三次换瓣2例

三次换瓣２例赵强，任长裕，蒋振斌，陈志强，周光华例１男，３７岁。因细菌感染性心内膜炎，主动脉瓣赘生物合并中度反流，于１９９１年３月行第一次主动脉瓣替换术，置入外径２３ｍｍＭｅｄｔｒｏｎｉｃＨａｌｌ机械碟瓣。术前血培养为肠链球菌，术后血培养仍阳性。第３...     

无支架异种生物瓣膜主动脉瓣替换术后左室功能变化

评价无支架异种生物瓣膜主动脉瓣替换术后２年左室功能的变化。将８０例同期施行主动脉瓣替换病人分为２组，５０例（年龄６９．３±９．３岁）应用ＴｏｒｏｎｔｏＳＰＶＴＭ瓣；３０例（年龄７１．６±７．７岁）作为对照组接受支架人工瓣膜替换。术前、术后１、６、１２及２４个月间记录Ｍ型及Ｄｏｐｐｌｅｒ超声心动图，采用计算机图像数字分析，定量测定左室功能的变化。随访期间，Ｔｏｒｏｎｔｏ组主动脉瓣跨瓣压差为０．８±０．６ｋＰａ（６．０±４．５ｍｍＨｇ），明显低于对照组２．３±０．９ｋＰａ（１７．３±６．８ｍｍＨｇ）；术后１个月，左室心肌质量下降２５％，左室＋Ｖｃｆ及－Ｖｃｆ明显增加（２．０±０．８／１．４±０．３ｓ－１，Ｐ＜０．０１；２．８±１．２／１．８±０．７ｓ－１，Ｐ＜０．０１）。术后６个月，左室功能进一步改善，心室肥厚的消退更趋完全，该变化在其后的随访期间保持稳定。结论：与支架瓣膜相比，无支架异种生物瓣膜具有较大瓣口开放面积及低跨瓣压差，这促进了术后左室功能的恢复及病理性肥厚的逆转     

四叶式主动脉瓣畸形合并严重冠心病一站式介入治疗1例北大核心CSCD

76岁女性患者,计算机断层血管成像显示主动脉瓣由3个基本等大的瓣叶、1个较小的瓣叶构成,为主动脉瓣四叶式type B型,左、右冠状动脉开口偏低,合并多支冠状动脉严重狭窄,主动脉瓣大量反流。患者接受经导管主动脉瓣置换术+经皮冠状动脉支架置入术一站式介入治疗,术后即刻效果良好,症状改善明显。随访12个月,无脑血管意外、房室传导阻滞、心肌梗死、瓣膜移位等事件发生。     

四叶式主动脉瓣畸形合并严重冠心病一站式介入治疗1例

76岁女性患者, 计算机断层血管成像显示主动脉瓣由3个基本等大的瓣叶、1个较小的瓣叶构成, 为主动脉瓣四叶式type B型, 左、右冠状动脉开口偏低, 合并多支冠状动脉严重狭窄, 主动脉瓣大量反流。患者接受经导管主动脉瓣置换术+经皮冠状动脉支架置入术一站式介入治疗, 术后即刻效果良好, 症状改善明显。随访12个月, 无脑血管意外、房室传导阻滞、心肌梗死、瓣膜移位等事件发生。     

有支架与无支架生物瓣膜行主动脉瓣置换临床对比研究

目的　探讨无支架Medtronic生物瓣行主动脉瓣置换的临床效果。方法　将 6 8例同期施行主动脉瓣置换术病人分为 2组 ,38例行无支架Medtronic生物瓣置换 ,30例对照组行有支架生物瓣置换。术前及术后 2个月随访行超声心动图检查。结果　无支架组和有支架组病人术后各项检测指标差异有显著性意义。无支架组跨瓣压差 (18 0± 3 7)mmHg(1mmHg =0 133kPa)明显低于有支架组(33 7± 8 3)mmHg;左室射血分数 0 6 5± 0 0 5 ,明显高于有支架组 0 5 6± 0 0 8;左室收缩末内径和左室舒张末内径分别为 (3 8± 0 8)cm和 (4 5± 0 4 )cm ,明显低于有支架组 (4 2± 1 4 )cm和 (5 1± 0 9)cm ;无支架组瓣环内径 (2 2 1± 1 8)mm大于有支架组 (19 5± 1 7)mm。结论　无支架Medtronic生物瓣较有支架生物瓣具有较低的跨瓣压差和良好的血流动力学 ,能促进左室功能的恢复。     

