主动脉瓣四叶瓣畸形的外科诊治

目的 提高对主动脉瓣四叶瓣畸形(QAV)的认识,总结术前超声心动图检查的特殊表现,探讨外科治疗的方法及疗效.方法 回顾性分析上海第二军医大学附属长海医院胸心外科2000年1月至2008年12月的766例主动脉瓣手术患者中11例QAV患者的临床资料,其中男9例,女2例,年龄4～55(32±16)岁.结果 本组11例患者占主动脉瓣手术患者的1.4%;其中合并感染性心内膜炎、左上腔静脉、升主动脉瘤、二尖瓣脱垂、三尖瓣关闭不全各1例;术前超声心动图检查明确诊断7例,误诊为单叶畸形1例,误诊为二叶畸形1例,误诊为风湿性改变者2例;术中发现B型7例,A型2例,F型1例,G型1例;11例患者均行主动脉瓣置换术(AVR),同时行主动脉根部拓宽术1例,升主动脉成形术1例,二尖瓣成形术(后瓣矩形切除+"C"成形环术)、三尖瓣成形术(Kay法成形术)各1例.结论 QAV在临床上非常罕见,术前超声心动图检查有助于明确诊断,但有时也存在一定的漏诊率;AVR是治疗QAV的有效措施.     

Current treatment status in patients with severe aortic valve stenosis and outcome of long term follow-up at advanced age: a Chinese single center study

Background  Surgical aortic valve replacement is the standard treatment for patients with severe aortic stenosis, but some registries have indicated that 30% to 60% of these patients are not treated surgically, usually due to advanced age and/or comorbidities. This single center study in China investigated the current treatment status in the patients with severe aortic stenosis and evaluated the long term clinical outcome in advanced age patients whether or not undergoing aortic valve replacement. 

Methods  Clinical data of 867 consecutive patients with severe aortic stenosis between January 2000 and December 2006 were retrospectively analyzed. The patients ≥65 years old were followed up by telephone or information from medical records. The primary end-point was all-cause mortality.

Results  The patients’ average age was (52±19) years (range, 1–91 years), and 34% were women. The percentages of the patients aged <15 years, between 15 and 34 years, between 35 and 54 years, between 55 and 64 years, between 65 and 74 years, and ≥75 years who underwent surgical aortic valve replacement were 82.3%, 87.2%, 88.8%, 78.2%, 65.3% and 22.2% respectively. In the patients (n=256) ≥65 years old, 43.4% had New York Heart Association class III and IV symptoms, 39.1% had hypertension, 33.2% had coronary heart disease, and 3.1% had stroke. In the patients not undergoing aortic valve replacement, 1.6% had renal insufficiency, 4.7% had chronic obstructive pulmonary disease, 2.0% had critical hematopathy, and 0.4% had mammary cancer. A total of 186 (72.7%) patients finished the follow-up, and the average duration of the follow-up was (60±26) months. In the patients between 65 and 74 years old, the total deaths and cardiac deaths in the patients undergoing aortic valve replacement decreased significantly compared with those with conservative treatment (10.3% vs. 53.7%, P <0.001 and 6.3% vs. 50.7%, P<0.001). Similarly, in the patients ≥75 years old, there was a significant difference between patients who had surgery and those who had conservative treatment in the total deaths and cardiac deaths (21.4% vs. 63.3%, P=0.007 and 14.3% vs. 46.9%, P=0.033). The total deaths in the patients aged between 65 and 74 years were significantly fewer compared with ≥75 years old patients (25.4% vs. 54.0%, P <0.001). Cox regression revealed that aortic valve replacement was the only independent predictor of mortality (HR 0.183; 95% CI, 0.101–0.332, P <0.001).

Conclusions  This single centre study showed that surgical aortic valve replacement was still the standard treatment for the patients with severe aortic stenosis and had a satisfying prognosis. However, the high risk patients with advanced age and comorbidities usually selected conservative treatment and had an unfavorable prognosis.

