经胸超声心动图评估人工机械主动脉瓣血管翳清除术及再次置换术的安全性及有效性

目的：本研究对比人工机械主动脉瓣血管翳患者采用血管翳清除术与再次置换术两种手术方式的围手术期临床结果及术前、术后经胸超声心动图（transthoracic echocardiogram, TTE）参数，探讨人工机械主动脉瓣血管翳清除术及再次置换术的安全性及有效性。方法：复旦大学附属中山医院自2019年9月至2022年3月外科手术中证实41例人工机械主动脉瓣梗阻原因为血管翳。其中17例采取血管翳清除术，而保留原有的人工机械瓣，24例采取人工机械主动脉瓣再次置换术。结果：两种手术方式在术前及术后1周TTE检测指标跨瓣峰值流速（transvalvular peak velocity, Vmax），跨瓣峰值压差（transvalvular peak pressure gradient, PGmax），跨瓣平均压差（transvalvular mean pressure gradient, TMPG），左心室舒张末期内径（left ventricular end-diastolic diameter, LVEDD），左心室收缩末期内径（left ventricular end-systolic diameter, LVSDD）及左心室射血分数（left ventricular ejection fraction，LVEF）两组间均无统计学差异，术前TTE两组均符合手术指征，术后两组TMPG均低于20mmHg。术中再次置换组较血管翳清除组体外循环时间及主动脉夹闭时间明显延长，两者差异具有统计学意义（P<0.001），体外循环时间与术后第１天复查血清肌钙蛋白T（cardiac troponin T, cTnT）增高呈中等正相关关系（rs=0.543,P<0.001）。术后第1天再次置换组白细胞（white blood cell, WBC）高于血管翳清除组（P<0.05）。术后住院期间再次置换组的患者并发症发生共10例（41.6%），其中包括2例为严重的多器官功能障碍，住院期间死亡人数为4例（16.7%）；而血管翳清除组出现并发症仅有４例（23.5%），无围手术期死亡。结论：围手术期临床结果及TTE指标显示血管翳清除术是一种安全有效的手术方式。TTE是人工机械主动脉瓣置换术后长期随访有效影像学手段。

The safety and efficacy of pannus removal or aortic valve re-replacement evaluated by transthoracic echocardiogram

Objective: This study investigated the perioperative clinical outcome and evaluated transthoracic echocardiogram(TTE) data between the simple pannus removal and the repeat aortic valve replacement to determine the safety and efficacy of simple pannus removal in patients with mechanical aortic valve dysfunction for pannus overgrowth. Methods: From September 2019 to March 2022, 41 cases of the mechanical aortic valve obstruction were confirmed pannus overgrowth underwent reoperation.Among them, 17 cases received the excision of pannus with preserving the prior implanted prosthesis and 24 cases accepted the repeat aortic valve replacement (AVR) .Results: There was no significant difference between procedures in mechanical aortic in aortic transvalvular peak velocity (Vmax),transvalvular peak velocity(PGmax) ,transvalvular mean pressure gradient (TMPG), left ventricular end-diastolic diameter(LVEDD), left ventricular end-systolic diameter(LVSDD) and left ventricular ejection fraction(LVEF).The preoperative TEE data of two groups had reached the indications for surgery, and both postoperative TMPG was below 20mmHg. Significant differences were acquired between procedures in cardiopulmonary bypass and aortic cross-clamp time (P < 0.01). There was a moderate positive correlation between CPB and postoperative serum troponin T (cTnT) (rs=0.543,P<0.001). White blood cells (WBC) of valve re-replacement on the first postoperative day was significantly higher than that in Pannus resection group (P<0.05). During postoperative hospitalization, 10 cases emerged complications (41.6%) , including 2 severe multiorgan dysfunction and 4 deaths (16.7%), while only 4 cases(16.7%) had complications in the pannus removal group without perioperative death. conclusion: The clinical indicators and TTE data show that pannus removal is a safe and effective procedure, with low postoperative complications and perioperative mortality. TTE can be used as an effective imaging method for long-term follow-up after mechanical aortic valve replacement.