心脏机械瓣膜置换术后妊娠妇女的抗凝治疗

1979年至 1999年期间 ,我们共行心脏瓣膜置换术 10 37例 ,其中 ,有 14例女病人行机械瓣膜置换术后妊娠 15次。现将此 14例病人的抗凝治疗方法报道如下。临床资料　 14例女病人年龄 2 3～ 36岁。行二尖瓣置换术 (ＭＶＲ) 11例 ,主动脉瓣置换术 (ＡＶＲ) 3例。植入瓣膜分别为Ｃａｒｂｏｍｅｄｉｃｓ瓣 5例 ,国产ＧＫ瓣 4例 ,ＣＬ瓣、Ｍｅｄｔｒｏｎｉｃ瓣各2例 ,Ｓｔ.Ｊｕｄｅ瓣 1例。术前病人心功能 (ＮＹＨＡ)ＩＶ级 4例 ,ＩＩＩ级 10例 ;术后心功能Ｉ级 8例 ,ＩＩ级 6例。全组病人均采用口服抗凝药治疗。进口华法林 (ｏｒｉｏｎｐｈａｒｍ…     

用无支架生物瓣膜行主动脉瓣置换术的早期临床经验

目的探讨无支架生物瓣的置入技术及其早期临床效果.方法对12例平均年龄65岁的主动脉瓣病变病人,选用St.Jude公司提供的TorontoSPV瓣膜,行主动脉瓣置换术.结果全组手术死亡1例,平均主动脉阻断时间(95.0±12.3)?min,其中单纯主动脉瓣置换者为(74.0±9.2)?min.术后1个月随访超声心动图显示均无主动脉瓣反流,跨瓣压差明显较其他人工瓣膜小,左心室舒张末期内径明显缩小,无栓塞、出血等并发症.结论尽管无支架生物瓣膜置入有一定难度,但其优良的血液动力学性能,提示其能提高病人的远期疗效.     

小瓣环主动脉瓣替换手术的策略

目的　探讨小瓣环主动脉瓣病变行主动脉瓣替换加瓣环扩大手术的中、远期疗效。方法　对 45例小瓣环主动脉瓣病变患者在主动脉瓣替换时 ,进行瓣环扩大手术。术中探查主动脉瓣瓣环直径 15～ 2 2mm。瓣环扩大方法为Manouguian法 39例 ,Nicks法 5例 ,Konno法 1例。术后患者随访时间为 ( 6 2± 3 4 )年。　结果　本组患者手术死亡 2例 ,无严重的出血并发症 ;平均输血量为376 5ml,11例术后未输血 ;随访无远期死亡。左心室舒张末径较术前有显著缩小 ,而不同瓣环的血液动力学结果差异无显著性。患者NYHA心功能术后较术前明显改善。　结论　小瓣环主动脉瓣病变患者进行主动脉瓣替换的同时 ,应用Manouguian法扩大瓣环 ,近、远期效果良好 ,无血液动力学意义的跨瓣压差 ,是一种安全、有效的术式。     

40例双瓣替换术体外循环分析

本文报告了４０例双瓣替换术体外循环及心肌保护方法。本组病例包括３８例主动脉瓣和二尖瓣替换术，２例主动脉瓣、二失瓣和冠状动脉搭桥术。术前心功能Ⅱ级６例，Ⅲ级２８例，Ⅳ级６例。升主动脉阻断时间平均９６分钟，自动复跳１０例，住院死亡２例，住院死亡率５％。并讨论了双瓣替换术心肌保护的有关问题。     

