心脏瓣膜替换术122例分析

本院自１９８４年３月至１９９２年１２月，应用侧倾碟瓣、牛心包生物瓣和Ｓｔ．Ｊｕｄｅ瓣施行心脏瓣膜替换１２２例。除１例外，病因均为风湿性病变。二尖瓣替换９６例，双瓣膜替换１７例，主动脉瓣替换９例。心功能（ＮＹＨＡ）Ⅲ级者７８例，Ⅳ级者２１例。术后１个月内死亡１５例（１２．３％）。死亡原因主要为心室颤动，细菌性、霉菌性心内膜炎，低心输出量综合征等。８３例随访６～９６个月，晚期死亡５例。余均症状改善，多数已恢复工作。本文还就换瓣手术指征，心室颤动的原因，重症患者机械呼吸的应用，术后心内膜炎等问题进行讨论。     

儿童三尖瓣下移的外科治疗

本文报道5例儿童三尖瓣下移畸形的手术治疗。术中发现3例为隔瓣叶和后瓣叶下移至右心室。2例为三个瓣叶附着在正常瓣环,但瓣叶和乳头肌发育不全,有3例合并房间隔缺损。4例施行瓣膜替换术,1例施行上腔静脉右肺动脉吻合术,术后均顺利恢复。     

49例儿童心脏瓣膜替换术的经验

目的：报告儿童心脏瓣膜替换术的经验。方法：４９例儿童心脏瓣膜替换者，男３４例，女１５例，年龄５～１４（平均１１６）岁。其中行二尖瓣替换术３２例、主动脉瓣替换术１０例、二尖瓣加主动脉瓣双瓣替换术５例、三尖瓣替换术２例，所用心脏瓣膜均为机械瓣。同期处理合并的心脏病变。结果：术后早期并发症包括：低心输出量综合征５例，呼吸衰竭２例，心律失常２例。其中早期死亡３例，死亡率６１２％。随访０５～１３（平均５４７）年，晚期死亡３例（６５２％）。结论：儿童心脏瓣膜替换时，人工心脏瓣膜尽量选用成人型号，术后常规行华法林抗凝，并要重视对风湿性心脏病瓣膜替换患儿风湿活动的治疗     

猪瓣膜替换二尖瓣患者瓣膜功能失调18例分析

本文报道应用猪瓣膜替换二尖瓣后长期生存150例,其中已有18例因发(?)猪瓣膜功能失调而再次施行瓣膜替换术。18例患者有心悸、气急、疲劳和胸痛等症状。主要的诊断依据是出现新的杂音,超声心动图和多普勒检查发现瓣膜破损和反流。瓣膜损害是瓣叶钙化和严重纤维组织增生,其中7例有慢性感染。再次替换18例损破的猪瓣膜,应用机械瓣12个,弹性支架猪瓣6个,手术存活13例,死亡5例。     

244例瓣膜替换及术后抗凝临床分析

目的总结心脏瓣膜疾病行瓣膜替换及术后抗凝治疗经验。方法2001年10月至2009年6月共收治各类瓣膜替换患者244例,男性97例,女性147例,年龄16-76（42．8±11．4）岁。心功能Ⅱ级66例、Ⅲ级127例、Ⅳ级51例。二尖瓣替换（MVR）127例,二尖瓣及主动脉瓣替换（DVR）76例,主动脉瓣替换（AVR）38例,乏尖瓣替换（TVR）1例,DVR＋TVR2例。同期行三尖瓣成形46例、房颤改良射频消融31例、冠状动脉旁路移植（CABG）3例。结果手术死亡7例,余均治愈出院。随访2个月至8年,失访14例,2例猝死,不明原因死亡3例。存活在访者2例出现脑出血,2例脑梗塞,1例双下肢动脉栓塞。心功能I级122例、Ⅱ级83例、Ⅲ级13例。结论瓣膜替换术治疗各种原因导致的严重瓣膜病变疗效好,术后低剂量抗凝,须定期复查,随时调整华法林剂量。     

