阜外医院课程讲义10本组合

HR[95%CI]0.54[0.38,P(logrank)<∆at1yr=20.0%NNT=5.0ptsAll-causemortalityNEnglJMed2012;366:1696-NumbersatTAStandard Transcatheteraortic‐valveim cannotundergosurgery.LeonMB,etc.NEnglJMed.2010OctNEnglJMedHR[95%CI]0.93[0.71,P(logrank)=No.atTCTCoreValveCoreValveUSPivotalTrialExtremeRiskPopmaJJ,etal.Transcatheteraorticvalverecementusingaself-expandingbioprosthesisinpatientswithsevereaorticstenosisatextremeriskforsurgery.JAmCollCardiol2014;63:1972-81.20122012ESCValvularHeartDiseaseCHOICEofInterventionforAVRsurvival>1BridgetoforseveresurgicalⅠAⅠCⅠC个月的患者，推荐TAVIⅠBⅠBBBCC存在共病，且治疗AS无预期受益的患者不推荐ⅢB4%-无012无2012ESC2012ESCValvularHeartDisease CandidatesCandidatesfor估计预 > 极好00分□好0分□相当不错0分□差‐2□ 限制很多4分□限制一点点2分□一点也没有限制0限制很多3分□限制一点点1分□一点也没有限制0 不能0分□能1不0分□2 不能0分□能‐7不0分□是‐6（包括家外和家务劳动一点也不0112整个时间0分□大部分时间‐2分□好长时间‐4有些时间‐6分□一点时间‐8分□一点时间也没有‐10□整个时间0分□大部分时间‐1分□好长时间‐2分□有些时间‐3分□一点时间‐5分□一点时间也没有‐6分□些时间‐5分□一点时间‐2分□一点时间也没有0分□整个时间‐6‐8‐6时间‐3分□一点时间也没有0分□SocietySocietyofSocietcecioracicSurgeons’risk AorticValve + +Repair+

•史不包括妊娠率6率2.卒中及5.再次手术9.长期住院（>14天ComparisonbetweenSocietyofThoracicSurgeonsScoreandComparisonbetweenSocietyofThoracicSurgeonsScoreandlogisticEuroSCOREforpredictingmortalityinpatientsreferredfortranscatheteraorticvalveim ItsikBen-Dor，etal.ComparisonbetweenSocietyofThoracicSurgeonsScoreandlogisticEuroSCOREforpredictingmortalityinpatientsreferredfortranscatheteraorticvalveimntation.CardiovascularRevascularizationMedicine,Volume12,Issue6,2011,345–349TheTheSTSscoreisthestrongestpredictorofsurvivalfollowingtranscatheteraorticvalve ntation,whereasaccessroute(transapicalversustransfemoral)hasnopredictivevaluebeyondtheperiproceduralphaseysis(endpoint1-year STSlogisticEuroSCORESuicideLeft FuturePatientwithaorticRightRightRightPAGEPAGE1RoleofRoleofTEEDuring EchoEchoExamforRuleoutotherfunctionalDetaileddescriptionEcho:theBestandEchoEchoTransthoracicEcho（TTE）TransesophagealEcho（TEE）VascularEchoTEEvs.TTEObservefrombackoftheClearimageswithoutpulmonaryairandchestwallDonotinterferetheinterventionalPatientcouldn’ttoleratewhileawake,esp.elderlypt.Couldn’tmeasuretransAVgradientcorrectlyObservefromthechest,imagesusuallynotgoodcomparedwithTEENeedtowaitandreadingechowhilescanning(TAVRproceduremostlybeenguidedwithfluoroscopy)CanmeasuretransAVgradientcorrectlyPatienttoleratesEchoEvaluationEchoEvaluationofTTE/TEEObservationofTEETEEObservationofTEEEvaluationof ContinuesContinuesequationmethodtocalculateAVAandarea