术中经食管超声诊断瓣膜置换后卡瓣一例报告

患者 ,女 ,5 5岁 ,体重 75ｋｇ ,发现心脏杂音 17年 ,以劳累后心慌、气短 14年 ,加重 2个月住院。经检查后诊断为 :风湿性心脏病 ,二尖瓣狭窄 (重 ) ,主动脉瓣关闭不全 (中 ) ,三尖瓣关闭不全 ,心脏扩大 ,心房颤动 ,心功能Ⅲ级。经强心利尿治疗后择期行双瓣置换及三尖瓣成形术。麻醉后肝素化建立体外循环 ,降温阻断升主动脉 ,用 2 7号Ｍｅｄｔｒｏｎｉｃ单叶机械瓣置换二尖瓣 ,以 2 3号Ｓｔ.Ｊｕｄｅ双叶机械瓣置换主动脉瓣。三尖瓣用 4 0滑线 ,双孔成形 ,并环缩瓣环 ,经过顺利。开放升主动脉 ,心脏复跳后 ,放置双平面食管超声 (ＴＥＥ)探…     

Aortic valve replacement with the Cryolife-O'Brien stentless aortic bioprosthesis: five-year experience

AIM: Improved hemodynamics with stentless bioprosthesis compared to stented valves have been well documented. It has been suggested that a simplified implant model, the Cryolife-O'Brien, offers less satisfactory outcomes compared with standard stentless models. This study was conducted to prospectively evaluate the midterm results after aortic valve replacement with the Cryolife-O'Brien stentless bioprosthesis. METHODS: In 1996, the prospective clinical trial using different stentless valves was initiated in our center. From September 1996 through August 2001, 132 consecutive patients with a mean age of 72.5 years underwent aortic valve replacement with the Cryolife-O'Brien porcine stentless bioprosthesis by the same surgeon. The predominant aortic valve lesion was stenosis in 110 cases and insufficiency in 22 cases. Patients have been followed-up from 2 to 60 months, mean 28 months. Echocardiography was performed by the same echocardiographer preoperatively, intraoperatively, postoperatively at discharge, 2 to 6 months later and annually thereafter. RESULTS: Sixty-five percent of patients received a valve 25 mm in diameter or larger, 42% had concomitant coronary bypass grafting. The 30-day operative mortality rate was 6.8 %. Nine late deaths, none related to the valve, have occurred. Severe aortic insufficiency caused by oversizing led to early reoperation in 3 patients. The peak and mean systolic gradients decreased significantly during the first 12 months after implantation (p<0.001) and the effective valve areas increased significantly during this time interval (p<0.001). Eleven patients have aortic insufficiency, trivial in 7 and mild in 4. The actuarial survival at 5 years was 86+/-3%. The rate for freedom from endocarditis was 100% and for freedom from thromboembolic events 92%. CONCLUSIONS: The Cryolife-OBrien stentless bioprosthesis has superior hemodynamics and a low rate of valve-related complications thus representing a very good alternative to conventional stented bioprosthesis. The midterm results are encouraging but further follow-up is needed to determine the valve's durability.     

Impact of implant technique following freestyle stentless aortic valve replacement

BACKGROUND: Stentless aortic bioprostheses have excellent hemodynamics and clinical outcomes. The purpose of the present study was to determine whether implant technique of the Freestyle aortic root bioprosthesis impacts clinical outcomes or hemodynamic performance. METHODS: The long-term multicenter study of the Freestyle stentless aortic bioprosthesis includes 500 consecutive patients implanted using the subcoronary and 162 using the full root technique. Clinical outcomes and echocardiographic hemodynamics were compared through 5 years. RESULTS: There were no differences between groups in time to death, valve-related death, or reoperation. The incidence of operative death was higher in the full root than in the subcoronary group (odds ratio 3.97, p = 0.001). Patients in the subcoronary group were more likely to have New York Heart Association functional class III or IV symptoms at 1 year (1.7% versus 0%, p = 0.04) and 5 years postoperatively (4.4% versus 0%, p = 0.02). Mean gradient was lower (p = 0.0004) and effective orifice area larger (p = 0.04) in the full root group. Left ventricular mass index decreased in both groups. The preponderance of patients in both groups had no or trivial aortic regurgitation through 5 years. CONCLUSIONS: Full root implantation of the Freestyle stentless aortic bioprosthesis was associated with higher operative mortality, but somewhat better hemodynamics, functional class, and freedom from aortic regurgitation. Higher operative mortality argues against the empiric replacement of the ascending aorta in the absence of aortic root pathology. In appropriately selected patients, both implant techniques are viable alternatives for valve implantation.     

