背景:经导管主动脉瓣植入术(TAVI)适用于经常有严重合并症和高手术风险的老年患者。尽管有很多优点,它具有早期和晚期并发症的可能性。文献主要报道围手术期问题。此病例报告描述了一种罕见的升主动脉破裂作为TAVI后的晚期并发症。
方法:一名患有严重主动脉瓣狭窄(AS)的81岁男性由于手术风险高(EuroSCOREII14.08%)和合并症而非手术患者,包括心血管问题,慢性阻塞性肺疾病,骨髓增生异常综合征.在TAVI手术期间,MedtronicCoreValve™Evolut™R-26通过右股动脉植入。术后期间无并发症,患者出院回家。六个月后,由于升主动脉破裂,患者在紧急情况下再次入院,并直接转移到手术室(EuroSCOREII53.20%,GERAADA得分64.9%)。计算机断层扫描血管造影(CTA)显示主动脉破裂,升主动脉周围有多个新鲜的血液储备和血栓,起源于TAVI瓣膜的镍钛诺框架与天然主动脉相连的部位。进行了冠状动脉上切除升主动脉并植入血管移植物(IntergardWoven移植物34mm),保留早期植入的TAVI瓣膜。手术后第9天,患者的一般情况恶化,他患有循环和呼吸功能不全。此外,需要胃出血的胃肠道出血,结肠镜检查和多次输血。患者出现尿脓毒症和急性肾功能衰竭,需要血液透析滤过。尽管接受了强化治疗,患者的医疗状况进一步恶化。最后观察到多器官功能衰竭。患者在术后第50天死亡。
结论:TAVI是治疗严重AS的安全方法,特别推荐非手术候选人。升主动脉破裂是TAVI的一种罕见但严重的并发症,通常发生在手术期间或手术后不久。本病例报告强调了术后监测此类TAVI并发症的重要性,即使在TAVI之后的后期,如果发生这种并发症,冒着风险进行救命手术。
BACKGROUND: Transcatheter aortic valve implantation (TAVI) is indicated for elderly patients who often have severe comorbidities and high operative risk. Despite many advantages, it carries the potential for both early and late complications. The literature reports mainly periprocedural problems. This case report describes a rare instance of ascending aortic rupture as a late complication following TAVI.
METHODS: An 81-year-old male with severe aortic stenosis (AS) was a non-surgical patient due to a high operative risk (EuroSCORE II 14.08%) and comorbidities, including cardiovascular problems, chronic obstructive pulmonary disease, myelodysplastic syndrome. During the TAVI procedure Medtronic CoreValve™ Evolut™ R-26 was implanted via the right femoral artery. Postoperative period elapsed without complications and the patient was discharged home. Six months later, the patient was re-admitted to the hospital on an emergency basis and transferred directly to the operating room due to ascending aortic rupture (EuroSCORE II 53.20%, GERAADA score 64.9%). Computed tomography angiography (CTA) showed aortic rupture with a multiple fresh blood reservoirs and thrombus around the ascending aorta originating from the spot where the nitinol frame of the TAVI valve was attached to the native aorta. Supracoronary excision of the ascending aorta with implantation of a vascular graft (Intergard Woven Graft 34 mm) was performed, preserving the earlier implanted TAVI valve. On the 9th day after surgery the patient\'s general condition deteriorated, he suffered from circulatory and respiratory insufficiency. Furthermore, a gastrointestinal bleeding with the need for gastro-, and colonoscopy and multiple blood transfusions occurred. Patient developed urosepsis and acute renal failure with the need for hemodiafiltration. Despite intensive treatment, further deterioration of the medical condition of the patient. and finally the multiple organ failure was observed. Patient died on the 50th postoperative day.
CONCLUSIONS: TAVI is a safe method of treating severe AS, especially recommended for non-surgical candidates. Rupture of the ascending aorta is a rare but serious complication of TAVI that usually occur during or shortly after the procedure. This case report highlights the importance of post-procedural monitoring for such TAVI complications, even in the late period following TAVI, and if such complications occur, taking the risk to perform a life-saving operation.