultrasound prompt aortic mezzanine (Figure 1)Pulmonary artery CTvascularangiography (CTA) did not show any obvious abnormalities, and the aortic mezzanine aneurysm ruptured at the root of the aortic aorticFigure 1 Bedside heart ultrasoundMore than 20 years ago, the mother found room spacing defects and scoliosisFifteen years ago, the opening of the chest room in the outer yard lack of repair surgeryHis mother, in her 30s, died of a ruptured aortic mezzanineAdmissions: Body temperature 36.0C, HR 124 times/min, RR 24 times/min, BP 78/45mmHgGod Qing, can lie flat, to answer the questionCongenital heart disease room defect repair surgery, no obvious abnormal diversion of blood flow, left heart enlargement, aortic sinus widening, arrhythmia (occasional early beat), EF 0.61, estimated pulmonary artery SBP 31mmHgPreoperativediagnosis: 34 weeks of pregnancy, shock, rupture of the aortic mezzanine (Stanford Type A), congenital heart disease, room defect repair surgeryThe proposed caesarean section and the cote aortic replacement (Bentall)after the same day of admission to the hospital, 15:02CTA after the operation room (opened upper exomer veins, vascular active drug maintenance), non-invasive blood pressure 82/42mmHg, HR128 times / minute, SpO2 89%, in disinfection clothing When giving oxygen denitrogen, to propofol 80mg, riffintani 50 mg, Rocum bromine 50mg, insert 7.0mm trachea duct conduit mechanical ventilation, airway pressure 14 cm H2O, PETCO2 38mmHg15:22 Gives birth to a live baby boy, instantapgar score 1, neonatal CPR, 5, 10, 15min after Apgar score is 2, 5, 7 pointsthe fetus after delivery of the addition of shufentanil 30 sg, midazolam 2mg, pump-injection propofol 4 to 6 mg kg-1 h-1, Riffentini 0.1 to 0.2 sg-kg-1 min-1 maintenance anesthesia, right neck built into the deep venous catheter, improve the invasive blood pressure (left upper limb, left lower limb), brain oxygen saturation and BIS monitoring16:30 obstetric surgery is the right artery / right feline venous intubation to establish in vitro circulation of Bentall surgery, the operation was initiated to ampicillin cyclic acid 0.6g, meth 250mg, heparin 3mg/kg, after the aortic blocking, by coronary sinus retrograde infusion 4:1 blood-high potassium stop-jump and ice cap auxiliary brain protectionthe heart stopped to cut open the aorta, see the aortic elevation artery mezzanine, the aortic valve is severely closed, the mezzanine is affected by the left coronary arteryAfter the nasal temperature of the nasopharynx dropped to 22 degrees C, stop the circulation to detect the aortic arch, no aortic layer lesions, after 15min to restore the heart and lung reflux, with the 23rd with the valve aorta artificial vascular line Bentall surgery, transplant left and right coronary artery to artificial blood vessels, continuous stitching match the artificial vascular far end and the rising aortaThe aorta opens after exhausting the root of the aorta, and after heating up the heart automatically restores the sinus heart rhythm, removing each intubation one by oneaccording to hemoglobin, blood clotting function (TEG) monitoring situation on demand infusion of red blood cell suspension, fresh frozen plasma, platelets, human fibrin, human clotting enzyme complex and so onDuring the operation hemorrhage about 400 ml, urine volume of 2,050 ml, input crystal fluid 4,500 ml, self-blood transfusion 750 ml (including in-machine residual blood), input fresh frozen plasma 300 ml, ordinary frozen plasma 300 ml, concentrated red blood cells 6U, platelets 11UVascular replacement surgery lasted 9.25h and the entire operation lasted 10.5hSeptember 29 01:45 maternal call can open their eyes, closely monitored (norepinephrine 0.06 sg-kg-1 min-1, epinephrine 0.06 sg?kg-1-min-1 maintenance BP 90 to 110/60 to 70mmHg, HR 90 to 100 times / minute) with tracheal catheterization into ICUSeptember 29 at 8:00 heart ultrasound indicated aortic mezzanine (tired and left coronary artery) with valve artificial large blood vessel replacement surgery, left heart enlargement, light moderate two-tip valve tri-tip valve reflux, heart function incomplete (EF 0.15), no significant fluid accumulation in the heart cavity Norepinephrine 0.3 sg-kg-1 min-1, epinephrine 0.15 sg kg-1-min-1 maintenance, maternal BP is still low (70-90/60 to 70mmHg), circulation is difficult to maintain, emergency in vitro membrane oxygenation (Extracorpiorealation oxygen, ECMO) assisted, continuous rennes replacement therapy (Continuous, fresco, On October 2nd, the ventilator was removed, ECMO, CRRT (ultrafiltration 660ml), aortic balloon reflexes were removed on 2October and discharged on 2 November The mother and child were safe and the baby was growing well until January 15, 2018 discuss the chances of aortic mezzanine occurring during pregnancy are extremely low Sawlani et al reported a incidence of pregnancy combined aortic