Late results after left-sided cardiac valve replacement in children

Selection of types of cardiac valve substitutes for children remains controversial. Between 1976 and 1984, 166 children, 15 years of age or younger, underwent aortic (N = 53) or mitral valve replacement (N = 90) or both (N = 23). Biological prostheses were used in 84 patients and mechanical prostheses in 71; both a mitral bioprosthesis and an aortic mechanical valve were used in 11 patients. The overall early mortality was 9%. Mean follow-up intervals were 4.1 years for the bioprosthesis group, 3.3 years for the mechanical valve group, and 3.5 years for the group receiving both. The 7 year survival rates (+/- standard error) were 63% +/- 6% in the bioprosthesis group and 70% +/- 7% in the mechanical valve group (p = NS). After aortic valve replacement the 7 year survival rates were 66% +/- 14% (bioprosthesis group) and 77% +/- 9% (mechanical valve group) (p = NS); after mitral valve replacement the rates were 65% +/- 7% (bioprosthesis group) and 54% +/- 17% (mechanical valve group) (p = NS). The incidence of thromboembolic events was 0.6% +/- 0.4% per patient-year in the bioprosthesis group (none after aortic valve replacement, 0.8% +/- 0.6% per patient-year after mitral valve replacement) and 1.4% +/- 0.8% per patient-year in the mechanical valve group (0.7% +/- 0.7% per patient-year after aortic valve replacement, 4.0% +/- 2.8% per patient-year after mitral valve replacement) (p = NS). The linearized rates of reoperation were 10.4% +/- 1.8% per patient-year (bioprosthesis group) and 2.3% +/- 1.0% per patient-year (mechanical valve group) (p less than 0.001). The 7 year probability rates of freedom from all valve-related complications were 43% +/- 6% in the bioprosthesis group and 86% +/- 4% in the mechanical valve group (p less than 0.001). In the aortic position, a mechanical adult-sized prosthesis can always be implanted, and satisfactory long-term results can be anticipated. In the systemic atrioventricular position, the results are less than satisfactory with either type of prosthesis; every effort should be made to preserve the natural valve of the child.     

Successful aortic root replacement for prosthetic valve endocarditis using the freestyle stentless bioprosthesis: report of two cases

We report two cases of prosthetic valve endocarditis which were successfully treated with aortic root replacement using the freestyle stentless bioprosthesis. Prosthetic valve endocarditis occurred in two patients after aortic valve replacement and modified Bentall operation, respectively. The aortic annulus was severely damaged and left ventriculo-aortic discontinuity was found in both cases. We used the freestyle stentless bioprosthesis, which fits well to the destroyed aortic annulus with left ventriculo-aortic discontinuity, because of its flexibility. Postoperative echocardiography revealed excellent hemodynamic results in both cases. Although the long-term results obtained with the freestyle stentless bioprosthesis, such as resistance to bacterial infection, have not been reported, this prosthesis appears to be very useful for treatment of prosthetic valve endocarditis. We expect that this prosthesis might be a option for PVE as an alternative to a homograft.     

