text/Yangcheng Evening News all-media reporter Lin Qingqing intern Wu Jinxiu
correspondent Hao Li Zhang Lanxi Jin Ting
pictures/the hospital provides
mitral valve disease, pulmonary hypertension , Ms. He, an "expectant mother" who has heart failure , needs to be treated as soon as possible She underwent heart surgery, but she was unwilling to give up her "precious baby" who was 18 weeks pregnant...
A few days ago, Guangdong Provincial People's Hospital Huang Huanlei's team worked under the harsh conditions of no CT-assisted positioning before the operation and no imaging during the operation. , successfully completed transapical mitral valve-in-valve surgery for Ms. He, who was 18 weeks pregnant. After searching the literature, this case of transapical mitral valve-in-valve surgery in pregnant women with "zero contrast agent" was the first in the world.
A broken "heart gate" is life-threatening, but you don't want to give up your "precious child"
Mitral valve disease causes the valve to be unable to open and close, just like a broken "heart gate" of the heart, causing blood to flow in The flow in the heart is disordered, which increases the burden on the heart, leading to serious consequences such as heart failure, pulmonary edema, etc., which can be life-threatening at any time. Ms. He (pseudonym) came to Guangdong Provincial People's Hospital for medical treatment. She was a pregnant woman with severe pulmonary hypertension caused by mitral valve disease, but she was also 18 weeks pregnant with her "precious baby."
Ms. He suffers from severe heart valve disease. In 2018, she underwent mitral valve and aortic valve replacement surgery due to rheumatic heart disease. Considering that she hoped to become pregnant, she chose the biological flap , which was not commonly used at her age. Because she also suffered from autoimmune disease , she needed to take immunosuppressive drugs every day. However, she failed to conceive naturally. After several in vitro fertilization assisted pregnancies, they all ended in failure. So until the beginning of this year when another IVF pregnancy was successful, the whole family was looking forward to this "precious baby".
But the test came again. When she was 18 weeks pregnant, Ms. He had obvious palpitation and shortness of breath again, and she couldn't even lie down while sleeping. Due to the special condition, complexity and danger, many hospitals were unable to treat her, so she had to go to the provincial hospital.
Obstetrics Department Director Han Fengzhen opened a green channel for Ms. He and quickly arranged for hospitalization. The cardiac color ultrasound examination after admission revealed that there was a major problem with the original artificial biological valve, and the valve could not open or close. He has symptoms of heart failure and mitral valve disease has caused a severe increase in pulmonary artery pressure, requiring cardiac surgery as soon as possible.
"In the current diagnosis and treatment guidelines, severe pulmonary hypertension is classified as level V (level 4), which is a contraindication to pregnancy. If you are already pregnant, you need to discuss the issue of termination of pregnancy ." Liu Yanli, deputy chief physician of the obstetrics department, said, "In 4 In the case of high-grade pulmonary hypertension, the probability of serious cardiovascular events in women during pregnancy is as high as 40%-100%! "At this time, Ms. He's best choice is to give up the fetus in her belly.
"I want to live to see you born healthy, my baby..." This is Ms. He's biggest wish. Either terminate the pregnancy or undergo heart surgery during pregnancy. Faced with such a dilemma, Ms. He had a strong desire to become a mother.
Obstetrics Department Director Han Fengzhen, Cardiology Department Xue Ling, Cardiac Surgery Director Huang Huanlei discussed repeatedly, and after repeated communication between Ms. He and her family, they decided to choose cardiac surgery during pregnancy.
"Like picking up ants on the ground on a swing "! Difficult surgery successfully completed
How to complete this complex heart surgery again while ensuring the safety of the fetus as much as possible?
Regarding Ms. He’s situation, there are two surgical options: conventional surgical thoracotomy mitral valve re-replacement and minimally invasive interventional valve surgery. The former requires general anesthesia and re-opening of the chest, and must be performed under extracorporeal circulation. However, hypothermia and hypotension may occur during extracorporeal circulation, and anesthesia, sedation, anti-infection and antibiotics must be used during and after the operation. Coagulants and other drugs may lead to high risks of miscarriage, bleeding, and stillbirth. After repeated discussions between Ms. He and her family, the medical team decided to fulfill Ms. He's wish and challenge the transapical "valve-in-valve" surgery that does not require cardiac arrest or extracorporeal circulation.
