Добавил:

Sekretar kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.

Вуз:

Ростовский Государственный Медицинский Университет

Предмет:

Медицина общая

Файл:

Книга_3753_Библиотеки_им_академика_М_И_Перельмана

.pdf

Скачиваний:

Добавлен:

31.08.2026

Размер:

24 Мб

Скачать

☆

<<< < Предыдущая 12 13 14 15 16 17 18 19 20 21 22 23 24 25 2627 / 3627 28 29 30 31 32 33 34 35 36 > Следующая >>>

258 M. Castillo-Sang

with biventricular failure VA-ECMO is a reliable approach (but does not ofﬂoad the left ventricle), while those with isolated left ventricular failure can be stabilized with either Impella (Abiomed, Danvers, Massachusetts, USA), IABP or another temporary percutaneous left ventricular assist device.

• Mitral valve pathology

The type/etiology of mitral valve pathology is very relevant in the early stages of evaluation of the patient in cardiogenic shock. In general, pathology can be primary (including endocarditis) or secondary mitral valve regurgitation; mitral regurgitation or stenosis; mitral prosthesis malfunction (Table 2).

• Different forms of minimally invasive mitral valve surgery

There are different techniques for minim ally invasive mitral valve surgery that vary by center and surgeon. In all, in the United States approximately 23–25% of all mitral valve operations are performed minimally invasive with 8% robotic assisted and the rest with other forms of minimally invasive techniques, predominantly right minithoracotomy [11, 12]. In Germany 55% of all mitral valve operations were performed minimally invasive while in Italy up to 71% of all mitral operations were performed minimally invasive based on a multicenter study [13, 14]. In the United Kingdom, based on study including three centers 27% of all mitral valve operations were performed minimally invasive between 2008 and 2016 [15].

• The endoscopic approach to mitral valve surgery

We perform our operations endoscopically assisted using a 5 mm 30-degree thoracoscope positioned in the second intercostal space and mid clavicular line allowing us to create a small

1.5–2-inches right chest working incision in the 4th intercostal space lateral to the nipple in men and lateral to the breast in women. We ﬁnd that

in order to insert mitral prostheses into the chest without undue deformation the minimal size incision is 1.5 inches (Fig. 2A and B). We use a deployable crossclamp (Cygnet clamp, Peters Surgical, Bobigny France) applied through the right minithoracotomy. A 5 mm port in the 4th parasternal space is used for an atrial lift retractor.

• Contraindications to endoscopic mitral surgery approach in cardiogenic shock

In the past many have deemed a prior right chest operation as a contraindication to endoscopic minimally invasive heart surger y, but we ﬁnd that this is relative to the type of previous operation. If the patient had undergone a video assisted lung resection an endoscopic mitral valve surgery is possible within the reasonable time it takes to take down adhesions. We have routinely performed endoscopic mitral valve surgery in patients who underwent right thoracotomies, but the time spent carefully taking down lung adhesions may prove too long in the setting of cardiogenic shock. Patients who had empyema and mechanical or chemical pleurodesis on the right side are true contraindications [12].

We perform the endoscopic mitral operation

in patients with systemic or near-systemic pulmonary artery pressures as well as those with a previous open-heart operation as this has been proven to be safe in redo sternotomies and in minimally invasive approaches [16, 17]. One true anatomical contraindication for endoscopic mitral surgery in cardiogenic shock is the presence of severe mitral annular calciﬁcation unless there is availability of an off label transcatheter balloon expandible valve with direct surgical implantation into mitral annular calciﬁ

cation (MAC), but we have not experienced this operation in the setting of cardiogenic shock.

