风湿性心脏病二尖瓣和主动脉瓣Ⅰ、Ⅲ型胶原重建的研究

目的　对风湿性心脏病二尖瓣、主动脉瓣胶原重建进行定性、定位、定量研究。方法手术切除风湿性二尖瓣和主动脉瓣组织各 3 0枚 ,尸检中取人正常二尖瓣和主动脉瓣组织各 5枚。应用免疫组织化学技术结合图像自动分析方法观察二尖瓣和主动脉瓣Ⅰ、Ⅲ型胶原分布及含量的变化。结果　正常二尖瓣组织Ⅰ、Ⅲ型胶原分别为 11.78± 0 .86、8.72± 0 .64 ,明显高于主动脉瓣组织 (9.5 6± 0 .3 2、6.82± 0 .3 4) (P <0 .0 5 ) ,二尖瓣Ⅰ /Ⅲ胶原比值 (1.3 6± 0 .0 6)低于主动脉瓣(1.42± 0 .0 8) (P <0 .0 5 ) ;风湿性病变时 ,二尖瓣和主动脉瓣Ⅰ、Ⅲ型胶原含量及Ⅰ /Ⅲ比值均增加 ,分别为 (2 2 .3 2± 2 .82、10 .76± 1.0 8、2 .0 6± 0 .12 )和 (16.86± 2 .3 6、9.12± 1.76、1.86± 0 .3 2 ) ,以Ⅰ型胶原为主 ,明显高于正常对照组 (P <0 .0 5 )。结论　风湿性二尖瓣和主动脉瓣胶原重建以Ⅰ型胶原增加为主 ,呈修复性纤维化改变。     

二尖瓣狭窄分离术后晚期复发病人瓣膜置换术278例分析

目的　探讨风湿性二尖瓣狭窄闭式扩张分离术后晚期复发瓣膜的病理改变 ,及其再次手术方式的选择。方法　 1978年 12月至 2 0 0 1年 12月共收治风湿性二尖瓣狭窄闭式扩张分离术后晚期复发性瓣膜病 2 78例。二尖瓣复发性病变均以狭窄为主合并不同程度的关闭不全。其中合并三尖瓣功能性关闭不全 12 7例 (4 5 7% ) ,合并复发性主动脉瓣病变 33例 (11 9% ) ;二尖瓣与主动脉瓣双瓣膜病变合并三尖瓣病变 6 1例 (2 1 9% )。二尖瓣复发性病变的病理特点主要表现为 (1)交界硬化融合型 4 6例 (16 5 % ) ;(2 )后瓣钙化卷缩型 18例 (6 5 % ) ;(3)交界钙化融合型 177例 (6 3 7% ) ;(4 )瓣膜与瓣下结构钙化型 37例(13 3% )。所有病人均行二尖瓣置换术 ,其中二尖瓣与主动脉瓣双瓣置换术 33例 ;三尖瓣功能性关闭不全作改良DeVega成形术 137例、Kay二瓣化环缩术加用成形环固定 5 1例。 结果　早期死亡 19例(6 8% ) ,主要死因为心力衰竭与多脏器功能衰竭。长期生存 2 5 9例 ,随访率 95 7% ,随访 6个月～ 2 2年 ,累计随访时间 116 2 2年。晚期死亡 15例 ,累计生存率 5、10、15年分别为 85 5 %、71 2 %、6 5 1%。抗凝过量出血的发生率为 1 11%病人·年。结论　风湿性二尖瓣狭窄闭式扩张术后晚期瓣膜复发性病变 ,再次     

自身血清,γ—干扰素对风湿性心脏病患者瓣膜成纤？…

目的 了解风湿性心脏病患者血清及γ－干扰素对瓣对瓣膜成纤维细胞胶原合成的影响，探讨转化生长因子β（ＴＧＦ－β）在瓣膜纤维化中可能起的作用和γ－干扰素用于预防及治疗瓣膜纤维化的可能性。方法 取５例风湿性心脏病患者的二尖瓣和主动脉瓣成纤维细胞进行体外培养并传代，将培养的每一例患者的二尖瓣、主动脉瓣细胞分为７组，每组均为５例。用「２，３－＾３Ｈ」脯氨酸掺入法测定各组细胞的胶原合成。结果 患者自身血清合培     