mezzanine at 0.0004%, accounting for 0.1% of all aortic mezzanine syllins There have also been cases in The Country The aortic mezzanine is one of the most serious complications of pregnancy The treatment measures of the A and B mezzanines during pregnancy are different Type A mezzanine main line Bentall plus full bow replacement stent like nasal surgery, only the elevated aorta performs Bentall surgery; After the diagnosis , the surgical mortality rate was as high as 18% for non-pregnant acute aortic mezzanine patients who had the condition to have immediate lytotic mezzanine repair surgery The maternal mortality rate of acute A and B aortic mezzanine maternal post-partum aortic repair or replacement was 21% and 23%, respectively, and the fetal mortality rate was 10.3% and 35.0%, respectively currently advocates that a type A aaortic mezzanine should be operated as soon as she is diagnosed Pregnancy combined aortic mezzanine should be based on the age of pregnancy to develop the corresponding treatment plan, the principle is to save maternal life, under this premise as far as possible to ensure that the fetus live Domestic advocates of 28 weeks before pregnancy, the maternal retention of the fetus in the palace, pregnancy after 32 weeks of the maternal, if the fetus is well developed, it is recommended that the first caesarean section after the birth of the fetus, and then chest surgery to repair the aortic mezzanine; anaesthetic, avoid the subsequent vascular replacement surgery when heparin heart and lung transcurrent caused by epidural hemorrhage or hematoma formation, late pregnancy combined A aortic mezzanine rupture of the maternal generally choose full hemp The most serious problem of whole hemp is the failure of trachea intubation and reflux misabsorption, other such as neonatal inhibition, uterine contraction inhibition, etc., can be effectively prevention through good anaesthetic management Anaesthetic induction and maintenance by reference to the guidelines for full hematosection, anesthesia induction and maintenance requires smooth, appropriate anaesthetic depth and stable circulation and important organ perfusion and organ protection Myscosin can cause maternal blood pressure to drop and tachycardia, pregnant women to carry out cardiovascular surgery before the same period of caesarean section, can use mystosin? Dong Xiuhua and others think that as far as possible do not use or less of mycouresin, in particular should avoid intravenous injection of large doses of mycosin, if necessary, can be in 5min slow intravenous injection of uterine 5U, or in the subsequent cardiovascular surgery, or the next 24h continuous intravenous drip contractionuterine 5 to 10U/h for this case, obstetricians thought the uterus contracted well and decided not to use pentorin It has been reported that in order to avoid caesarean section during the cardiovascular procedure due to systemic heparination caused by post-partum hemorrhage, after delivery can be delayed and monitored in the heart and lung transfer bleeding, if the bleeding can not control a feasible hysterectomy, wait for the fish protein reversal heparin or heart surgery after the completion of the abdominal Nevertheless, there is no uniform specification for how to deal with the uterus, prevention and control uterine bleeding during the first phase of The Post-Section al-Sisi consider this case of maternal pregnancy 1 birth 0, post-sectional uterine contraction good no obvious bleeding, and the newborn Apgar score is low, can not guarantee healthy survival and other factors, so no preventive hysterectomy and try to retain the uterus, tight lysic uterine and abdominal incision, heparination period closeobservation abdominal incision, vaginal bleeding and bleeding Results In Bentall surgery (including heparinization period) and after surgery, there were no abnormalities such as uterine hemorrhagic oozing, and the maternal uterus was successfully preserved, providing clinical experience for the surgical retention of the uterus the second day of maternal heart contraction is weak, EF 15%, decisive lying ECMO-assisted, CRRT, aortic cyostic backstroke and other heart and lung assistance measures, so that the maternal ischemia - reperfusion damaged heart, kidney, lung and other important organs to rest and gradually repay oxygen debt, for the final successful rescue of the mother played an important role Pregnancy combined acute A aorta mezzanine is a critical and critical severe case of thoracic surgery and obstetrics, it is necessary to strengthen the multidisciplinary the collaboration between the team (MDT), actively take corresponding treatment measures according to the mezzanine type, accurate anesthesia monitoring and management and organ protection, in order to effectively reduce the maternal and infant mortality rate and disability rate of acute aortic mezzanine