重症心脏瓣膜病合并巨大左心室的外科治疗

目的　总结心脏瓣膜病合并巨大左心室外科治疗经验。方法　对 34例巨大左心室心脏瓣膜病人 (L VEDD>70 mm,L VESD>5 0 m m,EF<0 .5 ,FS<0 .2 5 )施行心脏瓣膜替换术。心肌保护方法分别采用冷晶体停搏液灌注 ;温氧合血持续灌注和心脏不停搏心内直视手术。瓣膜缝合采用连续缝合。结果　本组治愈 32例 ,早期死亡 2例 ,术后C/ T、L VEDD较术前明显改善 (P<0 .0 1) ;L VESD、L VESVI也较术前改善 (P<0 .0 5 )。 L VEF、L VFS与术前比较无显著差异 (P>0 .0 5 )。随访 6个月～ 7年 ,晚期死亡 2例。心功能恢复 级者 2 1例 , 级者 8例 , 级者 1例。结论　巨大左心室心脏瓣膜病人经充分的术前准备后仍应考虑手术治疗 ,选择良好的手术时机对手术的成败具有重要意义 ;温氧合血持续灌注和心脏不停搏技术的应用及保留二尖瓣瓣叶及瓣下结构对提高手术成功率有一定帮助 ;合理的围术期处理是手术成功的重要一环。     

复发性心脏瓣膜病再次外科治疗效果及其相关因素

目的:回顾性分析对二尖瓣闭式扩张术、瓣膜成形术、瓣周漏、人工机械瓣功能障碍、生物瓣衰坏等原因引起的复发性瓣膜病变进行再次手术的效果和相关因素。方法: 复发性瓣膜病患者331（男143,女188）例,年龄12～73(46±12)岁,两次手术间隔时间2月～25(17±8)年。其中二尖瓣闭式扩张术后再狭窄143例,二尖瓣或主动脉瓣成形术后瓣膜病变复发53例,生物瓣衰坏32例,瓣周漏26例,换瓣术后其它瓣膜病21例,人工瓣膜替换或瓣膜成形术后心内膜炎17例, Ebstein畸形矫治术后三尖瓣关闭不全15例,人工瓣膜机械功能故障9例,室间隔缺损修补术并行瓣膜成形术后心内膜炎7例,完全或部分性心内膜垫缺损和矫正性大动脉转位术后二尖瓣或三尖瓣关闭不全6 例,二尖瓣球囊扩张术2例。再次手术方式为二尖瓣替换术,主动脉瓣替换术,二尖瓣和主动脉瓣替换术,三尖瓣替换术,瓣周漏修补术及三尖瓣成形术等。结果: 全组共死亡27例,占8.2％,早期主要死亡原因为低心排出量综合征、室性心律失常、多脏器功能衰竭、左心室破裂、感染性心内膜炎、肾功能衰竭。随访259例,随访期6月～21（10±7）年,心功能恢复至Ⅰ～Ⅱ级189例。复发性心脏瓣膜病再次手术的危险因素包括术前心功能差、重要脏器功能不全、急诊手术、主动脉阻断时间和体外循环时间长等。结论: 针对再手术相关的危险因素进行积极防治,适时而妥善的外科手术和围手术期处理仍可获良好效果。     

390例巨大心脏瓣膜替换术中体外循环管理经验

本文报告了390例巨大心脏瓣膜替换术体外循环管理及心肌保护的方法。一般情况本组男性158例，女性232例，年龄17～70岁，体重38～90kg，心功能Ⅱ级73例，Ⅲ级229例，Ⅳ级88例。心胸比率07～0．79者280例（71．8％），0．8～0．89者97例（249％），大于0．9者13例（3.3％）。有记录的左室舒张末期内径，见表1。体外循环时间57～329分，平均时间112分。心肌血运阻断时间28～270分，平均时间86分。手术种类见表2。表1左室舒张末期内径表2手术种类注：MVR二尖瓣替换术，AVR主动脉瓣替换术DVR双瓣替换术，TVR三尖瓣替换术方法本组均应用性能…     