     

Aortic Valve Replacement for Patients with Heyde Syndrome:A Literature Review

Objective To explore the characteristics and clinical outcomes of patients with Heyde syndrome (HS) who undergo aortic valve replacement (AVR).Methods Electronic databases including PubMed,Embase,Ovid,WANFANG,VIP and CNKI were searched to identify all case reports of HS patients undergoing AVR surgery,using different combinations of search terms"Heyde syndrome","gastrointestinal bleeding","aortic stenosis",and "surgery".Three authors independently extracted the dinical data including the patients' characteristics,aortic stenosis severity,gastrointestinal bleeding sites,surgical treatments and prognosis.Results Finally,46 case reports with 55 patients aging from 46 to 87 years,were determined eligible and included.Of them,1 patient had mild aortic stenosis,1 had moderate aortic stenosis,42 had severe aortic stenosis,and 11 were not mentioned.Gastrointestinal bleeding was detected in colon (n=8),jejunum (n=6),ileum (n=4),cecum (n=3),duodenal (n=3) and multiple sites (n=8).No specific bleeding site was identified in 23 patients.Preoperative hemoglobin level ranged from 43 to 117 g/L.All but one of 16 patients showed decreased level of high molecule weight von Willebrand factor.Of the 55 patients,43 underwent AVR,and 12 received transcatheter AVR.Aortic valves of 14 cases were replaced by mechanical valves,and 33 cases by biological valves.All patients recovered well during the follow-up,except 5 patients.One patient who had perivalvular leakage and gastrointestinal bleeding after AVR underwent the second AVR.Two patients had recurrent gastrointestinal bleeding.Two patients died of life-threatening acute subdural hematoma and multiple organ failure,respectively.Conclusions HS is a rare syndrome characterized by aortic stenosis and gastrointestinal bleeding.AVR is an effective treatment for HS.     

Effect of pulmonary autograft transplantation in the surgical treatment of aortic valve disease

Background Aortic root replacement with pulmonary autograft （Ross procedure） has the advantages of good haemodynamics and growth potential without the need for anticoagulation. In this study, we reviewed our experience of the Ross procedure for patients with aortic valve disease. Methods From October 1994 to January 2005, 42 Ross procedures were performed in our centre. There were 30 males and 12 females. The mean age was 28＋15 years （range, 5-56 years）. Congenital heart disease （CHD） with aortic valve stenosis （AS） and/or aortic valve insufficiency （AI） in 40 cases including one associated with ventricular septal defect （VSD）, degenerated aortic valve disease with AS in 1 and subacutive bacterial endocarditis （SBE） with AI in 1 were studied. The diagnosis was made by ultracardiography （UCG） in all patients. The mean aortic valve annulus diameter （AVD） was （2.45±0.31） cm and pulmonary valve annulus diameter （MPVD） was （2.34±0.21） cm. All patients had normal pulmonary valves. The New York Heart Association （NYHA） function class was Ⅱ in 36 cases and Ⅲin 6 cases. The operation was performed under moderate hypothermic cardiopulmonary bypass （CPB） with aortic root replacement using pulmonary autograft and pulmonary valve replacement with a homograft. Results There was no early hospital mortality. Postoperative UCG showed normal aortic valve function in all our patients. The mean gradient across the aortic valve was （6.11±0.12） mmHg. The left ventricular diastole diameter （LVDD） decreased significantly from （62±5） mm to （56±3） mm （P 〈0.001）. The mean postoperative left ventricular ejective fraction （LVEF） was 0.49±0.23. All patients were in NYHA class Ⅰ-Ⅱ. Follow-up was completed in 38 cases for a mean period of 3.2 years （range 1-10 years）. All survivors were in NYHA class Ⅰ with normal neo-aortic and pulmonary valve function. One patient died after secondary operation due to homograft fungal endocarditis 1 year af     

超声心动图诊断二叶式主动脉瓣畸形的价值

目的:分析二叶式主动脉瓣畸形(BAVD)的超声表现,以提高对该病的认识。方法:采用Sequoia 512或GE Vivid7彩超诊断仪,通过经胸超声心动图(TTE)及经食道超声心动图(TEE)检测38例BAVD患者的超声表现,重点于左室长轴及大动脉短轴切面观察主动脉瓣的数目、形态、活动及血流动力学状态。结果:先天性二叶式主动脉瓣畸形在大动脉短轴切面显示为两个瓣叶及两个瓣叶附着点,舒张期呈单一关闭线,38例BAVD中,29例合并主动脉瓣关闭不全(76%),18例合并主动脉扩张(47%),15例合并主动脉瓣狭窄(39%),6例合并主动脉瓣脱垂(16%),13例并发其他先天性心脏畸形(34%)。结论:彩色多普勒超声心动图是诊断BAVD的较好方法,对明确诊断该病及选择相应的治疗方案有重要意义。     