• Our experience

Our decision-making process in patients presenting with severe mitral stenosis or regurgitation, respiratory failure, on inotropic/pressor

Endoscopic Mitral Surgery in Cardiogenic Shock 259

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

Table 2 Etiology and management of severe mitral pathology in cardiogenic shock

Etiology Pulmonary

Primary MR Start if

Infectious MR

Secondary MR

Bioprosthetic valve MR or MS (structural deterioration)

Mechanical valve MR or MS

Rheumatic MS

Rheumatic MR

Etiological classiﬁcation of cardiogenic shock accompanying severe mitral valve disease. TMVr = transcatheter mitral valve repair. TMVR = transcatheter mitral valve replacement. PTMB = percutaneous transcatheter mitral balloon valvuloplasty. MR = mitral regurgitation. MS = mitral stenosis. RV = right ventricle. SVO2 = mixed venous oxygen saturation

vasodilator

depressed RV and/or PAS  2/3 systemic

Start if depressed RV and/or PAS  2/3 systemic

Inotropic support Mechanical

Implement early (SBP >90 mmHg with elevated lactate, large base deﬁcit or SVO2 <60%)

support

When 1 highdose or 2 inotropes with SVO2 <60%

Transcatheter (TMVr/R)

TEER option Endoscopic

No TMVr/R option

TEER option Endoscopic

Valve in valve option

No TMVr/R option

Primary PTMB if criteria met

No TMVr/R option

Surgical therapy

option

Endoscopic option

option

Endoscopic option if no TMVR

Endoscopic option

Endoscopic option if no PTMB

Endoscopic option

support and/or mechanical circulatory support hinges on the viability of the patient, expected quality of life and patient’s wishes. A clear and candid conversation with the patient and family about the expected risks and beneﬁts of a mitral valve operation under the above circumstances is paramount.

Our experience in managing mitral valve

patients in cardiogenic shock in the last two years

is summarized in Table 3. We have encountered patients in different levels of shock, some requiring only an inotrope and/or pressor while others required advanced mechanical support. The etiology behind the mitral valve pathology varied, the most common being ischemic mitral regurgitation (secondary MR) with an acute on chronic presentation due to decompensation. The predominant mechanical support was IABP

260 M. Castillo-Sang

Fig. 2 A and B Surgeon’s view of the operative ﬁeld using the 5 mm 30-degree angled endoscope

Table 3 Two-year experience of endoscopic mitral valve surgery in cardiogenic shock

Patient Age Etiology Procedure Pharmacologic

1 52 Papillary rupture-ischemic MR MVR Pressor + Inotrope Impella

2 68 Acute on chronic ischemic MR MVR Pressor + Inotrope Impella Yes

3 64 Acute on chronic ischemic MR Redo-

4 70 Acute presentation of chronic

Rheumatic MR

5 69 Acute presentation of chronic

Rheumatic MR

6 65 Acute on chronic ischemic MR MVR/

7 27 Endocarditis acute MR MVR Pressor + Inotrope None Yes

8 31 Endocarditis acute MR MVR Pressor + Inotrope None Yes

9 57 Acute presentation of Rheumatic

MR/MS

10 58 Acute presentation of RheumaticMSMVR Pressor IABP Yes

MVR

MVR/ TVR

TVR

MVR Inotrope IABP Yes

support

Pressor + Inotrope Impella Yes

Pressor + Inotrope IABP No

Pressor + Inotrope Impella Yes

Pressor + Inotrope IABP Yes

Mechanical support

VA-ECMO

Nitric oxide

Yes

11 50 Papillary rupture non-ischemic MVr Pressor + Inotrope IABP No

12 62 Endocarditis + chronic primary MR MVR/

TVr

13 53 Acute on chronic ischemic MR MVR/

TVr

Unpublished data of endoscopic mitral valve surgeries performed in the setting of cardiogenic shock and mitral valve disease. MR, mitral regurgitation. IABP, intra-aortic balloon pump. MVR, mitral valve replacement. MVr, mitral valve repair. TVR, tricuspid valve repair. ABE, acute bacterial endocarditis. VA ECMO, veno-arterial extra-corporeal membrane oxygenation. MS, mitral stenosis. Impella (Abiomed, Danvers, Massachusetts, USA)

Pressor + Inotrope IABP Yes

Inotrope IABP Yes

Endoscopic Mitral Surgery in Cardiogenic Shock 261

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

followed by Impella (Abiomed, Danvers, Massachusetts, USA). There were no operative mortalities, and all patients were discharged from the hospital. One patient died at 4 months from recidivism of IVDA, 12 were alive at follow-up up to 1 year. There were no operative strokes and one patient required hemodialysis postoperatively for one month.