风湿性心脏瓣膜替换术后远期疗效观察

目的:分析风湿性心脏病瓣膜替换术后远期疗效及其影响因素。方法:我院1980年-2004年施行心脏瓣膜替换613例,早期死亡30例。术后获访495例,获访时间为2700病人年, 平均5．45病人年。结果:晚期死亡37例。晚期死亡率1．61％病人年。机械瓣和生物瓣晚期死亡率分别为1．10％和6．10％病人年,15 年生存率分别为89．3％和43．1％。结论:影响心脏瓣膜替换晚期疗效主要因素为抗凝不当、术前心功能、年龄和心房颤动。机械瓣替换术晚期死亡原因主要为抗凝有关并发症、心室颤动、细菌性心内膜炎和心力衰竭,而生物瓣膜替换术晚期死亡原因则为生物瓣衰败。     

单一心脏中心生物瓣膜应用现状

目的 随着生物瓣膜取材、预处理、抗钙化修饰等各个步骤技术工艺的改进和提高,瓣膜使用寿命大大延长,降低了生物瓣膜置换术后的并发症与瓣膜相关并发症,生物瓣膜使用数量不断上升.总结2003-2008年间我院生物瓣膜使用现状.方法 2003年1月至2008年12月,我院共完成单纯心脏瓣膜替换手术1698例,平均年龄为（50±13）岁.其中生物瓣膜替换术858例,平均年龄为（53±9）岁.2003～2008年采用生物瓣/机械瓣的患者例数分别为9/142、18/240、132/155、170/123、240/117、289/63.生物瓣膜所占同期瓣膜手术数量百分比分别为5.96%、7.00%、46.00%、58.02%、67.23%、82.10%.结果 院内死亡共52例,死亡率3.06%（52/1698）.生物瓣替换术后患者死亡20例,总死亡率2.33%（20/858）.2003～2008年生物瓣替换术后死亡率分别为0%、5.56%、2.27%、1.17%、2.08%、2.42%.2003～2008年采用生物瓣替换术后并发症发生率分别为11.11%（1/9）、11.11%（2/18）、9.84%（13/132）、8.82%（15/170）、12.08%（29/240）、5.88%（17/289）.结论 采用生物瓣并没显著影响患者的近期疗效,且无需长期抗凝,大大改善了患者的生活质量.因而,对条件适合、年龄低于60岁的患者,如患者同意接受因生物瓣膜毁损而导致的再手术,可采用生物瓣膜手术.远期疗效尚需进一步随访.     

The design and development of a stented tissue mitral and aortic heart valve replacement for human implantation

A study was conducted into the development of a mitral and aortic heart valve replacement that caters for patients having suffered valve damage due to stenosis or rheumatic fever. The appeal of the valve is that it is constituted from a solid frame housing pericardial tissue leaflets, and allows the patient freedom from post-operative blood-thinning medication. The valve is designed to appeal to patients in developing areas of the world, as it features a clip-in mechanism to secure the valve assembly into the sewing ring, which is stitched in independently of the frame and leaflets. Re-operative valve replacement would then be made possible when the pericardial leaflets began to calcify. Novel aspects of the design added value to the science of heart valve replacements, through the use of sintered chrome cobalt in the valve components, the insights gained into mechanical testing of pericardium, and the patient benefits offered by the complete design. Further work is planned to fatigue test the assembly, undergo animal trials and make the valve available for commercial use.     