SOPofEchoExamforSOPSOPofEchoExamforDuringTAVRCase,MCase,MCase,MCase,Case,MCase,MCase,Case,MCase,MTTE3DTTE3DPreTAVRechoexamisveryimportantforscreening,evaluatingandruleoutthosepatientsnotsuitableforTAVRprocedure,bothTTEandTEEshouldbedoneDuringTAVR,echocouldmonitoring,evaluatingtheprocedure,butitseemedmainlyforevaluatingNotonlybio-prosthesisfunction,butalsoventricularfunctionandcomplicationsneedtobeobservedTTEmightbemoretoleratedandacceptedthanTEEin ,butneedmoreexperienceand主动脉瓣狭窄主动脉瓣狭窄 Sapien10例，长海医院VenusA140例 TranscatheterAorticValveRe April16,Conclusions‐Nonsurgicalim ntationofaprostheticheartvalvecanbesuccessfullyachievedwithimmediateandmidtermhemodynamicandclinicalimprovement.Prof.Prof.Prof. :esofAVRinLeonetal,NEnglJMed,2012, PhilippKieferetal.EuropeanJournalofCardio‐ThoracicSurgery(2014)术前准备术前准备症术前准备术前准备（经升主动脉 小（主动脉荷包（主动脉荷包 WebbJG,etalCirculation2009年行病例F病例M病例F病例F病例F病例M病例病例及 病例病例病例病例，ctivectiveCardioVascularandThoracicSurgery(2014)*ctivectiveCardioVascularandThoracicSurgery(2014)*2012ESC/EACTSGuidelines和2014 （TRANSCATHETERAORTICVALVE NTATION,TAVI） 主动脉瓣叶的总重量只有不到1克，总瓣叶面积在1,000mm2左右，瓣叶菲薄。瓣叶完全开放时瓣口面积一般在4cm2。 DiastolicPhaseSystolicphase pADETAILEDANDPRECISEUNDERSTANDINGOFTHEADETAILEDANDPRECISEUNDERSTANDINGOFTHEAORTICVALVARCOMPLEXISFUNDAMENTALTOTAVRSIZINGTheannulusispreciselydefinedasanejoiningthebaseofthe3leaflets measurementonlygivesasurrogatemeasurementoftheminoraxisoftheaorticannulusandisnotinaco- netotheLVOTzJilaihawietal,JACCHugeHugevariationinannulusVALVEVALVESIZINGISPARAVALVULARARISASIGNIFICANTPREDICTOROFMORTALITYAFTERTAVRSinningetal.JACC2012;Tamburinoetal.Circulation2011;Moatetal.JACCGilardetal.NEJM2012;Abdel-Wahabetal.HeartNo.ofHR(95%22Upto12.4Moatet1.66Gilardet20CROSS-SECTIONALCROSS-SECTIONALCTISABETTERMEASUREOFANNULARSIZETHAN2DTEEresultinginsevereARandarockingvalveJilaihawietal,JACC2D2DTEEOVERESTIMATIONOFANNULARSIZEOKBY2DTEE/70%OVERSIZINGBYCTDmean18.323mmSapien-AnnularruptureDieddespiteconversiontoSAVR使用冠状位及矢状位确定使用冠状位及矢状位确定CT:CT:DEFININGTHEBASAL25.928.023.7 RCT:CT:AXIALCUTSATMULTIPLEKNOWEXACTLYWHATYOUARELeafletIfIfcoronarieslowinrelationtoannulus:ConsidercoronarywireprotectionthrombusandThoracicaccessoverProminentseptalSuicideSuicidePre-CTNotedpostCorevalve-CTnotperformedatbaselineAngio-arteryseemsNoinformationonAPFEMORALFEMORAL2DIMENSIONALAppearsRR90degreeCTpre-WhyWhyshouldweneedoptimal瓣WhyWhyshouldweneedoptimalMDCTAssessmentofAorticRootOrientationJACC:CARDIOVASCULARINTERVENTIONS,VOL.3,NO.1,2010JANUARY2010:105–1GENERATEGENERATE“TISSUE-LIKE”3DMODELSFROMCTSIMULATETAVR3DVOLUMENTBEFORETHEACTUALREALMODELPAGEPAGE1手术设施aboutSurgical房间布局aboutRoom人员站位aboutStaff器械准备about人员沟通与协调aboutCommunication 临士C型臂员瓣膜组装台门士护回巡户窗台理护 门2助1助术者 