2 Operative Considerations

• Anesthesia considerations

There are several considerations for the anesthesia team managing the cardiogenic shock patient undergoing endoscopic mitral valve surgery. An important one is whether a doublelumen or single-lumen endotracheal tube will be used. We routinely use single-lumen tubes.

On induction of anesthesia, we focus on right ventricular protection for those without mechanical or with only an IABP. We prevent hypotension and once the patient is orotracheally intubated, or when connected to the anesthesia circuit if previously intubated, the inhaled nitric oxide is started 40 PPM if the systolic pulmonary artery pressure is greater than 2/3 systemic or at 20 PPM between 50% and 2/3 systemic (Fig. 3A and B). This dosing is based on the response we have observed in the operating room in acute

settings with active pulmonary edema complicating right ventricular dysfunction.

• Cannulation strategy

If we have the advantage of a preoperative CT scan to evaluate the aorto-iliac vasculature we opt to cannulate via the femoral vessels or alternatively via the right axillary artery (for those with prohibitive aorto-iliac disease). Our axillary cannulation consists of a pursestring on the artery and direct cannulation with a 15 or 17 Fr cannula with transesophageal echo guidance to identify the guidewire in the ascending or descending aorta. In cannulating the axillary artery, one must have a left arm arterial line, but we request bilateral arm arterial lines. The venous cannulation is universally via the common femoral vein with a two-stage 23Fr to 27Fr cannula (23Fr for BSA 1.6 m2; 25Fr for 1.6–

2.2m2; 2Fr for 2.2m2 or higher) (Fig. 4). We favor the bicaval cannulas such as the Medtronic Bio-Medicus NextGen (Medtronic, Minneapolis, Minnesota, USA). In patients supported with VA-ECMO we convert the cannulation to the cardiopulmonary bypass circuit and at the end of the operation, depending on the myocardial contractility weaning off bypass we decannulate or convert again to VA-ECMO.

The mitral valve replacement is performed with prosthesis selection based on standard EACTS or AHA guidelines. For those patients

Fig. 3 A intraoperative vital signs at the time of induction of a patient supported with inotropes showing systemic pressures preserved, pulmonary artery pressures

(105/50 mmHg) over 2/3 systemic and an elevated CVP of 27 mmHg. B This patient was supported with an IABP and inhaled nitric oxide

262 M. Castillo-Sang

Fig. 4 Femoral canulation strategy

on inotropic or IABP support and less than 60 years old we select a mechanical prosthesis if no contraindications for anticoagulation exist. For those with deeper hemodynamic compromise requiring Impella (Abiomed, Danvers, Massachusetts, USA), VA-ECMO or both, we elect to place a bioprosthesis. The argument for the latter is that with full unloading of the ventricular preload there will be stasis and poor washing of the prosthesis which may lead to thrombosis [18].

• Cardioplegia

We exclusively use Del Nido Cardioplegia for all minimally invasive mitral valve operations. In the setting of cardiogenic shock having adequate cardiac protection to minimize myocardial dysfunction is paramount, but it is also important to abbreviate the crossclamp time. Our arresting dose is 1,000 to 1,200 ml and redosing is

performed at 60– 70 min with 300–500 ml extra if 30 or more minutes of work are required.