维持性血液透析患者主动脉瓣和二尖瓣钙化的危险因素

目的 探讨主动脉瓣和二尖瓣钙化发病的相关危险因素。 方法 对符合标准的维持性血液透析（MHD）患者（年龄≥18岁,透析龄>6个月,排除曾因瓣膜疾病行外科手术或介入治疗者）,采用超声心动图检查心脏瓣膜钙化情况。采用Logisitc回归分析主动脉瓣和二尖瓣钙化的危险因素。 结果 在入选的181例（男98例,女83例）MHD患者中,94例（51.9%）主动脉瓣或二尖瓣钙化,其中主动脉瓣钙化90例（49.7%）,二尖瓣钙化30例（16.6%）,主动脉瓣和二尖瓣双瓣膜钙化26例（14.4%）。多因素Logistic回归分析表明年龄（β = 5.52, P = 0.007）、透析龄（β = 6.99,P = 0.039）和前白蛋白（β = -12.616,P = 0.004）与主动脉瓣钙化独立相关;年龄（β = 0.085,P = 0.05）与二尖瓣钙化呈弱正相关;透析龄（β = 6.057,P = 0.002）、原发性高血压病病史（β = 3.054,P = 0.008）、血红蛋白（β = -0.061,P = 0.035）和β2微球蛋白（β = 7.63,P = 0.01）与二尖瓣钙化独立相关。 结论 MHD患者主动脉瓣及二尖瓣钙化多发,且以主动脉瓣钙化更多见。年龄、透析龄和低前白蛋白血症是主动脉瓣钙化的危险因素,而二尖瓣钙化的危险因素包括年龄、透析龄、原发性高血压病病史、贫血和高β2微球蛋白血症。     

风湿性心脏病多瓣膜疾患的外科治疗

在我国，心脏瓣膜病以风湿性最为常见。风湿性心脏瓣膜病主要是二尖瓣病变，部分患者主动脉瓣同时受累，极少数病例病变侵及三尖瓣。其病理改变为瓣叶增厚，特别是瓣叶边缘部分、瓣叶交界融合、瓣口变窄、瓣下结构挛缩以及瓣膜钙化。单纯的主动脉瓣病变很少由风湿性病变引...     

自身血清、γ-干扰素对风湿性心脏病患者瓣膜成纤维细胞胶原合成的影响

目的 了解风湿性心脏病患者血清及γ-干扰素对瓣膜成纤维细胞胶原合成的影响,探讨转化生长因子β(TGF-β)在瓣膜纤维化中可能起的作用和γ-干扰素用于预防及治疗瓣膜纤维化的可能性. 方法 取5例风湿性心脏病患者的二尖瓣和主动脉瓣成纤维细胞进行体外培养并传代,将培养的每一例患者的二尖瓣、主动脉瓣细胞分为7组,每组均为5例.用[2,3-3H]脯氨酸掺入法测定各组细胞的胶原合成. 结果 患者自身血清使培养的瓣膜成纤维细胞胶原合成明显增加,这一作用能被TGF-β中和抗体抑制,γ-干扰素能显著抑制瓣膜成纤维细胞的胶原合成.结论风湿性心脏病患者血清中活性TGF-β升高可能在瓣膜纤维化中起重要作用,γ-干扰素有可能用于临床预防或减轻瓣膜纤维化.     

三瓣膜替换术中自体心包片加宽升主动脉及其瓣环2例

三瓣膜替换术中自体心包片加宽升主动脉及其瓣环２例王奇，朱朗标１９９２年２月和１９９４年５月，我们为２例风湿性心脏病联合瓣膜病变病人行二尖瓣、主动脉瓣及三尖瓣三瓣膜替换术的同时，用自体心包片加宽升主动脉及主动脉瓣环，取得良好效果。现报告如下：临床资料２...     

