Two cases of perinatal combination of acute aortic mezzanine Stanford Type A anaesthetic management

Example 1 The mother, 32 years old, was admitted to hospital for "pregnancy of 29 plus 4 weeks, sudden chest and back pain 13h"Diagnosis:(1) Acute aortic mezzanine Stanford A, moderate closure of the aortic valve, (2) acute lower wallmyocardial infarction;(3) Marfan syndrome, (4) pregnancy 6 maternity 2 pregnancy 2 pregnancy 29 and 4 weeksAfter multidisciplinary consultation, it is proposed to emergency department full-hemp caesarean section and Bentall plus coronary artery bypass transplantNYHAIVlevel, ASAIV levelPump edge into dopamine 5?g kg-1 min-1, BP 97/52mmHg, frequent chamber-like early fightthe use of heptalflone inhalation and propofol 1.0mg/kg static injection, until the consciousness disappears after the operation beginsAfter 1min, a baby boy was cut out, weighing 1.57kg, Apgar 2 points, immediately line trachea intubation, 8min after Apgar 8 pointsAfter the fetus was amputated, the maternal static injection of ammonium Rocum was given 0.8 mg/kg line trachea intubationAfter 15s, maternal blood pressure dropped rapidly to 68/35mmHg, and SpO2 and PETCO2 were also rapidly reduced, giving optoepine stoepine by 0.1mg immediately, and adding 3 times to a total of 0.3mg, 30s after improvementAfter the operation, the uterine cavity is placed in the Bakri balloon to suppress the bleeding and retain the uteruscardiosurgery continues to perform Bentall-coronary transplants, anaesthetic maintenance using heptafluoroetherine plus fentanyl, intermittent addition of myocardineAfter re-temperature pumping dopamine, epinephrine and nitrate glycerin, the aorta opened after independent re-jumping, BP 68/45mmHg, HR 50 times / minute, and repeated chamber early fighting, right chamber contraction weakness, to give anti-arrhythmia, installation of pacemakers, placement of aortic balloon backstroke and other treatment after smooth shutdownAfter the shutdown, the input platelet stake 1 treatment volume, plasma 800ml, cold precipitation 10U, red blood cell 6U and self-blood 800 ml, the operation lasted 9hOn the first day after surgery, the mother's cardiac arrest, actively rescue and install ECMO (in vitro membrane pulmonary oxygenation), 14d line pelvic hematoma removal surgery after surgeryICU was hospitalized for 21d, and then transferred to the hospital for comprehensive rehabilitationAfter 3, 6 months follow-up, the mother and baby are good2 maternal, 34-year-old, was admitted to hospital with "post-partum 2d, sudden chest and back tear-like pain 6h" and was previously thalassemiaDiagnosis:(1) Acute aortic mezzanine Stanford A, mild closure of the aortic valve; (2) Marfan syndrome; (3) coronary artery origin abnormal and affected; (4) thalassemia; (5) postnatal changes in the uterusNYHAIVlevel, ASAIV levelPump into the chamber of nitapriated sodium 0.8 sg-kg-1-min-1, BP125/67mmHgInduced in turn static injection of medazole, relying on miede, fentanyl and shun aquukamtoum, line trachea intubationAfter intubation, the back of the foot artery and the venous puncture in the right neck, anaesthetic maintenance with fentanyl as the main supplement with heptafluoroetherationpumped into dopamine and nitroglycerin after re-temperatureing, and went offline smoothlyThe mother in the deep low temperature stop cycle down Bentall, full bow replacement, like nasal stent placement and coronary artery bypass transplantation, the operation lasted 8hOn the second day after surgery, there was paraplegia of the right limb, myosmatic strength level 0, CT show sinusthrombosis formation, after surgery 17d line heart envelope window drainage, ICU hospital 25d After 6 months of follow-up, the maternal right limb muscle strength III-IV level, the baby survived well discuss pregnancy combined aortic mezzanine is dangerous, maternal and child mortality rates are very high, usually in the late stages of pregnancy, during childbirth, or early after childbirth The aortic mezzanine is divided into A-type and B-type by Stanford type Type A is affected by the elevated aorta, mainly surgical treatment, and type B and the artery under the left collarbone are mainly in the aorta of the far thoracic abdomen, and the intracavity stent is mainly therapy In the past six months, our hospital has performed large vascular surgery and/or obstetric surgery for 2 perinatal combined aorta mezzanine Stanford A mothers, and the mother and baby are safe Early diagnosis, control of blood pressure, monitoring of fetal condition, timely termination of pregnancy and emergency surgery are the key to treatment, such as aortic peeling, acute aortic valve closure incomplete, heart bag filling, etc., should be operated immediately Btaverman et al believe that Marfan syndrome may be the root cause of the aortic mezzanine during pregnancy, associated with increased heart load in the late stages of pregnancy and large vascular conch Zeebregts and other recommendations, 28 pregnancy weeks, emergency surgery at the same time actively protect the fetus; The perioperative period should strictly control blood pressure, prevent blood pressure from being too high to exacerbate the tearing of the mezzanine, but also to avoid low blood pressure affecting the placental blood flow perfusion When the mezzanine is affected by the root of the aorta often leads to severe reflux of the aortic valve, the HR should be avoided during anesthesia, and drugs such as dopamine should be used to strengthen heart function Type A mezzanine can also be caused by a tear ingress of the endometriosis of the aorta root and the opening of the coronary artery, coronary ischemia should be avoided in anesthesia For mothers who perform bypass surgery, should pay attention to the neutrality of fish protein, do not overuse the use of hemostatic drugs, to prevent coronary bridge thrombosis At the same time, the mother of caesarean section, induction should pay attention to the anaesthetic analgesics on the fetal respiratory inhibition Better-developed fetal induction is best not anaesthetic analgesics, can use heptafluoretherine in combination with propofol; Maternal gastric drainage difference, Rocum bromine rapid induction intubation is very necessary Communication with the obstetrician before the birth of the fetus should be avoided by pressing the uterine base to prevent the breakage of the mezzanine place Bakri balloons in the uterus, play an obstetric hemorrhage effect, preserve the uterus and fertility function, reduce the difficulty and time of surgery Maternal coagulation function is enhanced, anticoagulant and fibrosis function is weakened Large vascular surgery multi-factors lead to platelet activation and functional damage, fibrin dissolution and coagulation factor consumption, which is the main reason for the large amount of blood used during perioperative surgery Self-contained platelet separation can be caused by the return of platelets, plasma and red blood cells to the mother after the shutdown, reducing the transfusion of allogeneic components It is recommended that the self-contained platelet separation be feasible without relative taboos Pregnancy combined acute aortic mezzanine mother and child risk is very high, once diagnosed should be timely surgery to avoid the mezzanine rupture caused by maternal and child death, at the same time need multidisciplinary consultation to develop treatment strategies to ensure the safety of mother and child