老年人主动脉瓣置换术后病死率分析

目的 对年龄≥70岁的主动脉瓣狭窄患者主动脉瓣置换术后的病死率进行分析.方法 回顾性分析246例年龄≥70岁、并接受主动脉瓣置换的主动脉瓣狭窄患者的临床资料.其中高血压144例(58.5%),心房颤动42例(17.1%),肥胖27例(11.0%),有心脏手术史18例(7.3%).结果 手术30 d内死亡29例,病死率为...     

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.     

钙化性主动脉瓣狭窄的外科治疗

目的评价钙化性主动脉瓣狭窄外科治疗效果及成功因素。方法对26例钙化性主动脉瓣狭窄患者随访分析,年龄55～70岁,平均62岁。主动脉跨瓣压差52～191mmHg,平均97mmHg,室间隔、左室后壁厚度14～19mm,合并关闭不全7例。手术均在全麻、低温和体外循环下行机械瓣置换,同期行Manouguian法扩大主动脉瓣环9例、CABG3例、Wheat术1例。结果术后早期和晚期各死亡1例。随访心脏超声LVEF为51%～72%,室间隔及左室后壁厚度8～12mm,人工瓣跨瓣压差8～26mmHg。心功能为Ⅰ～Ⅱ级。结论瓣膜置换是治疗钙化性主动脉瓣狭窄唯一安全有效的方法,恰当的手术时机、合适的瓣膜型号是提高手术远期疗效的重要保证。     

主动脉瓣人工瓣膜置换术156例分析

目的总结成人主动脉瓣人工机械瓣膜置换手术的经验.方法1996年1月至2005年1月对156例成人行主动脉瓣置换,术中均行人工机械瓣膜置换,其中双叶瓣125例,单叶瓣31例.13例行瓣膜侧倾缝合,6例行主动脉瓣瓣环加宽.结果存活151例,死亡7例,死亡率4.48%.结论对主动脉瓣膜行人工机械瓣瓣膜置换手术术前充分估计瓣环大小,术中良好的灌注、心肌保护、选择合适瓣膜和恰当手术方法,可降低死亡率.     

St.Jude Medical Regent主动脉瓣应用于小主动脉瓣环患者的初步经验

目的总结对小主动脉瓣环患者行St.JudeRegent主动脉瓣替换的初步经验。方法对11例小瓣环主动脉瓣病变患者行St.JudeRegent主动脉瓣替换。患者平均年龄(42.9±13.1)岁,体重(68.2±10.1)kg,体表面积(1.71±0.13)m2。术前主动脉瓣跨瓣峰值压差平均(74.4±34.3)mmHg。替换19号St.JudeRegent主动脉瓣7例,21号4例。结果本组患者无手术死亡,无严重并发症。平均输血量227.3ml,4例未输血。随访无远期死亡。术后患者心功能较术前明显改善。术后6个月复查超声心动图,提示肥厚的左心室显著退缩,人工瓣跨瓣峰值压差为(20.8±5.0)mmHg。19号瓣平均有效瓣口面积为(1.68±0.17)cm2,21号瓣为(1.96±0.25)cm2。结论小瓣环主动脉瓣病变患者行St.JudeRegent主动脉瓣替换的近期效果良好。     

经皮主动脉瓣置换术进展

主动脉瓣瓣膜病变有较高的发病率及病死率。每年全球有200000例患者接受外科瓣膜置换术。还有更多患者因风险太高或有些老年患者害怕生活方式会被改变而未接受传统外科手术治疗,而且这一人群在不断扩大。自20世纪90年代经皮主动脉瓣置换术(percutaneous aortic valve replaceme     

经导管主动脉瓣置换术后的抗栓治疗策略

经导管主动脉瓣置换术(TAVR)自开展以来发展迅速,随着越来越多临床研究结果的公布,TAVR的适应证已经扩展至全风险范围主动脉瓣狭窄人群.接受TAVR治疗的患者血栓栓塞和出血事件均十分常见,这对TAVR术后的抗栓治疗提出了挑战.而此前的指南关于TAVR的抗栓治疗建议大多基于专家意见而非循证医学证据.本文将基于最近的临床...     