先天性主动脉瓣二叶畸形的外科治疗

目的 总结先天性主动脉瓣二叶畸形患者的临床特点及外科治疗经验.方法 回顾性分析2008年1月-2010年12月我科行外科手术治疗的先天性主动脉瓣二叶畸形患者34例,年龄23-78(51.0±12.4)岁,其中男性28例(82.3%),女性6例(17.6%).单纯主动脉瓣狭窄10例(29.4%),主动脉瓣狭窄伴关闭不全19例(55.8%),单纯主动脉瓣关闭不全5例(14.7%).合并主动脉根部扩张30例(88.2%),合并感染性心内膜炎6例(17.6%).行单纯主动脉瓣置换术32例,行Bentall 术1例,主动脉瓣置换+ 升主动脉置换术1例.其中21例植入机械瓣,13例植入生物瓣.结果 无死亡及其他严重并发症.术后超声心动图示升主动脉内径((45.4±5.9)mm vs(40.9±6.5)mm,P<0.05)及左室舒张末内径(LVEDD)((56.9±15.5)mm vs 年44.3±9.0)mm,P<0.05)较术前明显减小.结论 先天性主动脉瓣二叶畸形合并主动脉根部扩张要根据病情行不同方式手术.     

老年性退行性主动脉瓣的外科治疗

目的探索总结老年性退行性主动脉瓣替换术的经验。方法31例老年性退行性主动脉瓣患者，其中主动脉瓣狭窄21例、主动脉关闭不全2例、主动脉瓣合并二尖瓣3例、主动脉瓣合并冠状动脉硬化5例。术中主动脉表面超声扫描，主动脉钙化5例。升主动脉采用球囊阻断、手术方法有单纯瓣膜替换、瓣膜替换加冠状动脉旁路术。结果1例因升主动脉严重钙化，叩之似“水泥管道”，考虑升主动脉切开后难于关闭而放弃手术。其余病例手术顺利，无脑及外周器官栓塞并发症。1例应用双侧乳内动脉行旁路术者，术后12 d发生胸骨裂开，全麻下行Rob iscek胸骨固定术，3周后恢复出院。结论术中升主动脉表面超声扫描是一种可靠简便的判断升主动脉硬化的方法。手术时尽量减少升主动脉操作，升主动脉球囊阻断是一种简单可靠的方法。     

105例儿童心脏瓣膜置换术分析

目的探讨儿童心脏瓣膜病的病因、手术指征、瓣膜选择和术后抗凝等问题。方法回顾性分析1984年5月至2004年5月间105例接受瓣膜置换术的儿童患者临床相关资料。患者年龄1.5～16(13±3)岁;其中先天性心脏瓣膜病43例,风湿性心脏瓣膜病55例,感染性心内膜炎7例;二尖瓣置换58例,主动脉瓣置换28例,三尖瓣置换5例,二尖瓣和主动脉瓣双瓣置换13例,二尖瓣和三尖瓣双瓣置换1例,三尖瓣成形26例;术前心功能Ⅱ级36例,Ⅲ、Ⅳ级69例。所有患者均采用人工机械瓣膜,置换术后患者均长期口服小剂量华法令抗凝。结果早期死亡5例(4.8%),主要为术后严重低心排血量综合征。随访6个月～20年,平均(10±4)年,随访91例,失访9例。晚期死亡4例,2例死于感染性心内膜炎,1例死于顽固性心衰,1例死于严重心律失常。随访到的87例存活者恢复良好,未发现有与抗凝相关的严重并发症,瓣膜功能良好,心功能均为Ⅰ～Ⅱ级。结论儿童心脏瓣膜置换术采用机械瓣效果良好,术中应尽可能采用较大型号的瓣膜,手术同期纠正合并畸形、术后低强度抗凝是安全可靠的。     

