| Backgroud:With the improvement of medical care and the improvement of life expectancy,the number of patients with severe aortic stenosis in China is increasing.Studies have show that five-year survival rate of symptomatic severe aortic stenosis patients was only 15%to 50%.Surgical aortic valve replacement is the first line therapy for AS patients,which has been shown to reduce mortality and improve quality of life.However,for the elderly patients with poor heart function,more complications and severe aortic stenosis who can not tolerate aortic replacement surgery under cardiopulmonary bypass,transcatheter aortic valve replacement(Transcatheter Aortic Valve minimally invasive Implantation,TAVI)may be a good choice.The heart center in our hospital which completed the first TAVI procedure in March 2013,has become one of the largest center in China Our team including cardiologist,s anesthesiologists and nurses are experienced which contributes to a high success rate and good operation prognosis.since TAVI is a new minimally invasive technique with great potential of further application,and has its special surgical procedure,selection of anesthetic method and drug have become one of the research hotspots in anesthesiology.Anesthesiologists were involved during the procedure since the first TAVI was initiated in our hospital.With the increase of the number of cases and the evolution of surgical methods,we analysed these cases,made some exploration and improvement of the anesthesia management.Objective:1.Collect the preoperative,intraoperative and postoperative recovery perioperative data of TAVI patients in our center to clear and define the characteristics and anaesthetic requirements of patients undergoing TAVI,and get the key points of anesthetic management2.Retrospective compare intubated general anesthesia with non intubation general anesthesia for TAVI,and explore the application of depth of sedation monitoring(bispectral index,BIS)Methods:1.Collect the data of patients undergoing TAVI in our center from March 2013 to December 2015.These data include:?peroperative:general information,heart function,treatment and complications,cardiac surgery risk score EuroScore score;? intraoperative:Duration of surgery,bleeding volume,blood transfusion volume,cardiovascular complications including ventricular fibrillation,and the use of vasoactive drugs and so on;?postoperative:30 day mortality and length of ICU stay,reintubation,pulmonary infection and postoperative cognitive dysfunction(POCD),postoperative nausea and vomiting(PONV).2.all TAVI patients in our center from March 2013 to December 2015 to was divided into general anesthesia(General anesthesia,GA)group and BIS guided non-intubation anesthesia group(Bispectral Index-guided non-intubation general anesthesia,BN).Results:1.From March 2013 to December 2015,117 cases of TAVI were completed in our center,among which 116 cases were included with complete preoperative data.?general data and preoperative conditions:74 males(58.7%),BMI 23.18 ± 3.28.NYHA 3/4 class accounted for 74.3%.The mean preoperative EF was 52.3%± 13.1%.There were 97 cases(85.84%)with history of heart failure.All patients have one or more coexisted diseases,mainly heart and lung system diseases,diabetes mellitus and chronic renal dysfunction.?The average operation time was 134 ±57 minutes.The mean intraoperative blood loss volume was 131 ± 15ml.About 77%of patients required vasoactive drugs,and 12(10.6%)received red blood cell transfusions.Ventricular fibrillation occurred in 2 patients,and aortic injury occurred in 1 patients.? The average length of stay in hospital was 15 days.The incidence of complication were as follows:1 caseof acute renal failure(0.9%),2 cases of cerebral infarction(1.8%),18 cases of cardiac pacemaker implantation(15.9%),27 cases of pulmonary infection(23.9%),34 cases of postoperative pleural effusion,5 cases(30.1%),POCD(4.4%),4 cases of PONV(3.5%).The postoperative re intubation rate was 2.7%,mainly due to pulmonary infection and vascular complications.The30-days mortality rate was 4.5%.2.A total of 113 patients were successfully transferred to ICU after TAVR from March 2013 to December 2015.There were 36 cases in group GA and 77 cases in group BN.?There were no significant differences in age,gender,BMI,ASA classification,and coexisted diseases between the two groups(P>0.05).?The comparison of intraoperative results:compared with BN group,the operation time was longer(166± 72 minutes vs.127 ±44 minutes,P=0.04),the volume of blood loss was larger(187±40ml vs.105± 12ml,P=0.014),the proportion of vasoactive drugs use(more than 97.2%vs.67.5%,P<0.001)and blood transfusion(22.2%vs.5.2%,more than P=0.017)were higher in GA group.There was no significant difference in complications such as ventricular fibrillation and cardiac tamponade(P>0.05).?Postoperative results:there was no significant difference in 30 day mortality(P=0.24);length of hospital stay was longer(17±7d vs.16±6d,P=0.006),incidence of postoperative pulmonary infection(47.2%vs.13.0%,P<0.001)and pleural effusion(47.2%vs.22.1%,P=0.009)were higher in GA group.There was no significant difference between two groups in the incidence of other complications(P>0.05):pacemaker implantation and cerebral infarction,acute renal failure,POCD,reintubation and other complications.?Analysis of Logistics for the correction of confounding factors showed that:with general anesthesia,preoperative pulmonary infection and transfusion of red blood cells is related to postoperative pulmonary infection(OR = 4.8,8.5,31.7),and chronic renal insufficiency are negative correlation(OR = 0.05);postoperative risk factors of pleural effusion may be of general anesthesia,red blood cell transfusion and preoperative pulmonary infection is positive correlation(OR = 4.8,5.3,12.4);The length of hospital stay was positively correlated with preoperative pulmonary infection and postoperative pleural effusion(OR values were 4.8,3.3,4.1),not related to anesthesia.Conclusion:1.Patients underwent TAVI surgery in our center were elderly with poor heart function and many coexisted diseases such as hypertension,coronary heart disease,diversity,peripheral vascular disease,diabetes mellitus,post-PCI,chronic obstructive pulmonary disease,chronic renal insufficiency,valvular heart disease etc.The duration of operation was long,and vasoactive drugs such as epinephrine and norepinephrine were needed to maintain hemodynamic stability.Red blood cells may be transfused during surgery to improve oxygen supply.Postoperative pulmonary infection,pleural effusion and other pulmonary complications occurred,most common circulatory system complication was atrioventricular block,permanent pacemakers were needed for some patients.There may be risks for postoperative cerebral infarction,acute renal failure.2.In TAVI surgery,compared with tracheal intubated general anesthesia,BIS guided non intubated general anesthesia is better with the advantages of shorter operation time,less blood loss,lower incidence of postoperative pulmonary infection and pleural effusion,shorter hospitalization and so on.There is no different between these two methods with regard to the 30-day mortality rate. |
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