Application of the crossclamp can be challenging in cases where there is an indwelling Impella pump (Abiomed, Danvers, Massachusetts, USA). In our experience applying a soft insert crossclamp such as the Cygnet clamp (Peters Surgical, Bobigny France) results in better occlusion of the aorta. One should turn to bypass mode the Impella device and advance it as much as possible into the ventricle so as to crossclamp only the smaller diameter driveline. Alternatively, the Impella can be pulled back into the descending aorta to apply the crossclamp understanding that it will not be reinserted and that a new one or an alternative mechanical support will be needed at the end of the case. In cases where the ascending aorta cannot be clamped and there is no aortic insufﬁciency ﬁbrillatory arrest with hypothermia is also an acceptable option in the absence of Impella pump.

Endoscopic Mitral Surgery in Cardiogenic Shock 263

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

Fig. 5 Preoperative chest X-ray of a patient presenting in cardiogenic shock and acute severe mitral regurgitation secondary to papillary muscle rupture showing pulmonary

• Volume and coagulopathy management on cardiopulmonary bypass

Patients undergoing emergent mitral valve operations in the setting of acute cardiovascular decompensation are volume overloaded (Fig. 5). Managing their volume overload improves pulmonary function, right ventricular recovery as well as hepatic congestion increasing the probability of renal recovery and weaning off inotropic and/or mechanical support. Alleviating hepatic congestion will also improve the coagulation proﬁle and risk of postoperative bleeding. For patients with longer standing heart failure and hepatic congestion with documented coagulopathy and on preoperative anticoagulation we will prime the cardiopulmonary bypass circuit with

edema. A pulmonary artery catheter, a percutaneous temporary LVAD and an endotracheal tube are in place

fresh frozen plasma typically 3–4 units. We also aggressively ultraﬁltrate and remove volume from the patient between 2–5 L depending on the preoperative condition.

• Conduct of replacement

Mitral valve replacement should be chordal sparing and the choice of valve prosthesis is a result of a discussion with the patient/family and clinical situation. We arrest the heart with antegrade cardioplegia and enter the heart through the interatrial groove. Once the atrial exposure is achieved using the USB Medical HV retractor (USB-Medical, Hatboro, PA, USA) the anterior leaﬂet of the mitral valve is resected preserving the commissural and all posterior chordae. If the

264 M. Castillo-Sang

Fig. 6 Implanted bioprosthesis using an endoscopic technique

replacement is performed for an ischemic/ruptured papillary muscle it is important to resect all non-viable tissue and if necessary recreate the chords using ePTFE (Fig. 6). It is important to have appropriate chest and mediastinal drainage postoperatively as pleural and pericardial effusions can be common in the postoperative period. On elective cases we deploy a 24 Fr soft silastic drain in the pericardium through the oblique sinus and a 19 Fr in the right pleural cavity. For emergent cases we use two 24 Fr drains in the pleural cavity and one

hemodynamic stability and recovery. For patients with biventricular dysfunction and pulmonary hypertension a combination of epinephrine, milrinone and inhaled nitric oxide are our preferred combination. Patients will be transported to the intensive care unit on inhaled nitric oxide for a wean that will depend on the pulmonary artery pressures and right sided ﬁlling pressures. Once the patient is capable of taking oral sildenaﬁlwe start it and continue this treatment if the pulmonary artery pressures and right ventricular function dictate it.

in the pericardium.

weaned off onto inotropes alone removal of these devices is important to avoid the need for anti-

3 Postoperative Management

coagulation posto peratively. We universally perform a groin cutdowns to remove devices such as Impella, IABP and VA-ECMO cannulas

• Postoperative inotropic support and fate of the mechanical support

and are prepared to perform a thrombectomy in all these cases. Our rationale is that attempting a

percutaneous approach for removal may lead to Once the endoscopic mitral operation is completed, if the patient is not mechanically supported, judicious use of inotropes allows for

complications that can jeopardize a favorable

outcome for the patient. In removing mechanical

support that requires anticoagulation one also

For those on mechanical support that can be

Endoscopic Mitral Surgery in Cardiogenic Shock 265

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

decreases the risk for acute blood loss anemia and transfusions which can perseverate right ventricular dysfunction.