改良Manouguian法联合主动脉环上瓣置入的临床应用

目的 介绍改良Manouguian法主动脉瓣环扩大成形术联合环上瓣置入在成人双瓣膜置换术中应用的临床效果。方法 从2004年8月～2007年6月，选择12例（男4例，女8例；年龄47.7±11.5岁）二尖瓣、主动脉瓣双瓣膜病变伴主动脉瓣环窄小的患者，术中测得主动脉瓣环直径17～21mm。采用改良Manouguian法扩大主动脉瓣环，主动脉瓣位置入ATS AP（环上瓣）机械瓣，二尖瓣位置入ATS 标准机械瓣，行双瓣膜置换术。主动脉瓣位置入ATS AP瓣18mm 2例，20mm 8例，22mm 2例。二尖瓣位置入ATS 标准瓣25mm 8例，27mm 4例。术后3～12个月行多普勒超声心动图检查。结果 本组无手术和住院死亡病例。术后3个月随访，心功能I级8例，II级2例。多普勒超声心动图检查未发现PPM现象。结论 二尖瓣、主动脉瓣双瓣膜病变伴主动脉瓣环窄小的成人患者在双瓣膜置换术中采用改良Manouguian法行主动脉瓣环扩大成形术联合使用ATSAP机械瓣，可置入足够大的人工瓣膜，以提高手术的成功率和远期疗效。     

国人主动脉瓣狭窄主动脉根部解剖的研究

目的:随着经导管主动脉瓣置换术的发展,了解主动脉根部的解剖对于主动脉瓣瓣膜支架的选择和减少并发症是非常必要的?方法:34例主动脉瓣狭窄患者及39例正常对照行双源CT(Dual Source CT,DSCT)及经胸心脏超声(transthoracic echocardiography,TTE)检查,DSCT在斜冠状面及矢状面分别测量收缩末期及舒张末期主动脉根部各径线,瓣环直径和左室流出道直径?超声测量主动脉根部及左室流出道直径,并且和DSCT测量值对比?结果:主动脉瓣狭窄组左冠状动脉(left coronary ostia,LCO)高度?右冠状动脉(right coronary ostia,RCO)高度?冠状窦(sinus of Valsalva,SV)直径?左右冠状窦高度与对照组相比,差异无统计学意义;主动脉瓣狭窄组瓣环(aortic annulus,AA)直径?主动脉窦和升主动脉连接处(Sino-Tubular Junction,STJ)直径?升主动脉 (ascending aorta,AO) 直径?左室流出道 (left ventricular outer tract,LVOT) 直径?主动脉瓣和二尖瓣之间纤维结构(continuity fibrous,CF)距离,室间隔 (interventricular septum,IVS) 厚度明显比对照组大(P < 0.05)?主动脉瓣狭窄组及对照组收缩末期AA?SV?STJ?AO直径?IVS厚度明显比舒张末期大(P < 0.05),收缩末期LVOT直径明显比舒张末期小(P < 0.05)?主动脉瓣狭窄组及对照组AA及LVOT直径冠状面测量值均大于矢状面测量值?主动脉根部直径(AA?SV?STJ?AO)TTE测量值与DSCT测量值相比,相关性好(相关系数分别为r = 0.84,r = 0.87,r = 0.82,r = 0.82),差异均有统计学意义(P < O.05)?结论:主动脉瓣狭窄患者主动脉根部扩张?左室流出道变长扩张?室间隔变厚及冠状动脉变异较大,由于TTE的诊断作用有限,因此经导管主动脉瓣置换患者术前进行DSCT检查对于瓣膜支架的选择及减少并发症有重要意义?     

A Clinicopathological Study on Aortic Valves in Children

In order to investigate the clinicopathological characteristics of aortic valve disease in children, all the native surgically excised aortic valves obtained between January 2003 and December 2005 were studied macroscopically and microscopically. The patients’ medical records were reviewed and the clinical information was extracted. According to preoperative echocardiography, intraopera- tive assessment, and postoperative pathology, combined with clinical symptoms and signs, aortic valve diseases were divided into three categories: aortic stenosis (AS), aortic insufficiency (AI), and aortic stenosis with insufficiency (AS-AI). The etiology was determined according to the macro- scopic, microscopic and clinical findings. The results showed that among 70 aortic valves, patient age ranged from 6 to 18 years, with a mean of 15.4 years, and there were 56 boys and 14 girls (male: fe- male=4:1). Forty-four children only had pure aortic valve disease, and the other 26 children had aor- tic valve disease associated with other heart valve diseases. There were 5 cases of AS (7.14%), 60 cases of AI (85.71%) and 5 cases of AS-AI (7.14%). The causes were congenital aortic valve mal- formation (32 cases, 45.71%), rheumatic disease (28 cases, 40%), infective endocarditis (7 cases, 10%), Marfan syndrome (2 cases, 2.86%), and undetermined (1 case, 1.43%). It was concluded that the common causes of aortic valve disease in order of frequency in children were congenital aortic valve malformation, rheumatic disease, infective endocarditis, and Marfan syndrome. AI was more common in children with aortic valve disease. Compared with adult patients, congenital bicuspid aor- tic valve in children was often AI. Histologically, the leaflets of congenital bicuspid aortic valve were mainly myxomatous, fibrosis and calcification less seen. AI was frequently found in rheumatic dis- ease, mostly associated with other heart valve diseases. Macroscopic and microscopic examinations together with clinical information, echocardiographic findings and operative details were important in evaluating the etiology of aortic valve disease.     