二尖瓣综合成形术—临床病理研究与手术策略探讨

作者对１６２例二尖瓣成形术中二尖瓣临床病理观察结果和同期摘除的８个瓣膜病理解剖结果进行了分析，以探讨手术策略。Ⅰ型病变６４例，Ⅱ型２３例，Ⅲ型７５例，其中２２例为先天性，２７例退行性变，１例为感染性心内膜炎，余１１２例为风湿性病变。摘除的瓣膜中，７例为风湿性，均为Ⅲ型病变。瓣膜全部结构均受累，瓣叶明显增厚，瓣口呈漏斗或半漏斗型。镜检：增生胶原纤维与瓣叶组织无明显界面，有的腱索并包埋于增厚瓣膜组织中     

二尖瓣、主动脉瓣机械瓣置换术后二尖瓣机械瓣血栓形成一例

患者女,56岁。因二尖瓣、主动脉瓣机械瓣置换术后3.5年,反复发生心累、气促5个月余入院。患者3.5年前因风湿性心脏病,二尖瓣、主动脉瓣双瓣膜病变而行二尖瓣、主动脉瓣机械瓣置换术。所使用瓣膜为St.Jude机械瓣,二尖瓣机械瓣25 mm。     

二尖瓣及主动脉瓣置换术后患者远期的超声心动图特征及其临床意义

目的了解二尖瓣和主动脉瓣置换术后患者远期的超声心动图特征,并探讨其临床意义。方法将1999年1月至2008年6月间四川大学华西医院施行的二尖瓣及主动脉瓣机械瓣双瓣膜置换术、且完成了术后≥5年超声心动图评价的204例患者纳入研究,其中男60例,女144例;年龄15～74（48．42±11．00）岁。术后随访时间5～13（6．34±2．05）年。观察所有患者术前、术后超声心动图指标,并进行比较。结果与术前相比,患者术后左心房径（LA）、左心室径（LV）明显缩小（P〈0．05）,右心室径（RV）、左心室射血分数（LVEF）及左心室缩短分数（LVFS）增加（P〈0．05）。以二尖瓣狭窄为主的患者术后LA、LV、左心房面积（LAA）、左心房容积（LAV）、二尖瓣平均跨瓣压差（MPGmv）、二尖瓣速度时间积分（VTImv）及二尖瓣压力降半时间（PHTmv）均明显减小或降低（P〈0．05）,而二尖瓣有效瓣口面积（EOAmv）、有效瓣口面积指数（EOAImv）明显增加（P〈0．05）;以二尖瓣反流为主的患者术后LA、LV明显缩小（P〈0．05）。以主动脉瓣狭窄为主的患者术后LV、室间隔厚度（IVS）、左心室质量（LVM）、左心室质量指数（LVMI）、主动脉瓣最大前向血流速度（Vav）及平均跨瓣压差（MPGav）均明显减小或降低（P〈0．05）,主动脉瓣有效瓣口面积（EOAav）、有效瓣口面积指数（EOAIav）明显增加（P〈0．05）,而左室后壁厚度（LVPW）变化不明显（P〉0．05）;以主动脉瓣反流为主的患者术后LV、LVM、LVMI、EOAav及EOAIav均明显减小（P〈0．05）,而Vav、MPGav明显增加（P〈0．05）。在二尖瓣部位,与置入25mm瓣膜患者相比,置入27mm瓣膜患者Emv、MPGmv及VTImv均较低（P〈0．05）;在主动脉瓣部位,与置入21mm瓣膜患者相比,置入23mm瓣膜患者Vav、MPGav及VTIav均较低（P〈0．05）。术后远期二尖瓣部位中度人工心脏瓣膜．患者不匹配（PPM）38例（21．3％）,重度PPM4例（2．3％）;术后远期主动脉瓣部位中度PPM50例（24．5％）,重度PPM43例（21．1％）。接受三尖瓣成形术的患者其术后远期三尖瓣反流（TR）程度构成比明显改善（P〈0．05）,而未接受三尖瓣成形术患者其术后远期TR程度构成比明显恶化（P〈0．05）。结论与术前相比,双瓣膜置换术患者术后远期的左心功能及血流动力学指标均得到明显改善,但远非正常;与二尖瓣部位相比,主动脉瓣部位PPM的问题更为突出;由于术后远期TR残流或加重的情况较为普遍,左心手术时积极考虑同期三尖瓣成形手术是必要的。     