4 Severe Mitral Valve Stenosis

PULMONARY EDEMA

DIASTOLIC + SYSTOLIC

HEART FAILURE AND

SHOCK

ACUTE ON CHRONIC

SYSTOLIC HEART

FAILURE AND

CARDIOGENIC SHOCK

CHRONIC SECONDARY

MR WITH ACUTE

EXACERBATION (NEW

AMI, WORSENING

LVEF)

CHRONIC RHEUMATIC

MR (VOLUME

DECOMPENSATION)

CHRONIC PRIMARY MR

(ACUTE WORSENING

OF MR)

Patients presenting acutely with decompensated severe mitral valve stenosis are typically in diastolic heart failure with pulmonary edema and a degree of low cardiac output state which negates afterload reduction but requires support to improve forward cardiac ﬂow and decrease pulmonary congestion. This often cannot be achieved with pharmacological agents alone and thus needs mechanical support, typically in the form of an intra-aortic counter pulsation balloon. In addition, many of these patients will go into atrial ﬁbrillation which places them in a low cardiac output state despite of preserved or

ACUTE SYSTOLIC HEART

CARDIOGENIC SHOCK

ACUTE ISCHEMIA WITH

PAPILLARY RUPTURE

slightly depressed LVEF. We have experienced a

systolic function deterioration in these patients

perhaps also secondary to a systemic inﬂamma-

tory response that compounds the diastolic fail-

ure and ultimately leads to more advanced

hemodynamic support such as Impella

ACUTE PRESENTATION

OF MITRAL VALVE

DISEASE

PULMONARY EDEMA

DIASTOLIC FAILURE AND LOW CARDIAC

OUTPUT

FAILURE AND

INFECTIOUS ACUTE

DAMAGE (CORONARY

EMBOLIZATION)

CARDIOGENIC AND

SEPTIC SHOCK

RHEUMATIC MITRAL

STENOSIS MR WITH

NORMAL OR

DEPRESSED LVEF

REGURGITATION OF

ANY NATURE WITH

(Abiomed, Danvers, Massachusetts, USA) and/or

VA-ECMO implantation. Others have reported

the presentation of severe mitral stenosis as car-

diogenic shock with variable outcomes (Fig. 7A–

C) [19]. Atrial ﬁbrillation is poorly tolerated in

mitral stenosis and leads to further decrement of

the cardiac output and use of inotropic drugs

often precipitates this circumstance [20]. For this

reason, it is important to identify the need and

institute mechanical support early to maintain a

better hemodynamic state and preserve end organ

function. In these situations, early operation is

the key to having a favorable outcome.

MITRAL

NORMAL OR

DEPRESSED LVEF

Fig. 7 A Intraoperative transesophageal echo showing smoke in the left atrium and a poorly opening mitral valve. B Severe mitral stenosis with color ﬂow. C Intraoperative picture of the severely stenotic rheumatic mitral valve

266 M. Castillo-Sang

Patient with decompensated presentation of mitral stenosis require management in the intensive care unit with invasive monitoring in the form of pulmonary artery catheter, arterial line and foley catheter. Goal directed therapies need to be instituted to maintain adequate cardiac output, minimize pulmonary edema and to preserve the right ventricular function [21, 22]. In doing this end-organ function is preserved in the kidneys and liver. Maintaining mean arterial pressure of at least 65 mmHg, a cardiac index of 2 L/min/m

and a central venous pressure below 15 mmHg are important goals. Often times these patients have signiﬁcant pulmonary hypertension and elevated pulmonary vascular resistance which taxes the right ventricular function and can lead to cardio-renal syndrome. We are relatively liberal in the use of inhaled pulmonary vasodilators such as inhaled iloprost or nitric oxide (for non-intubated patients) or nitric oxide (in intubated patients) to support the right ventricle [23, 24]. We also favor the use of milrinone for pulmonary vasodi lation if tolerated by the hemodynamics and cardiac rhythm without inducing vasoplegia or atrial ﬁbrillation. For those with a uremic syndrome and vo lume overload it is important to institute renal replacement therapy and improve the overall metabolic state of the patient as well as to improve platelet function.