Medtronic Freestyle Aortic Root Bioprosthesis: Implant Techniques

BACKGROUND: The Medtronic Freestyle aortic root bioprosthesis is a complete porcine aortic root to allow implantation (1) as a subcoronary valve replacement by removing graft sinus aorta, (2) as a cylinder with the sinotubular junction intact within the aorta (root inclusion), or (3) as a complete aortic root replacement. The choice among the three implant techniques depends on surgeon preference or upon the pathology encountered. The advantages and differences among the three implant techniques are examined. METHODS: The Medtronic Freestyle bioprosthesis was implanted in 1163 patients in a Food and Drug administration (FDA) clinical trial between August 1992 and October 1997. There were 21 centers in the international trial using a single data repository. Clinical data was collected prior to and at operation, at 3 to 6 months and annually. The data were compiled and statistical analysis performed at the data center. RESULTS: Patients having subcoronary valve implants were older (80% > 65 years) and aortic occlusion time was about 20 minutes less than the other methods. Patients having aortic root replacement presented with more aortic valve insufficiency (20%). Pathology of the aortic root and ascending aorta requiring repair was 26%, and larger (27 mm) valves were used in 40% of patients. Risk of operation was lowest (5.0%) with subcoronary valve implants and highest (11.7%) with root replacement technique. Thromboembolism was higher, early and late, with root inclusion (3.0, 3.9%/patient per year) and root replacement (3.2, 3.0%/patient per year) than for subcoronary implants (1.8, 1.6%/patient per year). There were more patients taking warfarin at the 4-year point with root inclusion (20%) or root replacement techniques (24%) than among patients having subcoronary implants (14%). Explants of the valve occurred in 2% of patients, none of whom had aortic root replacement. CONCLUSIONS: The Medtronic Freestyle bioprosthesis is an effective and versatile device for replacement of the aortic valve. It offers implant techniques that can treat the aortic root pathology encountered at surgery and allows the operation to proceed according to surgeon preference.     

Clinical and hemodynamic assessment of the Hancock II bioprosthesis.

The Hancock II bioprosthesis was used for heart valve replacement in 614 patients from 1982 to 1990. Aortic valve replacement (AVR) was performed in 376 patients, mitral valve replacement (MVR) in 195, and aortic and mitral valve replacement (DVR) in 43. The mean age was 62.7 years, and 78% of all patients were in New York Heart Association functional class III or IV before operation. Coronary artery bypass graft was necessary in 232 patients and replacement of ascending aorta in 55. There were 31 operative deaths (AVR, 4%; MVR, 6%; DVR, 9%). Follow-up was complete in 98.5% of the patients and extended from 12 to 103 months, with a mean of 49 months. At the last follow-up, 85% of the patients were in New York Heart Association class I or II. The actuarial survival at 8 years was 79% +/- 3% for AVR, 68% +/- 4% for MVR, and 65% +/- 10% for DVR. The freedom from stroke at 8 years was 93% +/- 2% for AVR, 83% +/- 5% for MVR, and 90% +/- 5% for DVR. At the end of 8 years 96% +/- 1% of all patients were free from endocarditis, 92% +/- 1% were free from primary tissue failure, and 89% +/- 3% were free from reoperation. The actuarial freedom from valve-related death at 8 years was 98% +/- 1% for AVR, 86% +/- 5% for MVR, and 91% +/- 6% for DVR. Hemodynamic assessment was obtained by Doppler echocardiography in all operative survivors and demonstrated satisfactorily effective valve orifices and transvalvular gradients. The clinical results obtained with the Hancock II bioprosthesis have been gratifying, particularly in the aortic position. This bioprosthesis is our biological valve of choice.     

Long-term follow-up of supra-annular pulmonary autograft aortic root replacement in patients with bicuspid aortic valve

Objective: The performance of the Ross procedure in the case of geometric mismatch between pulmonary autograft and a bicuspid aortic root has not yet been fully evaluated. To prevent geometrically caused autograft dysfunction, a modification of the surgical technique is necessary. Methods: Between January 1996 and January 2007, 50 patients (33 male, 17 female; mean age 50+/-14 years; range 13-63 years) underwent replacement of a diseased bicuspid aortic valve (stenosis in 14 cases; insufficiency in 21; combined disease in 15) with a Ross procedure. The pulmonary autograft was inserted partially in supra-annular position to correct the geometric mismatch between the deeper base of the non-coronary sinus and the right/left coronary sinus. In 24 of these patients, additional tailoring of the non-coronary sinus was necessary. In eight patients the non-coronary sinus was covered with a glutaraldehyde treated autologous pericardial patch to prevent pseudoaneurysm formation. Patients were followed up 1, 2, 5 and 10 years postoperatively. Results: There were no early or late deaths. There were six reoperations. One patient was reoperated because of persistent severe aortic valve insufficiency 9 months postoperatively. Three patients were reoperated for formation of subannular pseudoaneurysm, 6, 9 and 30 months postoperatively. One patient was reoperated for closure of a paravalvular dehiscence. Another patient was reoperated 1 year postoperatively because of a severe pulmonary stenosis due to excessive calcification of the bioprosthesis. Echocardiographic follow-up of the remaining patients showed no evidence of residual or recurrent pulmonary autograft regurgitation or progression of aortic root dilatation. Conclusion: Autograft replacement of the bicuspid aortic valve is challenging, as the geometric mismatch has to be adjusted. Valve dysfunction is avoided by a supra-annular implantation technique, but pseudoaneurysm formation at the base of the non-coronary sinus is a worrying aspect. Patch reinforcement may solve this issue.     