儿童心瓣膜病的外科治疗

目的 报告儿童心瓣膜手术的经验。方法 ８７儿童心瓣膜病变患者,男５８例,女２９例,年龄４～１４岁,平均年龄１０．２岁。其中二尖瓣置换术３６例,主动脉置换术１３例,二尖瓣和主动脉瓣双瓣膜置换术６例,主动脉瓣成形术１３例,二尖瓣成形术１９例,所用心瓣膜均为机械瓣。同期处理三尖瓣关闭不全４１全,室间隔缺损２３例,房间隔缺损９例,佛氏窦瘤破裂８例,动脉导管未闭３例。结果 术后早期并发症包括：低心排血量综合     

Nd：YAG激光与强脉冲光非剥脱性嫩肤的动物实验

目的探讨Nd：YAG激光长脉宽波长1064nm与强脉冲光（intense pulsed light,IPL）波长560～1200nm两种波长照射SD大鼠皮肤后组织学变化趋势,为临床非剥脱性光嫩肤的科学治疗提供理论依据。方法应用两种波长照射SD大鼠背部脱毛皮肤,通过HE染色和免疫组织化学染色方法检测真皮厚度、Ⅰ型和Ⅲ型胶原蛋白的表达,并测定平均吸光度值进行半定量分析。结果两种波长照射后真皮厚度、Ⅰ型及Ⅲ型胶原蛋白平均吸光度值均高于正常对照组（P〈0．05）,激光组均又高于IPL组（P〈O．05）,Ⅰ型胶原蛋白平均吸光度增加值均高于Ⅲ型胶原蛋白（P〈0．001）。结论两种波长均可使SD大鼠真皮厚度和Ⅰ型、Ⅲ型胶原蛋白增加,激光组优于IPL组。Ⅲ型胶原蛋白在照射早期增加幅度较高,而Ⅰ型胶原蛋白在照射后期增加幅度较高,提示非剥脱性光嫩肤真皮重塑机制可能与Ⅰ型胶原蛋白增加的时间和量有关。     

升主动脉瘤中结缔组织生长因子的表达与瘤壁病理性重塑的实验研究

目的 研究结缔组织生长因子(CTGF)在散发升主动脉瘤(AAA)中的表达及意义,初步探讨AAA发病中主动脉壁病理性重塑的机制.方法 选择升主动脉瘤术中切除标本18例为AAA组,冠状动脉旁路移植患者术中主动脉标本18例为对照组,HE染色和Masson染色分别检测主动脉壁的一般情况及胶原含量.免疫组化方法检测主动脉壁中CTGF的表达情况并比较其半定量结果,分析CTGF与临床指标的相关性.应用实时PCR的方法检测所有标本中CTGF和胶原Ⅰα1、Ⅲα1(Ⅰ、Ⅲ型胶原)的mRNA表达水平.结果 病理结果显示,与对照组标本比较AAA组标本弹力蛋白降解,胶原纤维增生,平滑肌细胞增生及排列紊乱.AAA组免疫组化结果表明CTGF表达明显增加(44%±4%),主要位于中膜及外膜,对照组表达量较少(33%±5%,P＜0.01).CTGF的mRNA表达与免疫组化结果一致(P＜0.01).AAA中胶原Ⅰα1、Ⅲα1的mRNA水平较对照组高表达(相对表达比值分别为10.54/3.80和1.79/1.19,P＜0.01).相关性分析结果显示CTGF免疫组化半定量结果与胶原纤维半定量结果及主动脉瘤径均呈正相关(r=0.784,P＜0.01;r=0.793,P＜0.01).结论 CTGF在AAA主动脉壁中表达明显增强,Ⅰ、Ⅲ型胶原在AAA中表达增加.CTGF表达与主动脉直径大小密切相关.AAA的发病机制涉及主动脉壁的病理性重塑过程,在各种因子作用下主动脉壁胶原代偿性增加.CTGF可能参与其中并发挥了重要作用.