luteng,PAGEPAGE5CardiacAnesthesiologists?LiuMing-Zheng,NationalCenterforCardiovascularAorticAorticStenosis:es,andRossJetal.Circulation.1968;38(1Suppl):61-7.OttoCM.etal.NEnglJMed.2014;371(8):744-Aged>75~80y(~Lung,LiverorKidneyVeryLowAnestheticAnestheticChoicesforSpecialMonitoring:Dall'Araetal.IntJCardiol.2014;177(2):448-54.WeakNoNoRescueDehédinBetal.JCardiothoracVascAnesth2011,25:1036–1043.Ben-Doretal.CardiovascRevascMed2012,13:207–210.MACMAC：MonitoredAnesthesiaPreservationofMarginalCardiovascularandRespiratoryFunctionNon-disturbedProcedureWhitePF.etal StimulusStimulusIntensityinPercutaneous i HowHowDeepinPercutaneousRamsayMAetal.BMJ1974,2:656-BIS:RapidOnsetPreferableAmnesia EasytobeawakedCriteriaofOptimalSedationDose:0.02~0.05mg/kgI.V.(<3Onsettime：Several•gesia:(-Respiratorysystem:Awake:Antagonists:Flumazenil(<2•gesiaDose:0.1~0.15microg/kgOnsettime：SeveralSedation:Respiratorysystem:Awake:SedationDose:0.2~0.5mg/kg,1~2mg/kg/hOnsettime：<30t1/2：Several•gesia:(-Respiratorysystem:Awake:SedationDose:0.5~1.5microg/kg/hOnsettime：~10t1/2：~2•gesia:Respiratorysystem:Awake:ChestWallABG:CallforCPBandPivotalRoleinRescuePivotalRoleinRescueardiacDepthofAnesthesiaCardiacAnesthesiologists?ThankThankyouforyourattention瓣

IncidenceofCHBrequiringpermanentpacemakerim ntationhasbeenhigherwiththeCoreValve(19.2%to42.5%)thanwiththeSapienvalve(1.8%to8.5%)[largerprofileandextensionlowintotheLVOTOccurrenceofBAVPre‐existingRBBBriskfactorforIncidenceofleftbundlebranchblockafterim ntationIncidenceofleftbundlebranchblockafterim ntationofMedtronicCoreValve®orEdwardsSAPIEN®valvevanderBoon,R.M.etal.(2012)NewconductionabnormalitiesafterTAVI—frequencyandNat.Rev.Cardiol.Incidenceofcompleteatrioventriculardissociationafterim ntationIncidenceofcompleteatrioventriculardissociationafterim ntationofMedtronicCoreValve®orEdwardsSAPIEN®valvevanderBoon,R.M.etal.(2012)NewconductionabnormalitiesafterTAVI—frequencyandNat.Rev.Cardiol.AnatomyAnatomyandrelationshipbetweentheaorticvalvularcomplexandtheatrioventricularconductionsystemvanderBoon,R.M.etal.(2012)NewconductionabnormalitiesafterTAVI—frequencyandNat.Rev.Cardiol.AvailableAvailableprostheticaorticvalves‐‐MedtronicCoreValve®orEdwardsSAPIEN®vanderBoon,R.M.etal.(2012)NewconductionabnormalitiesafterTAVI—frequencyandNat.Rev.Cardiol.Incidenceofnewim ntationofapermanentpacemakerafterim ntationoftheMedtronicCoreValve®ortheEdwardsSAPIEN®valvevanderBoon,R.M.etal.(2012)NewconductionabnormalitiesafterTAVI—frequencyandNat.Rev.Cardiol.••••••••；Hb:129g/lPlt:189×109/lCreat:RCA高度:15.6mm；LM高度15•PartiallyPartiallydeployedCoreValvedislocatedintotheascendingCopyright©AmericanHeartCompleCompleydeployedCoreValveprosthesisdislocatedintotheascendingCopyright©AmericanHeartDislocatedDislocate