Combined valve replacement and myocardial revascularization

Combining valve replacement with coronary artery bypass (CABG) for significant concomitant disease remains a controversial subject. To determine the operative results following combined valve replacement and CABG, we evaluated 201 patients seen consecutively between July 1977 and June 1982. CABG for vessels with greater than 70% stenosis was performed with aortic valve replacement in 106 patients, with mitral valve replacement in 82, and with aortic and mitral valve replacement in 13. There were 143 men and 58 women; the mean age was 67 years. Nine operative deaths (8.5%) occurred with aortic valve replacement and CABG: 5 of 25 (20%) when cardioplegia was not used and 4 of 81 (4.9%) with cardioplegia (p less than 0.01). The operative mortality rate for isolated aortic valve replacement without coronary disease during the same period was 5.9% (10 of 168). The late actuarial survival rate is similar for aortic valve replacement alone or aortic valve replacement and CABG. There were no operative deaths among patients having undergone aortic and mitral valve replacement and CABG; the rate was 15% (9 of 60) in patients having undergone aortic and mitral replacement and CABG. The operative mortality rate was 21.9% for mitral valve replacement and CABG (18 of 82). Rheumatic disease was present in 14 of these patients, two of whom had early deaths (14.3%), both after repeat mitral operations; 11 mitral valve replacements and CABG were done for degenerative mitral regurgitation with no deaths, and the remaining 57 patients had ischemic mitral regurgitation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Surgical technique of aortic valve replacement for small aortic annulus in elderly patients

Recent reports have shown that aortic valve replacement in elderly patients over 65 years with atherosclerotic aortic stenosis and a small aortic annulus is possible by using a small sized bioprosthesis (Carpentier-Edwards pericardial valve). Here we present out surgical technique. Firstly, the native calcified aortic valve was removed completely to gain total exposure of the surrounding aortic root and sinus of Valsalva like Bentall procedure. Secondly, a small sized bioprosthesis was implanted with intermittent noneverting mattress 2-0 sutures with spaghetti and small polytetrafluoroethylene (PTFE) felt. Aortic annulus is the dilated by inserting Hegar dilator sizing from 25 to 27 mm. Therefore, aortic valve replacement for small aortic annulus in intra- or supra-annular position should be easily accomplished. Good surgical results and hemodynamic state were achieved in 25 consecutive cases using this technique.     

Ten-year survival following aortic valve replacement: A multivariate analysis of coronary bypass as a risk factor

The additional risk of coronary bypass surgery was analysed in 664 patients over 40 years of age undergoing aortic valve replacement between 1969 and 1981. Four hundred sixty-seven patients underwent aortic valve replacement alone, while 197 patients with coronary artery disease underwent combined aortic valve replacement and coronary bypass surgery. There were no significant differences in the preoperative hemodynamic characteristics of the two groups of patients. There were 41 (9%) operative deaths following aortic valve replacement alone and 20 (10%) following aortic valve replacement with coronary bypass surgery. Since 1976, operative mortality has fallen to 5% and perioperative myocardial infarction to 2% following the combined procedure. Ten-year actuarial survival (standard error) was 56 (3%) following aortic valve replacement and 49 (6%) following aortic valve replacement and coronary bypass surgery. A multivariate analysis including both groups of patients revealed that age, functional class and year of operation significantly affected ten-year survival (p less than 0.05). The same analysis showed that coronary artery disease requiring coronary bypass surgery also decreased ten year survival in patients undergoing aortic valve replacement (p = 0.06).