Abstract：

Objective To study the expression of connective tissue growth factor(CTGF)and its significance in sporadic ascending thoracic aortic aneurysm(AAA), and initially to investigate the mechanisms of pathological remodeling in AAA. Methods AAA specimens were taken from 18 patients during elective surgical intervention, and 18 control specimens of ascending aorta were obtained from patients undergoing coronary artery bypass surgery. Specimens were stained with HE and Masson to evaluate the arrangement and aggregation of cells and collagen types Ⅰ and Ⅲ; immunohistochemistry staining was performed using antibodies directed against markers of CTGF; real-time PCR analysis was performed to quantify the expression level of CTGF and collagen types Ⅰ and Ⅲ. Results Pathological results show degradation of elastin and hyperplasia of collagen fibers as well as disordered arrangement of smooth muscle cells in AAA. When compared with controls, protein levels of CTGF were significantly increased[(44 ±4)% vs.(33 ± 5)%, P ＜ 0. 01]. Similar patterns were shown in mRNA levels of CTGF(P ＜ 0. 01). Using real-time PCR method, elevated levels(relative expression ratio of mRNA: 10. 54/3. 8 and 1.79/1.19,respectively; P ＜ 0.01, both)of collagen types Ⅰ and Ⅲ were observed. CTGF expression had a correlation with both collagen fibers and aortic aneurysm diameter(r = 0. 784, P ＜ 0. 01; r = 0. 793, P ＜0. 01). Conclusions These results indicate increased expression of aortic collagen types Ⅰ and Ⅲ as well as CTGF in AAA specimens, which is likely to be responsible for the aortic wall pathological remodeling.The expression of CTGF was positively correlated with the aortic diameter. As a cytokines factor can stimulate collagen synthesis, CTGF may be involved in the pathogenesis and progression of AAA.     

瓣环结构重建的瓣膜置换手术

目的 总结瓣环结构重建的瓣膜置换手术技术及临床效果.方法 2003年1月至2009年5月59例病人行瓣环结构重建的瓣膜置换手术,其中细小主动脉根部43例,感染性心内膜炎累及瓣环结构13例,钙化性主动脉瓣病变钙化斑累及主动脉瓣环2例,主动脉瓣二尖瓣置换手术后主动脉根部出血1例.行主动脉瓣环重建加主动脉瓣置换术40例,二尖瓣瓣环重建二尖瓣置换术7例,主动脉-二尖瓣纤维环重建加主动脉二尖瓣置换术12例.结果 二尖瓣瓣环重建加二尖瓣置换手术与常规二尖瓣置换手术的主动脉阻断时间差异无统计学意义;而主动脉瓣瓣环重建加主动脉瓣置换以及二尖瓣-主动脉瓣纤维连接重建加二尖瓣主动脉瓣置换手术的主动脉阻断时间均明显延长.本组术后早期死亡4例,占6.7%.术后再次开胸止血2例,Ⅲ度房室传导阻滞2例,呼吸功能不全2例,急性肾功能衰竭2例.术后6个月复查超声心动图,无瓣周漏.结论 瓣环结构重建手术适合于瓣环过小需置人与体表面积相匹配的人工瓣膜、瓣膜病变累及瓣环结构的完整性或手术损伤等情况,尽管其手术操作较为复杂,主动脉阻断和体外循环时问均有所延长,但手术操作引起死亡的比率并未增加.

Abstract：

Objective To investigate the surgical technique and clinical outcomes of reconstruction of the annulus and the intervalvular fibrous body during valve replacements. Methods Fifty-nine patients underwent reconstruction of the annulus or the intervalvular fibrous body during the valve replacement. Indications for the operation were small aortic annulus which may cause patient/prosthesis mismatch in 43, active infective endocarditis with the abscess in the periannulus tissue in 13, extensive calcification of the aortic annulus in 2 and an active bleeding complication of the aortic root after aortic and mitral valve replacement in 1. The reconstruction was done with fresh autologous pericardium. Results The aortic clamping time in reconstruction of the intervalvular fibrous body with double valve replacement was longer than that of the regular double valve replacement. Four patients died in the perioperative period, giving an overall in- hospital mortality of 6.7%. Postoperative complication were: re-sternotomy for bleeding in 2, Ⅲ degree A-V block in 2, respiratory dysfunction in 2, and acute renal failure in 2. Patients were followed up for 6 months by echocardiography study, and no periannular leakage was found. Conclusion Reconstruction of the annulus is an effective technique for patients with a small aortic annulus, extensive calcification of the interventricular fibrous body and active infective endocarditis with abscess. Although the operative procedure is challenging and taking more time, the technique is safe and reproducible.     

