Director Yu just now thought Ruan Bin was so proud!

Although the other party is very strong, some things can be invincible by talent!

For example, after seeing various examination results now, he should have some consideration in his mind.

"I'm still 90% sure!" Ruan Bin said lightly.

"Hiss... are you sure?"

"Sure!"

"Then which approach would you choose?" Director Yu squinted his eyes. He now felt that he had the obligation to tell Ruan Bin about the fatal problem of the patient's surgery!

"Puncture it with the retrograde femoral artery!" Ruan Bin thought for a while.

"Retrograde femoral artery pathway puncture? Although this approach is a conventional approach, combined with the current patient situation, it has become the most difficult approach, right?" Director Yu frowned.

"The echocardiography of the chest wall of the patient: the area of ​​the aortic valve is 0.5 cm2, the mean pressure difference is 86 mmhg, and the left ventricular ejaculation fraction is 64%. Transesophageal echocardiography shows: the diameter of the aortic valve annulus is 23.5 mm. Angiography prompts: There is mild calcification of the iliac artery and femoral artery, and the inner diameter is good. ct prompts: the aorta is twisted, obvious bends can be seen at the distal end of the aortic arch, and two twists can be seen at the descending aorta!"

"If the surgery is performed, suppose that the femoral artery is performed, and a 29 mm stent that can be autoinflated is sent. However, due to severe distortion of the aorta, the stent is blocked in the distal plane of the aortic arch. When the stent continues to move, the catheter is easily folded at the first bend of the descending aorta, and the degree of distortion of the descending aorta is increased. In addition, the patient is a 103-year-old man, and his blood vessels are aging to a terrible level. No one of us knows whether this decaying blood vessel can support the forced push of the catheter and the cyst sphere. If forced pushing it in, it may cause severe tearing of the wall of the descending aorta on the stent plane and heavy bleeding..." Director Yu said in a deep voice.

This is also his most worrying issue!

This is also the main reason why he dared not perform this surgery!

"In light of the current patient's situation, I actually recommend using the transapical anterior approach!" Director Yu continued.

At present, the patient is not only too old and has severe aging blood vessels, but also has mild calcification of the iliac artery and femoral artery, and moderate calcification of the ascending aorta. If the catheter passes through these places, it will not be able to pass. If you choose to try to pass forcibly, you will be afraid that the aging blood vessels will not support this method!

If you choose to perform CTO interventional surgery on the elderly to remove calcium first, the risk is also very high!

Ruan Bin smiled after hearing this. He also knew that there are three surgical approaches for transcatheter aortic valve implantation. The first is: transfemoral vein anterior route: puncture the femoral guidewire to the right atrium, puncture the atrium septum and expand the puncture hole, use a floating catheter to cross the mitral valve mouth and the aortic valve mouth, and send it into the femoral artery to clamp the guidewire and pull out of the body to establish a steel wire track.

This pathway avoids the damage to the artery by a larger diameter sheath; compared with the transarteral pathway, cardiac pulsation has a smaller impact on the stent valve and is positioned accurately; a sheath with a larger inner diameter can be used, and the stent valve is easy to pass through. However, this pathway requires puncture of the atrial septum, which may cause pericardial tamponade. If the dilated puncture hole is large, a defect in the atrial septal may be left after the operation. The large diameter sheath can pass through the mitral valve can cause incomplete closure or damage, which in turn causes hemodynamic abnormalities. This pathway operation is complicated and requires proficient interventional technology, which has been eliminated.

The second type is transapical anortic route: This operation requires general anesthesia and tracheal intubation, incision of the chest wall at the anterior lateral side of the anterior cardiac area and expose the apical part. Under rapid ventricular pacing, the apex of the left ventricle is punctured, and a delivery track is established under x-ray fluoroscopy, and the route is similar to the transfemoral vein pathway.

The advantage is to avoid damage to the peripheral artery, which can be applied to patients who cannot operate through the femoral iliac artery, and can observe and adjust the position of the valve more intuitively. Because the damage to the aorta is reduced, the incidence of cerebral infarction is reduced. However, surgery requires surgical thoracic opening, which has high requirements for the sterile environment of the surgery, which will cause a certain degree of damage to the patient.

This is the surgical approach recommended by Director Yu. It is mainly because Jiang Yurong's great-grandfather's heart is now severely calcified by vascular calcification, which can easily cause arterial vascular damage. However, using this transapical anterior pathway can avoid damage to the aorta!

However, Ruan Bin felt that this approach required opening a 5-cm-diameter wound on the chest wall and sending the artificial intervention valve to the body to replace the lesion valve. The wound was still opened and caused damage to the patient, which was still imperfect in his eyes!

After all, the old man is 103 years old, so he doesn’t make an incision without opening it!

As for the third type, it is the one chosen by Ruan Bin - the retrograde transfemoral pathway: transfemoral artery → iliac artery → descending aorta → aortic arch → ascending aorta → aortic valve → left ventricle. The surgical operation method and pathway are similar to the percutaneous aortic stenosis balloon dilation, and are simpler than the transvenous pathway.

This pathway avoids damage to the mitral valve, but peripheral artery lesions cause arterial stenosis to pass through the sheath and may damage the surrounding artery, and may lead to cerebral infarction. It is necessary to cross the aortic arch and the stenotic aortic valve, which is relatively difficult to operate.

The main reason is that the old man's aortic arch is bent now, which is one of the reasons why Director Yu strongly opposes Ruan Bin's approach!

Although transcatheter aortic valve replacement is suitable for patients with high surgical risk or inability to operate. Although it is a very invasive surgical method, it also has fatal complications, including the rare descending aorta rupture! If the patient uses the third approach in this situation, the catheter encounters resistance from the aortic twist during the advancement, which can easily cause aorta rupture.

This is also the reason why he proposed to ask the patient to go to Jianxi Hospital for surgery!

Jianxi Hospital is currently the largest teaching and training base for tavi (transcatheter aortic valve implantation) in China! Lao Yu also studied and trained there for half a year three years ago!

"Director Yu, I know the problems you are worried about. What if I can solve these key difficulties?" Ruan Bin said with a smile.

"Can you solve it?" Director Yu was disbelief.

"Of course, what I have to do is to perform CTO surgery on the elderly, first pass him through the calcified parts such as the iliac artery → descending aorta → aortic arch → ascending aorta, and then perform transcatheter aorta implantation!" Ruan Bin said.

"I know your CTO surgery is competent, but how do you deal with this aortic arch bend? It's almost impossible to deal with it, right?" Director Yu frowned.
Chapter completed!