手术主动脉瓣置换术中左主支架变形的术中可视化,Journal of Cardiothoracic Surgery

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手术主动脉瓣置换术中左主支架变形的术中可视化
Journal of Cardiothoracic Surgery ( IF 1.5 ) Pub Date : 2023-01-31 , DOI: 10.1186/s13019-023-02120-9
Philipp P Müller ₁ , Christian Heim ₁ , Michael Weyand ₁ , Frank Harig ₁

Affiliation

虽然冠状动脉旁路移植术通常被认为是治疗左主干狭窄的首选，但由于西方国家人口稳步老龄化、手术风险高以及患有单支冠状动脉疾病的患者影响到左主动脉。尽管如此，左主干支架置入术仍存在争议，尤其是在伴有心脏直视手术指征的患者中。我们想介绍一名患有严重主动脉瓣狭窄的 78 岁男性患者，由于经导管主动脉瓣置换术的解剖学禁忌证，他在我们的心脏中心接受了手术主动脉瓣置换术。由于单支冠状动脉疾病，左冠状动脉主干的支架置入术在三年前进行，而在干预时正在监测中度主动脉瓣狭窄。术中我们发现支架在左冠状动脉主干内变形，覆盖近25%的冠状动脉口。因此，如果不进一步损坏支架和/或孔口的开口，就不可能像我们正常执行的那样将心脏停搏液直接注入该孔口。我们不得不通过逆行方式插入心脏停搏液，也就是通过冠状窦。虽然左主干支架置入术对于特定人群可能是合理的，但对于近期有心脏直视手术适应症且围手术期风险较低的患者，应谨慎使用。

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Intraoperative visualization of a deformed left main stent during surgical aortic valve replacement

While coronary artery bypass grafting is typically considered first choice for the treatment of left main stenosis, there is a trend towards left main stenting due to a steadily aging population in western countries with a high operative risk and patients with single vessel coronary artery disease affecting the left main artery. Nevertheless left main stenting remains controversial, especially in patients with concomitant indications for open-heart surgery. We want to present a case of a 78-year-old male patient with high-grade aortic stenosis who underwent surgical aortic valve replacement at our heart center due to anatomical contraindications for transcatheter aortic valve replacement. Stenting of the left main coronary artery was performed three years earlier due to single vessel coronary artery disease while moderate aortic valve stenosis was under surveillance at the time of the intervention. Intraoperatively we found the stent to be deformed inside the left main coronary artery, covering nearly 25% of the coronary ostium. So injection of cardioplegia directly into this ostium, as we perform normally, was not possible without further damaging the stent and/or the opening of the ostium. We had to insert cardioplegia via the retrograde way, so via the coronary sinus. While left main stenting can be reasonable for a specific population of patients, it should be used cautiously in patients with concomitant indications for open-heart surgery in the near future and a low perioperative risk profile.

更新日期：2023-01-31

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