#1
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Дилемма в операционной при плановом АКШ
Укрепляя контакты и обшение между кардиологами и анестезиологами хотел бы предложить Вашему вниманию мой вчерашний случай. Мужчина 68 лет без больших сопутствующих проблем, провалил стресс-тест.Ангиограмма - функция выброса 50%, три сосуда забиты на 99%.Pull-back градиент между левым желудочком и аортой 19 мм.Назначен на плановое АКШ.
После индукции и интубации пишеводное Эхо.Аортальный клапан - трехстворчатый.кальцифицирован, небольшая аортальная недостаточность. Плошадь клапана 1,1 см ( планиметрически); 1,05 см по VTI. Градиент 25 мм, Максимальная скорость кровотока(Maximl flow velocity) 2.7 м.с. Дилемма: менять или не менять аортальный клапан??Почему? |
#2
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The area is not critical, but you could have underestimated the gradient in the settings of reduced SV. Also concerning is a mildly decreased systolic function. What is the end systolic diameter of LV? Does he have a significant LVH? What is the mitral filling pattern on tissue Doppler?
Impression: AV replacemnet is inducated at the time of the surgery with a tissue valve This 68 y/o male with mild systolic abnormality and moderate to severe AS will need a valve replaced anyway in 2-3 years. My call would be to replace the valve as this would not probably add perioperative mortality but may improve his longterm prognosis. One also need to realize that perioperative mortality in such patients is high to start with, so I would not like to open him twice. Would be interesting to see what Dr. Habarov has to say. |
#3
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BONOW ET AL., ACC/AHA TASK FORCE REPORT
JACC Vol. 32, No. 5, November 1998:1486-1588 Aortic Valve Replacement in Patients Undergoing Coronary Artery Bypass Surgery Patients undergoing coronary artery bypass surgery who have severe AS should undergo AVR at the time of revascularization. Decision making is less clear in patients who have CAD requiring coronary bypass surgery who have mild to moderate AS. Controversy persists regarding the indications for "prophylactic" AVR at the time of coronary bypass surgery in such patients. This decision should be made only after the severity of AS is determined carefully by Doppler echocardiography and cardiac catheterization. Confirmation by cardiac catheterization is especially important in patients with reduced stroke volumes, mixed valve lesions, or intermediate mean aortic valve gradients (between 30 and 50 mm Hg) by Doppler echocardiography, as many such patients may actually have severe AS (as discussed in detail in section III.A. of these guidelines). The more complex and controversial issue is the decision to replace the aortic valve for only mild AS at the time of coronary bypass surgery because the degree of AS may become more severe within a few years, necessitating a second, more difficult AVR operation in a patient with patent bypass grafts. It is difficult to predict whether a given patient with CAD and mild AS is likely to develop significant AS in the years after revascularization surgery. As noted previously (section III.A.3. of these guidelines), the natural history of mild AS is variable, with some patients manifesting a relatively rapid progression of AS with a decrease in valve area of up to 0.3 cm2 per year and an increase in pressure gradient of up to 15 to 19 mm Hg per year; however, the majority may show little or no change (72-84). The average rate of reduction in valve area is ~0.12 cm2 per year (84), but the rate of change in an individual patient is difficult to predict. Retrospective studies of patients who have come to AVR after previous coronary bypass surgery have been reported in whom the mean time to reoperation was 5 to 8 years (733-737). The aortic valve gradient at the primary operation was small, <20 mm Hg, but the mean gradient increased significantly to >50 mm Hg at the time of the second operation. It is important to note that these represent selected patients in whom AS progressed to the point that AVR was warranted. The number of patients in these surgical series who had similar gradients at the time of the primary operation but who did not have significant progression of AS is unknown. Although definitive data are not yet available, patients with intermediate aortic valve gradients (30 to 50 mm Hg mean gradient at catheterization or 3 to 4 m/s transvalvular velocity by Doppler echocardiography) who are undergoing coronary artery bypass surgery may warrant AVR at the time of revascularization, but this is controversial because there are limited data to indicate the wisdom of this general policy. In most patients with normal stroke volumes and small mean gradients (<30 mm Hg and/or <3 m/s), there is greater controversy regarding AVR at the time of coronary artery bypass surgery, and the strength of this recommendation is reduced. Решение о замене клапана будет зависеть от: 1. Наличия клиники. Одышка, стенокардия или синкопальные состояния в пользу замены клапана. Вопрос чем вызвана клиника - поражением клапана или CAD? У бессимптомных больных менять клапан при снижении АД во время нагрузки (ВЭМ), дисфункция ЛЖ или выраженной ГЛЖ, тяжёлом АС. Кстати, больной тест с нагрузкой завалил не из-за падения АД? 2. Дисфункции ЛЖ. В данном примере при 3-х сосудах ФВ=50%, скорее всего, следствие ИБС. 3. Прогнозируемом прогрессировании АС. Быстрое (0.3 см кв. в год) за замену клапана. Проблемы: решение субъективно и прогресс бывает внезапный. Шанс у 68-летнего больного "дожить" (6-8 лет) до замены клапана большой. |
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#7
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Papadoctor, мне очень интересно будет узнать Ваше мнение.
Больной 48 лет, высокая лёгочная гипертензия вследствие тромбоза (in situ) лёгочной артерии (СДЛА при катетеризации 120 мм рт. ст.). В один прекрасный момент начинается кашель с кровохарканием (на высоте кашля), объём крови с мокротой 200-250 мл. Данных за ТЭЛА нет (сцинтиграфия КТ с контрастом), но D-димер повышен. Вводить аминокапроновую кислоту, тромбоцитарную массу? Подавлять кашель? |
#8
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Можно конечно и не менять, но тогда зачем делать байпас, если пациент не имеет симптомов. У вас есть данные, что это спасает жизнь? Если да, то поделитесь. Я вот со времен CASS не помню никаких хороших ауткамных исследолваний. Кстати в CASS лучше жили только диабетики с поражением трех сосудов и систолической дисфукцией. Кстати, если не секрет, то сколько пациент ходил на тредмиле. Если играев в теннис, то не менее 6 минут? |
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