白塞氏病致主动脉瓣关闭不全的外科治疗

目的总结白塞氏病所致主动脉瓣关闭不全的外科疗效,探讨相关手术方式.方法回顾性分析1997年4月～2004年5月在我院收治的白塞氏病所致主动脉瓣关闭不全的病例8例,其中外院术后再次入院2例,我院首次收治6例.外院2例首次均在外院行主动脉瓣替换术(AVR),转入我院后1例行AVR,1例行同种主动脉Bentall手术.我院首次收治6例中,3例行AVR,3例行主动脉根部替换术(ARR),ARR中Bentall手术2例,Cabrol手术1例.结果住院期间1例患者因左心衰竭死亡.随访3～36个月(平均26个月间),无1例患者死亡.首次AVR术后5例,因机械瓣松动二次手术2例;三次手术2例,包括1例二次行同种主动脉Bentall手术后再次行AVR;余1例瓣膜松动尚未手术.首次即行根部替换术的3例,术后无瓣膜松动和瓣周漏发生.结论白塞氏病所致主动脉瓣关闭不全应首选主动脉根部替换术.     

单中心100例经导管主动脉瓣置换(TAVR)结果分析

目的 报道单中心100例经导管主动脉瓣置换术(transcatheteraortic valve replacement,TAVR)结果,总结相关经验。方法 连续入选2010年10月至2018年3月在我中心行TAVR的主动脉瓣狭窄患者100例,观察分析手术成功率、死亡率、术后并发症等结果。结果 患者平均年龄(78.1±6.8)岁,其中男性68例,胸外科协会(Society of Thoracic Surgeons's,STS)平均分数9.9±6.0。12例患者经颈动脉途径,87例经股动脉,1例经升主动脉。均使用自膨胀瓣膜,手术成功率97%。术中预扩张球囊平均大小(19.6±2.0) mm,后扩张球囊平均大小(21.4±2.2) mm,瓣膜植入平均深度为瓣环下(4.3±3.4) mm。术前、术后平均跨主动脉瓣压分别为(51.3±19.7) mmHg和(11.7±6.1) mmHg (P<0.001),术前、术后瓣口面积分别为(0.6±0.2) cm2和(1.7±0.5) cm2 (P<0.001)。随访30天内,死亡率为2%,中风发生率为1%,永久心脏起搏器植入率9%,TAVR术后起搏器植入组与非起搏器植入组的瓣膜植入深度分别为(7.2±3.1) mm和(4.2±3.3) mm (P=0.011)。二叶式主动脉瓣组与三叶式主动脉瓣组在并发症及血流动力学方面未见明显异常。结论 TAVR对我国主动脉瓣狭窄患者具有较高的安全性及有效性,二叶式与三叶式主动脉瓣膜的手术结果相似。TAVR永久性起搏器植入发生率较低,这与植入深度密切相关,可能与较小球囊扩张有关。     