Aortic valve calcification is an independent factor of left ventricular hypertrophy in patients on maintenance haemodialysis.

BACKGROUND: Calcification and dysfunction of aortic and mitral valves are frequently found in chronic dialysis patients, but their influence on the development of left ventricular hypertrophy (LVH) is not well defined. METHODS: Conventional echocardiography and Doppler measurement of trans-aortic flow velocity were performed in 135 chronic haemodialysis patients, and left ventricular mass index (LVMI) and trans-valve pressure gradients were calculated. Average values of systolic, diastolic and pulse pressure (PP), interdialytic weight gain, chronic overhydration (difference between mean post-dialysis and dry weights), plasma calcium, phosphate, haemoglobin, and urea reduction ratio over the year preceding this study were obtained in every patient. RESULTS: Aortic valve calcification was present in 105 patients (78%), associated with stenosis in eight (6%); 39 patients (29%) had aortic regurgitation. Mitral annular calcification occurred in 35 (26%) cases and mitral regurgitation in 45 (33%). LVH was observed in 104 patients (77%). Logistic analysis revealed that only aortic valve calcification predicted LVH. LVMI was higher in patients with aortic valve calcification than in those without calcification: (mean+/-SD) 241+/-52 vs 154+/-64 g/m(2), P=0.001. LVMI was not different between patients with normal, calcified, or regurgitating mitral valves. Patients with aortic valve calcification had higher trans-valve peak flow velocities and pressure gradients than those with non-calcified valves: 1.65+/-0.53 vs 1.37+/-0.33 m/s, P=0.01, and 12.1+/-8.9 vs 7.9+/-3.6 mmHg, P=0.01, respectively. The LVMI correlated directly with both variables (r=0.27 and r=0.24, P<0.005). Stepwise linear regression on nine covariates potentially influencing LVMI (age, body mass index, time on dialysis, systolic blood pressure, PP, chronic overhydration, haemoglobin concentration, trans-aortic flow velocity, and urea reduction ratio) showed that LVMI was independently associated with (i) PP, (ii) haemoglobin (inverse correlation), (iii) peak aortic flow velocity, and (iv) chronic overhydration (r=0.502, R(2)=0.252, ANOVA F-ratio=10.19, P<0.0005). CONCLUSION: Our findings show that aortic valve calcification is associated with LVH in chronic haemodialysis patients, probably because valve resistance to ventricular outflow is increased as shown by trans-aortic flow velocities and pressure gradients. The effect on LVMI is independent of PP, anaemia, and overhydration.     

Q开关和长脉宽1064nm Nd:YAG激光真皮胶原重建疗效的比较性研究

目的:本研究拟定量地比较Q开关和长脉宽1064 nm掺钕:钇-铝石榴石(neodymium-yttrium-aluminum garnet,Nd:YAG)激光诱导真皮胶原重建的疗效。方法:应用Q开关和长脉宽1064 nm Nd:YAG激光分别对36只雌性昆明小鼠左侧后背皮肤进行连续4次治疗,每次间隔1周,右侧相应的部位作为自身对照。分别于第1次治疗后1h、1天、7天、21天、30天和60天对小鼠皮肤行活组织取材。应用免疫组化方法分别对皮肤组织样品中真皮I、III型胶原进行检测,染色结果应用Motic医学数字图像分析系统进行定量分析。结果:与正常对照组相比,Q开关1064 nm Nd:YAG激光治疗后7天、21天、30天和60天,真皮I型胶原及III型胶原水平明显增高(均P0.01)。长脉宽1064 nm Nd:YAG激光治疗后21天、30天和60天,真皮I型胶原水平明显增高(均P0.01);激光治疗后7天、21天、30天和60天,真皮III型胶原水平明显增高(分别为P0.01、P0.05、P0.01、P0.01)。两组激光的比较:激光治疗后7天、21天和30天,Q开关1064nm Nd:YAG激光治疗组真皮I型胶原水平较长脉宽1064nm Nd:YAG激光治疗组明显增高(均P0.01),而激光治疗后60天明显降低(P0.05);激光治疗后7天和21天,Q开关1064nm Nd:YAG激光治疗组较长脉宽1064nm Nd:YAG激光治疗组真皮III型胶原水平明显增高(分别为P0.05、P0.01)。结论:Q开关和长脉宽1064nm Nd:YAG激光均可引起真皮胶原重建,但二者的作用效果不尽相同。     