The ﬁrst-line management of mitral stenosis is percutaneous transcatheter mitral balloon valvuloplasty (PTMB) and this has been used even in

the setting of cardiogenic shock [25]. Patients with rheumatic stenosis and accompanying regurgitation or valve calciﬁcation are not candidates to PTMB and in these patients our approach for isolated mitral or mitral and tricuspid valve surgery is universally through the right chest endoscopically with a 1.5– 2-inch incision at the 4th intercostal space and with a 5 mm 30-degree angled scope in the 2nd intercostal space mid-clavicular line (Fig. 8) with a femoral vessel cutdown of 1–2-inch incision which has been proven to be safe and effective in rheumatic mitral stenosis [26]. This is the case even in emergency operations and reoperations with no sternotomy conversions and an average of 5–7 such operations per year.

We would be remiss not to emphasize that it is paramount that not only the surgeon be comfortable with elective complex endoscopic mitral valve surgery, but also the anesthesia, perfusion and nursing members of the team as many of these operations take place outside of regular work hours and are performed perhaps with less familiarized members of the team. To this end we recommend that everyone in the cardiac team gets experience performing endoscopic valve surgery.

5 Ruptured Papillary Muscle

CHRONIC SECONDARY MR

WITH ACUTE

EXACERBATION (NEW

AMI, WORSENING LVEF)

ACUTE ON CHRONIC

SYSTOLIC HEART FAILURE

AND

CARDIOGENIC SHOCK

CHRONIC RHEUMATIC MR

(VOLUME

DECOMPENSATION)

CHRONIC PRIMARY MR

(ACUTE WORSENING OF

MR)

PULMONARY EDEMA

DIASTOLIC + SYSTOLIC

HEART FAILURE AND

SHOCK

ACUTE SYSTOLIC HEART

FAILURE AND

CARDIOGENIC SHOCK

ACUTE ISCHEMIA WITH

PAPILLARY RUPTURE

ACUTE PRESENTATION OF

MITRAL VALVE DISEASE

INFECTIOUS ACUTE

DAMAGE

(EMBOLIZATION)

CARDIOGENIC AND SEPTIC

SHOCK

DIASTOLIC FAILURE AND

RHEUMATIC MITRAL

STENOSIS MR WITH

NORMAL OR DEPRESSED

LVEF

PULMONARY EDEMA

LOW CARDIAC OUTPUT

MITRAL REGURGITATION

OF ANY NATURE WITH

NORMAL OR DEPRESSED

LVEF

Endoscopic Mitral Surgery in Cardiogenic Shock 267

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

Fig. 8 Postoperative picture 10 days after surgery showing the endoscopic approach. A =5 mm 30-degree endoscope. B =Atrial lift retractor port. C =Chest drain

<<< < Предыдущая 12 13 14 15 16 17 18 19 20 21 22 23 24 25 2627 / 3627 28 29 30 31 32 33 34 35 36 > Следующая >>>

Соседние файлы в папке Библиотека им академика М.И. Перельмана

#
31.08.202624 Мб0Книга_3748_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202624 Мб0Книга_3749_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202624 Мб0Книга_3750_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202624 Мб0Книга_3751_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202624 Мб0Книга_3752_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202624 Мб0Книга_3753_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202624 Мб0Книга_3754_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202624 Мб0Книга_3755_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202624 Мб0Книга_3756_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202623 Мб0Книга_3757_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202623 Мб0Книга_3758_Библиотеки_им_академика_М_И_Перельмана.pdf