经导管主动脉瓣膜植入与常规主动脉瓣膜置换手术在多风险因素主动脉瓣狭窄患者中的应用

［摘要］ 目的评价经导管主动脉瓣膜植入（transcatheter aortic valve implantation,TAVI）与常规主动脉瓣膜置换在高风险因素患者中应用的安全性及效果。 方法选择主动脉瓣狭窄患者80例,按手术方式分为常规组47例、小切口组18例和TAVI组15例。常规组采用常规开胸主动脉瓣膜置换手术,小切口组采用胸骨上段小切口主动脉瓣膜置换手术,TAVI组采用全身麻醉非体外循环下TAVI。比较3组患者手术效果及并发症发生情况。 结果小切口组24 h引流量明显少于常规组（P＜0.01）。常规组和小切口组阻断时间差异无统计学意义（P＞0.05）。小切口组手术时间、呼吸机辅助通气时间、重症监护室（intensive care unit,ICU）停留时间短于常规组,术中出血量少于常规组（P＜0.01）;TAVI组手术时间、呼吸机辅助通气时间、ICU停留时间短于常规组和小切口组,术中出血量少于常规组和小切口组,平均动脉压（mean artery pressure,MAP)变化值大于常规组和小切口组,住院费用多于常规组和小切口组（P＜0.05或P＜0.01）。3组并发症发生率差异无统计学意义（P＞0.05）。 结论TAVI手术在治疗高风险因素的患者中较常规主动脉瓣膜置换手术安全性高,创伤小,并发症少,恢复快,值得临床推广应用。     

年龄对风湿性主动脉瓣置换术后患者生活质量影响的前瞻性研究

目的研究年龄对风湿性主动脉瓣置换术后患者生活质量的影响。方法采用前瞻性队列研究方法,将符合入选条件的2010年3月至2010年12月期间在长海医院接受主动脉瓣置换术的风湿性心脏病患者根据年龄分为3组: A组, <45岁; B组, ≥45岁且<65岁;C组, ≥65岁,每组14例。使用SF-36量表评估患者术前和术后不同时间(3、6、12个月)的生活质量。采用配对非参数Wilcoxon秩和检验分析3组术后与术前生活质量评分的变化;采用重复测量方法分析年龄对患者术后生活质量评分的影响。结果(1)与术前相比,A、C两组术后3个月生理职能(RP)、总体健康(GH)、活力(VT)和精神健康(MH)等4个维度,以及术后6、12个月SF-36量表8个维度评分差异均有统计学意义 (P<0.05);B组术后3个月RP、GH、VT和社会职能(SF)等4个维度评分差异均有统计学意义 (P<0.05),术后6个月除MH外,余7个维度差异均有统计学意义 (P<0.05),术后12个月,8个维度评分差异均有统计学意义 (P<0.05)。(2)各组之间比较,除A组GH评分趋势显著好于B、C两组(P=0.000)外,余7个维度评分差异均无统计学意义。结论风湿性主动脉瓣置换术后患者生活质量有明显改善;年龄不是影响患者术后生活质量的危险因素,但对年轻患者及时行手术治疗更有利于其GH的恢复。     

室间隔缺损合并主动脉瓣关闭不全的外科治疗

报告8例室间隔缺损合并主动脉瓣关闭不全的临床特点及治疗方法。发病率占同期室间隔缺损修补术的5.3％，其中1例行单纯室间隔缺损修补；1例行空间隔缺损修补及主动瓣成形矫治术；6例行室间隔缺损修补加主动脉瓣置换术。术后早期死亡1例，其余病例手术效果满意。我们对发病机制，不同类型的主动脉瓣病变采用不同的手术方法进行了分析和讨论。     

50岁以上的主动脉瓣病变患者的外科治疗:附73例报告

目的对73名50岁以上的中老年患者进行回顾性分析,探讨该人群先天性二叶主动脉瓣畸形发病特点、外科治疗策略及术后并发症情况。方法 2009年1月～2011年9月收治73名50岁以上的中老年主动脉瓣病变患者,其中男性45人,女性28人,年龄51～75岁,平均年龄为(61.8±0.7)岁。患者中1例行Bentall术,1例行Wheat术,其余全部接受了主动脉瓣置换手术,同时行主动脉瓣,二尖瓣双瓣置换术7例,合并行二尖瓣成形术6例,三尖瓣Devega环缩术11例,冠状动脉搭桥术8例,主动脉-左室隧道修补术1例,左房血栓取出术1例,射频消融术1例。结果患者围手术期死亡2例。手术体外循环时间为78～217 min,平均(131.9±6.0)mln;阻断时间56～158 min,平均(88.2±4.8)min。ICU时间为(23.0～647.4)h,平均(97.9±10.5)h。术后并发症包括5例低心排综合征;4例术后出血行再次开胸止血术;术后伤口清创4例;1例术后急性肾功能衰竭需行血液透析。术后左心室舒张末期内径较术前有明显减小[(52.6±1.7)mm vs(43.2±1.0)mm,P=0.001],手术前后左室射血分数无明显变化[(62.2±2.5)vs(65.5±1.3),P=0.257]。结论完善的术前检查、充分的术前风险因素评估、围术期的早期干预、手术策略制定上考虑患者耐受程度、预防手术并发症对降低手术死亡率是非常必要的。通过以上处理,可以将中老年二叶主动脉瓣膜置换术的手术风险降低到与同期瓣膜置换手术相似或者更低的水平。     

