经心尖主动脉瓣置换术治疗高危单纯无钙化主动脉瓣关闭不全的手术配合

Nursing cooperation for patients with high risk pure non-calcified aortic regurgitation receiving transapical aortic valve replacement

目的探讨国产J-Valve^(TM)支架瓣膜行经心尖主动脉瓣置换(TAVR)术治疗高危单纯无钙化主动脉瓣关闭不全的手术配合方法。方法收集2017年3月至2018年3月在首都医科大学附属北京安贞医院高危单纯无钙化主动脉瓣关闭不全患者资料,共15例。所有患者均使用国产J-Valve^(TM)系统为患者行TAVR术。经过细致的术前评估(包括术前访视、熟悉仪器设备、介入耗材设备等)、术中流畅的手术配合[包括严格遵循无菌原则、术中患者体温保护、X线防护、激活全血凝固时间(ACT)的监测以及支架瓣膜的装配等]和术中安全管理(包括防止输送器移位和动脉置管的护理等)。观测患者术中是否使用心肺转流、发生心室快速起搏、中转行常规体外循环下TAVR术,是否有冠状动脉阻塞、植入瓣膜是否有移位,有无瓣膜内狭窄及瓣周漏等情况发生,观测术后即刻平均主动脉瓣跨瓣压差;患者在ICU是否顺利脱离呼吸机拔除气管插管,术中平均出血量、患者在ICU时间和呼吸机辅助通气时间、射血分数以及是否存在瓣周漏等;了解患者心功能分级、活动耐量以及是否存在胸闷、心绞痛等症状。结果本研究中所有患者均成功完成TAVR术,未使用心肺转流、未发生心室快速起搏,无中转行常规体外循环下TAVR术,未发生冠状动脉阻塞或植入瓣膜移位,未见瓣膜内狭窄及瓣周漏等情况。术后即刻平均主动脉跨瓣压差为[5.8(4.9,12.9)]mmHg(1 mmHg=0.133 kPa)。所有患者在ICU均顺利脱离呼吸机拔除气管插管,术中平均出血量为[200.0(100.0,500.0)]mL,患者在ICU时间为(1.2±0.4)d,呼吸机辅助通气时间为[19.0(8.5,23.5)]h,平均射血分数为(56.2±15.6)%,仅有2例患者存在微量瓣周漏。末次随访中,10例患者心功能Ⅰ级,4例为Ⅱ级,1例为Ⅲ级;患者的活动耐量都较术前明显改善;患者术后胸闷、心绞痛等症状较术前明显改善。结论手术室护士正确掌握TAVR术的手术配合方法,术前做好患者的心理护理以及各项术前准备,手术过程中与外科医师密切配合,是患者手术成功的保证。

Objective To investigate the operative cooperation of transcardial aortic valve replacement(TAVR)with domestic J-Valve^(TM) stent in the treatment of high-risk simple non calcified aortic regurgitation.Methods From March 2017 to March 2018,15 patients with simple high-risk non calcified aortic regurgitation in Beijing Anzhen Hospital,Capital Medical University were collected.All patients were performed transapical TAVR using domestic J-ValvetmTM system.After careful preoperative evaluation[including preoperative visit,familiarity with instruments and equipment,interventional consumables and equipment,etc.],smooth operation cooperation(including strict adherence to aseptic principle,intraoperative patients temperature protection,X-ray protection,activated clotting time of whole blood(ACT)monitoring and stent valve assembly,etc.]and intraoperative safety management(including the nursing of preventing the displacement of the conveyor and catheterization of artery,etc.).Whether the patient successfully disengaging from the ventilator in ICU,and extubate the tracheal intubation blood volume,ICU time and ventilator-assisted ventilation time,ejection fraction and whether there is perivalvular leakage;to understand the cardiac function classification,activity tolerance,chest tightness,angina pectoris and other symptoms.Whether the tracheal intubation successfully removed from the ventilator in ICU was observed.The average intraoperative blood loss,the patients′time in ICU and ventilator assisted ventilation,the ejection fraction were observed.Whether the perivalvular leakage being presented was observed.The cardiac function classification,activity tolerance,chest tightness,angina pectoris and other symptoms were observed.Results All patients successfully completed transapical TAVR,without cardiopulmonary bypass,ventricular rapid pacing,and conventional cardiopulmonary bypass.No coronary artery occlusion or valve displacement occurred.No valvular stenosis and perivalvular leakage were found.The mean intra-aortic pressure difference immediately after operation was[5.8(4.9,12.9)]mmHg(1 mmHg=0.133 kPa).The mean blood loss was[200.0(100.0,500.0)]mL,the duration of ICU stay was(1.2±0.4)d,the duration of ventilator assisted ventilation was[19.0(8.5,23.5)]h,and the mean ejection fraction was(56.2±15.6)%.Only 2 patients had micro perivalvular leakage.In the last follow-up,10 patients had grade Ⅰ cardiac function,4 patients were gradeⅡ,and 1 patient was gradeⅢ;the activity tolerance of patients was significantly improved compared with that before operation;the symptoms of chest tightness and angina pectoris were significantly improved after operation.Conclusion The operating room nurses should correctly grasp the operation cooperation method of TAVR,do a good job in psychological nursing and preoperative preparation of patients,and cooperate closely with surgeons during the operation,which is the guarantee of successful operation.