On the day of the operation, with the full cooperation of the Department of Cardiology, Anesthesiology , cardiac operating room and obstetrics department, Huang Huanlei, Director of Valvular and Minimally Invasive Surgery of the Cardiac Surgery Department, led the surgical team to measure the native biological valve of the mitral valve through transesophageal cardiac color Doppler ultrasound inner diameter to determine the position of the apex. Huang Huanlei made a small 4-cm incision on the anterolateral side of the fifth intercostal space on the left chest, punctured the apex of the heart under the guidance of esophageal ultrasound, inserted the J-Valve valve delivery system under DSA fluoroscopy, and adjusted the interventional valve and the native valve annulus. relative position. Finally, the 25 mm J-Valve was released within the native valve, and the valve delivery system was removed. The core procedure of the surgery takes less than 1 hour, while the valve release only takes 3-5 minutes. Transesophageal cardiac color ultrasound examination showed that the interventional valve was in good shape and position, with no obvious paravalvular leakage and smooth forward blood flow during diastole. After the operation, Ms. He's pulmonary artery pressure quickly dropped from 91 mm Hg to 38 mm Hg, and the pregnancy risk dropped from level 4 to level 3. The lives of Ms. He and the fetus were saved at the same time!
"It's like picking up ants on the ground while swinging!" Hong Liang, one of the members of the surgical team and the attending physician at the Department of Cardiac Surgery, couldn't help but lament the difficulty of the operation to reporters after the operation. In previous interventional surgeries, doctors needed to use contrast agents to understand the patient's detailed heart structure. In this operation, in order to minimize the impact of radiation and contrast agents on the pregnant woman and the fetus, Huang Huanlei's team not only used lead clothing to protect the fetus in the pregnant woman's belly, but also acted "boldly" We chose the "zero contrast agent" method, using only ultrasound and guidance plus short-term, intermittent X-ray fluoroscopy, and completed the highly difficult "valve-in-valve" surgery while the heart was beating continuously. . The pregnant woman's exposure to X-rays during surgery was less than one-fifth of that of a normal patient. "This is equivalent to actively increasing the difficulty of the operation and taking greater risks in order to reduce the risk to pregnant women and fetuses," Hong Liang said.
Why does this biological valve need to be replaced in less than 5 years?
Why did the artificial biological valve inserted by Ms. He in 2018 develop problems in less than 5 years?
Huang Huanlei said: "Due to the hypercoagulable state during pregnancy and the impact of drugs on the early embryo, there is still a lack of very safe anticoagulant treatment options for mechanical valve replacement. Therefore, Ms. He, who has a strong desire to become pregnant, chose a biological valve, and during pregnancy The state has a greater impact on cardiopulmonary hemodynamics and will accelerate the aging and degeneration of biological valves. "
It is reported that there are currently two types of artificial mitral valves to choose from: biological valves and mechanical valves. In our country, biological valves are often suitable for elderly patients over 60 or 65 years old, and generally last for 5 to 8 years; for young and middle-aged people, mechanical valves are often more suitable. Because the mechanical valve has a long service life and can be used normally for thirty or forty years, it requires a large amount of medication to maintain it.
"It is extremely prudent to choose a treatment plan for valve disease during pregnancy, but after she successfully gives birth, she can also replace it with a mechanical valve." Huang Huanlei said that this is also a personalized plan chosen based on Ms. He's wishes and actual situation. .
Ms. He was discharged from the hospital successfully three days after the operation. A month later, a follow-up prenatal checkup showed that the mother and fetus were in good condition. Ms. He's pulmonary hypertension was only mild, and she could survive the delivery safely, and it might even be relieved after delivery. During the follow-up visit, Ms. He and her husband expressed their gratitude to the medical team with tears in their eyes: "For the arrival of a new life, you have shared the unimaginable pressure and risks with us, thank you!"
Regarding the economic conditions of Ms. He's family, Guangdong The Provincial Charity Federation Luo Zhengxiang Cardiovascular Foundation and the valve company also provided full support, allowing the family the opportunity to make full use of the achievements of the development of medical science and technology and satisfy their desire to welcome a new life healthily. (For more news information, please pay attention to Yangcheng Pai pai.ycwb.com)
Source | Yangcheng Evening News • Yangcheng Pai
Editor | Chen Hui