二尖瓣成形术治疗感染性心内膜炎二尖瓣关闭不全

目的 评估二尖瓣成形术治疗感染性心内膜炎的可行性和疗效.方法 1990年10月至2007年7月,83例感染性心内膜炎致二尖瓣关闭不全的病人接受二尖瓣手术.男62例,女21例.41例(49.4%)行二尖瓣成形术(MVP),42例(50.60%)行二尖瓣置换术(MVR).同时行主动脉瓣置换术37例,三尖瓣成形术12例,室间隔缺损修补术4例,冠状动脉旁路移植术2例,主动脉瓣成形术1例,房间隔缺损修补术1例,股动脉取栓术1例.术中18例行食管超声检查评估二尖瓣反流情况.结果 MVP与MVR组病人比较,术前左室收缩末内径(41.63±8.60)mm对(37.69±6.38)mm,P＜0.05;术前射血分数0.62±0.07对0.66±0.76,P＜0.05;术前心功能分级平均(2.88±0.61)级对(2.45±0.71)级,P＜0.01.体外循环47～265min,平均(117.06±46.77)min;主动脉阻断26～210min,平均(86.95±39.07)min;呼吸机辅助呼吸5～120h,平均(21.49±16.06)h.MVP与MVR组病人体外循环和主动脉阻断时间均差异无统计学意义,MVP组气管插管和住ICU时间均显著低于MVR组(P＜0.05).MVR组病人瓣叶赘生物明显多于.MVP组病人(P＜0.05).MVP组术者相对固定.住院死亡3例(3.6%),均为二尖瓣置换病人.出院时病人心功能均为Ⅰ级或Ⅱ级.随访1～165个月,平均(39.33±39.76)个月,随访率95%.MVR组发生瓣周漏1例,反复胸腔积液1例,脑出血2例,其中1例死亡,10年生存率75%.MVP组无死亡,10年生存率100%.结论 感染性心内膜炎二尖瓣病变的病人瓣叶毁损不严重,如术者临床经验丰富,大多可行二尖瓣成形术,并取得良好手术结果.

Abstract：

Objective Valve replacement is a conventional therapy for the mitral insufficiency caused by IE. Mitral valve repair as an optional procedure for the disease has become feasible in recent years. However, concerns from surgeons about the recurrence of endocarditis after mitral valve repair remained. in this study we evaluated the long-term clinical outcomes of patients treated with surgery for the mitral insufficiency caused by infective endocarditis (IE). Methods Between July 1990 and July 2007, 83 consecutive patients (male 62, female 21) with mitral valve IE were enrolled in this study. Forty-one (49.4% )patients received mitral valve repair ( MVP,group A) and 42(50. 6% ) patients received mitral valve replacement ( MVR, group B). Thirty-seven cases had concomitant aortic valve replacement; 1 patient had aortic valve repair; 4 cases had ventricular septal defect repair; 1 case had atrial septal defect repair, 12 cases had bicuspid valve repair; 2 cases had coronary artery bypass graft and 1 case had femoral artery thrombus. Intraoperative transesophageal echocardiography were performed in 18 cases for the evaluation of mitral valve regurgitation. Mean cardiopulmonary bypass time, aortic clamping time and postoperative ventilation time were recorded and analyzed. Mid- and long-term clinical and echocardiographic outcomes were assessed.Results Preoperative left ventricular end systolic diameter, left ventricular ejection fraction and the classification of New York Heart Association in group A were significantly lower than those in group B (P ＜ 0. 05), but no difference was observed between the 2 groups in the cardiopulmonary bypass time and the crossclamping time. However, the intubation time and ICU time were shorter in group A than those in group B ( P ＜ 0.05 ). More vegetations were seen in the MVR group than in the MVP group. Three (3.6% ) patients died after the operation in group B. All patients were assessed as in NYHA Ⅰ-Ⅱ at discharge.A follow-up was done between 1 to 165 months (mean 39 months) with a mean follow-up rate of 95%. In the MVR group, peri-valvular leakage happened in 1 case, cerebral hemorrhage happened in 2 cases and repetitive pleura! effusion in 1 case. One death happened in the MVR group and none in the MVP group. The 10-year survival rate (100% ) in group A was nonsignificantly higher in group A than that (75% ) in group B(P =0.081). Conclusion Mitral valve repair is feasible for treating mitral valve lesions caused by endocarditis, and may provide an optimistic long-term outcome to the patients. The indication for mitral valve repair is mild to moderate mitral valve lesion. Experienced cardiac surgeons, use of antibiotics before and after the operations based on drug-sensitivity test and blood test, as well as follow-up the patients yearly, are important factors for the favorite outcomes.     