钙化性心瓣膜病319例超声心动图分析

报告４０岁以上经二维超声心动图检查者１６４９例，检出瓣膜（瓣环）钙化３１９例。男性瓣膜（瓣环）钙化（２２７／１０１２）的检出率（２２．４３％）是女性（９２／６３７）检出率的（１４．４４％）１．６倍。男女的检出率都随年龄增加而增高，男性７０岁年龄组的检出率为５０岁年龄组的３．３倍，女性为４．１３倍。主动脉瓣膜（瓣环）钙化与其他瓣膜（瓣环）钙化比较，男性为２４．４７倍，女性为１４．５１倍。在２２２例诊断为心血管病的瓣膜（瓣环）钙化者中，冠心病占７０．７％。主动脉瓣口返流在本组资料中，单纯主动脉瓣钙化与单纯主动脉瓣环钙化比较无显著差异（Ｐ＞０．０５）     

主动脉根部正常的二叶式主动脉瓣(BAV)狭窄伴升主动脉瘤样扩张的手术治疗

 目的  对二叶式主动脉瓣(bicuspid aortic valve,BAV)狭窄伴升主动脉瘤样扩张患者进行回顾性分析,探讨其发病特点及手术方式的选择。方法  回顾分析复旦大学附属中山医院自2004年6月至2012年8月治疗的60例BAV狭窄合并升主动脉瘤样扩张患者行升主动脉瓣替换加主动脉替换(aortic valve replacement,AVR)术的资料。采用超声心动图测量主动脉根部内径、升主动脉内径及射血分数(ejection fraction,EF)值,部分患者行CT检查,对术前、术后及随访数据进行比较。结果  手术死亡3例(5%),出院的57名患者随访到53例,随访率92.9%。随访时间平均(20.3±18.6)个月,所有患者均行超声心动图检查。超声心动图测量主动脉根部内径为28~47 mm,平均(38.2±4.1) mm,较术前差异无统计学意义(P>0.05),升主动脉内径为26~35 mm,平均(31±2) mm;EF为0.49~0.71,平均0.6±0.2,无出院后死亡病例。结论  BAV狭窄伴升主动脉瘤样扩张患者,如其主动脉窦管部内径仍在正常范围内,可考虑行AVR加升主动脉替换术,该手术操作简单,手术风险降低,术后近期效果较好,远期疗效与Bentall术相近。     

主动脉瓣返流对顺式阿曲库铵临床药效学的影响

【目的】 对比研究顺式阿曲库铵在主动脉瓣关闭不全(AI)中重度主动脉瓣返流患者诱导阶段药效学的改变&#65377;【方法】 30例患者纳入此项研究中:实验组选择主动脉瓣关闭不全,中重度返流择期行主动脉瓣瓣膜替换术患者15例(AI组)&#65377;另选择15例行普通外科手术的非心脏病患者作为对照组(C组)&#65377;两组患者均给予芬太尼5 μg/kg + 异丙酚0.5 ~ 2 mg/kg + 顺式阿曲库铵0.1 mg/kg(2倍ED95)麻醉诱导,麻醉维持采用异丙酚 + 瑞芬太尼的全凭静脉麻醉方式&#65377;应用TOF-WATCH SX加速度仪记录顺式阿曲库铵的起效时间&#65380;无反应时间&#65380;临床作用时间及恢复指数&#65377;【结果】 AI组的起效时间(min)较C组明显延长 (5.6 ± 0.8 vs 3.4 ± 0.4,P < 0.001)&#65377;两组患者的恢复时间和恢复指数差异没有显著性&#65377; 【结论】 顺式阿曲库铵用于中重度主动脉关闭不全患者的麻醉诱导,和对照组比较药物起效时间明显延长,但持续时间恢复指数并没有区别&#65377;