老年人主动脉瓣置换术后病死率分析

Objective To analyze the mortality in people aged 70 years and over who had undergone aortic valve replacement (AVR) for aortic stenosis.Methods The clinical data of 246consecutive cases aged 70 years and over,who had received AVR,were retrospectively analyzed.The 144 cases (58.5 % ) had hypertension,42 cases ( 17.1 %) had atrial fibrillation,27 cases ( 11.0 % )were obeses,and 18 cases (7.3%) had undergone previous heart surgery.Results The 29 cases (11.8%) were dead within 30 days after operation.Among them,15 cases (8.8%) were with isolated AVR and the other 14 cases (18.7%) were with an associate procedure,the difference was significant (P ＜ 0.05).The rate of postoperative complication was 24 .4%.The commoncomplications were:48 cases (19.5%) with low cardiac output,24 cases (9.8%) with renal dysfunction,52 cases (21.1% ) with prolonged ventilatory support and 12 cases (4.9%) with sepsis.In the Poisson regression analysis,the main predictors of mortality were low cardiac output,renal failure,sepsis and associate procedure.The main predictors of morbidity were CBP time ＞ 120 min,atrial fibrillation and chronic obstructive pulmonary disease.Conclusions The balance between the benefits and risks of the surgery should be well evaluated before deciding to perform AVR.     

老年人主动脉瓣置换术后病死率分析

Objective To analyze the mortality in people aged 70 years and over who had undergone aortic valve replacement (AVR) for aortic stenosis.Methods The clinical data of 246consecutive cases aged 70 years and over,who had received AVR,were retrospectively analyzed.The 144 cases (58.5 % ) had hypertension,42 cases ( 17.1 %) had atrial fibrillation,27 cases ( 11.0 % )were obeses,and 18 cases (7.3%) had undergone previous heart surgery.Results The 29 cases (11.8%) were dead within 30 days after operation.Among them,15 cases (8.8%) were with isolated AVR and the other 14 cases (18.7%) were with an associate procedure,the difference was significant (P ＜ 0.05).The rate of postoperative complication was 24 .4%.The commoncomplications were:48 cases (19.5%) with low cardiac output,24 cases (9.8%) with renal dysfunction,52 cases (21.1% ) with prolonged ventilatory support and 12 cases (4.9%) with sepsis.In the Poisson regression analysis,the main predictors of mortality were low cardiac output,renal failure,sepsis and associate procedure.The main predictors of morbidity were CBP time ＞ 120 min,atrial fibrillation and chronic obstructive pulmonary disease.Conclusions The balance between the benefits and risks of the surgery should be well evaluated before deciding to perform AVR.     

Mitral valve repair versus replacement in simultaneous aortic and mitral valve surgery

BACKGROUND:

Double valve replacement for concomitant aortic and mitral valve disease is associated with substantial morbidity and mortality. Excellent results with valve repair in isolated mitral valve lesions have been reported; therefore, whether its potential benefits would translate into better outcomes in patients with combined mitral-aortic disease was investigated.

METHODS:

A retrospective observational study was performed involving 341 patients who underwent aortic valve replacement with either mitral valve repair (n=42) or double valve replacement (n=299). Data were analyzed for early mortality, late valve-related complications and survival.

RESULTS:

The early mortality rate was 11.9% for valve repair and 11.0% for replacement (P=0.797). Survival (± SD) was 67±11% in mitral valve repair with aortic valve replacement and 81±3% in double valve replacement at five years of follow-up (P=0.187). The percentage of patients who did not experience major adverse valve-related events at five years of follow-up was 83±9% in those who underwent mitral valve repair with aortic valve replacement and 89±2% in patients who underwent double valve replacement (P=0.412). Age >70 years (HR 2.4 [95% CI 1.1 to 4.9]; P=0.023) and renal dysfunction (HR 1.9 [95% CI 1.2 to 3.7]; P=0.01) were independent predictors of decreased survival.

CONCLUSIONS:

In patients with double valve disease, both mitral valve repair and replacement provided comparable early outcomes. There were no significant differences in valve-related reoperations, anticoagulation-related complications or prosthetic valve endocarditis. Patient-related factors appear to be the major determinant of late survival, irrespective of the type of operation.     

Simultaneous transfemoral transcatheter aortic valve replacement and trans‐septal mitral valve‐in‐ring implantation after partial laceration of an Alfieri stitch

In patients with an Alfieri Stitch transcatheter mitral valve replacement (TMVR) may be difficult due to the double orifice configuration of the mitral valve. We report a case of simultaneous and completely percutaneous TAVR and TMVR using LAMPOON‐related techniques prior to TMVR to allow for optimal valve deployment.