Cardiac Valve Calcifications and Left Ventricular Hypertrophy in Hemodialysis Patients

Cardiac valve calcification (VC) is a common finding in end-stage renal disease patients. It was shown recently that VC is an independent predictor for all-cause and cardiovascular mortality in peritoneal dialysis patients. In hemodialysis (HD) patients, VC was associated with all-cause and cardiovascular mortality, but after adjusting for other cardiovascular risk factors and complications, as well as left ventricular mass index (LVMI), it lost significance. The aim of the study was to assess the relationship between VC and left ventricular hypertrophy in hemodialysis patients. Echocardiographic examination with mitral and aortic valves assessment and LVMI calculation was performed in 65 HD patients ages 49 ± 12, with duration of HD therapy 38 ± 32 months. VC were found in 32 of 65 patients (49%)—Group VC(+), mitral valve calcifications (MVC) in 10, aortic valve calcifications (AVC) in 9, and both valves calcifications (MVC + AVC) in 13 patients. Patients with VC were older, on HD therapy were longer, had higher systolic and pulse pressure, and had higher LVMI. Patients with both VCs had the highest LVMI. No significant differences were found with respect to Ca, P, PTH, and mean Ca × P product, but the incidence of Ca × P product above 4.43 mmol²/L² was higher in VC(+) compared with those without VCs. VC coexists with left ventricular hypertrophy, particularly when both valves are calcified. Even short-lasting incidents of increased Ca × P product may lead to cardiac VC.     

心脏不停跳二尖瓣置换术的心肌保护作用

目的　通过与常规心脏停搏二尖瓣置换术的对比研究 ,评价心脏不停跳心瓣膜置换术的心肌保护作用。方法　 2 4例风湿性心脏病行二尖瓣置换术患者随机分为两组 ,每组 12例。实验组 :采用心脏不停跳二尖瓣置换术 ;对照组 :采用常规心脏停搏二尖瓣置换术。于麻醉诱导后、升主动脉开放后 (或心内主要操作完成 ) 2小时、12小时、2 4小时、36小时、48小时和 72小时分别采中心静脉血 ,检测血清心肌肌钙蛋白 I(c Tn I)含量 ;观察心肌超微结构 ;记录心律失常情况、术后多巴胺用量、辅助通气时间和 ICU恢复时间等临床指标。　结果　升主动脉开放后 (或心内主要操作完成 ) 2小时、12小时、2 4小时和 36小时 ,实验组 c Tn I均较对照组低 (P<0 .0 5 ,0 .0 1) ;心肌组织超微结构观察对照组线粒体嵴间隙明显增宽 ,可见嵴断裂 ,实验组线粒体肿胀不明显 ,嵴无断裂。术后临床恢复情况与对照组比较 ,实验组发生心律失常例数少 ,多巴胺用量少 (P<0 .0 1) ,辅助通气和 ICU恢复时间短 (P<0 .0 5 )。　结论　浅低温心肺转流心脏不停跳心内直视手术可减轻心肌缺血 -再灌注损伤 ,有较好的心肌保护作用。