经皮主动脉瓣置换术

<正> 退行性主动脉瓣狭窄是老年人常见的心脏瓣膜病,其传统的治疗方法主要是外科主动脉瓣置换术,该手术已成为国外主动脉瓣病外科治疗总数中高居第一的瓣膜手术。外科手术采用胸部正中切口,在体外循环和心脏停搏状态下进行,手术创伤大、出血多、住院时间长。对高危的主动脉瓣狭窄患者(年龄75岁,LVEF≤40%),外科手术的医院死亡率高达10%～33%,术后1年的病死率仍在20%左右。近10年来,已将微创小切口和胸腔镜技术用于主动脉瓣置换术,其创伤明显减小,能避免胸骨劈开,术中出血少,患者术后恢复快,但仍然需要体外循环,需要外科医生、体外循环的转流师、麻醉师的协调配合。经皮主动脉瓣置换术(percutaneousaortic valve replacement,PAVR)是近年来介入心脏病学出现的一个新领域,为主动脉瓣膜病的外科治疗开拓了新视野。     

手术治疗重度主动脉瓣狭窄24例疗效分析

目的观察重度主动脉瓣狭窄的手术治疗效果。方法24例重度主动脉瓣狭窄患者均在全麻、低温及体外循环下行主动脉瓣置换,同期行主动脉瓣环扩大术2例、二尖瓣置换术5例、三尖瓣成形术5例。结果本组术后死亡2例,发生并发症8例,其中低心排综合征6例,急性肾功能不全2例。其余患者随访1~2 a,心功能恢复良好。结论瓣膜置换术是治疗重度主动脉瓣狭窄的有效方法。手术时机的选择、围术期的心肌保护、合适的瓣膜型号是提高手术成功率的重要因素。     

使用左心室导丝起搏技术行经导管主动脉瓣置换术

目的:总结经导管主动脉瓣置换术（TAVR）中应用左心室导丝起搏技术的初步经验。方法:本研究为回顾性研究。收集2019年10至12月于中国医学科学院阜外医院应用左心室导丝起搏技术行TAVR治疗的患者13例。收集患者的临床资料、手术操作,术中密切观察血压、心电图变化,行升主动脉造影评估瓣膜释放后主动脉瓣反流情况,记录院内和...     

Transcatheter versus surgical aortic valve replacement in severe, symptomatic aortic stenosis

Aortic stenosis (AS) is the most common type of valvular heart disease in the elderly. Surgical aortic valve replacement (SAVR) has been the standard practice for treating severe, symptomatic AS, but recently new treatment options have emerged. Transcatheter aortic valve replacement (TAVR) is now an established treatment option in patients at high surgical risk. In this review, we focus on recent developments and compare the two treatment methods in specific populations in terms of efficacy and safety (e.g., in patients with history of prior thoracic surgery, type of anesthesia employed, access site used or need for permanent pacing). The impact of comorbidities (pulmonary hypertension, arterial hypertension and obesity paradox), the cost-effectiveness of TAVR vs. SAVR and advances in transcatheter valve technology as well as issues that merit further investigation are further discussed. Moreover, outcomes and complications of TAVR in patients of different risk category (extremely high, high, intermediate and low risk) are analyzed. We strongly believe that during the following years, TAVR may evolve as the treatment of choice in a broader group of patients with symptomatic AS and beyond those with intermediate and high-risk features.     

Transcatheter aortic valve replacement in elderly patients

Aortic stenosis is the most common native valve disease, affecting up to 5% of the elderly population. Surgical aortic valve replacement reduces symptoms and improves survival, and is the definitive therapy in patients with symptomatic severe aortic stenosis. However, despite the good results of classic surgery, risk is markedly increased in elderly patients with co-morbidities. Transcatheter aortic valve replacement (TAVR) allows implantation of a prosthetic heart valve within the diseased native aortic valve without the need for open heart surgery and cardiopulmonary bypass, offering a new therapeutic option to elderly patients considered at high surgical risk or with contraindications to surgery. To date, several multicenter registries and a randomized trial have confirmed the safety and efficacy of TAVR in those patients. In this chapter, we review the background and clinical applications of TAVR in elderly patients.     

Load independent impairment of reverse remodeling after valve replacement in hypertensive aortic stenosis patients

Background

We evaluated the impact of hypertension on the left ventricular mass regression in aortic stenosis after aortic valve replacement.

Methods

We prospectively studied 135 patients with severe aortic stenosis at baseline and 1 year after surgery. In 32 patients we analyzed myocardial gene expression of collagen types I and III, connective tissue growth factor, transforming growth factor-β1, metalloproteinase-2 and its tissue inhibitor and compared its levels vs controls.

Results

Seventy-six patients (56.3%) had a history of hypertension. Hypertensive patients were older, had higher Euroscore-II and NYHA class, with no differences in stenosis severity. At 1 year follow-up there was a median decrease of mass index of 14.2% (P25–75: − 4.3%–30.4%; p < 0.001). Mass regression was significantly higher in patients without hypertension, with a median decrease of 25.9% (P25–75: 12.0%–38.7%) vs 5.4% (P25–75: − 12.5%–20.1%; p = 0.001), despite similar increase in effective orifice area and no differences in valvuloarterial impedance. After 1 year, higher baseline left ventricular mass index (p = 0.005) and the absence of hypertension (p = 0.002) or diabetes (p = 0.041) were the only independent predictors of mass regression higher than the median. Comparing with controls, aortic stenosis patients had an increased expression of collagen types I and III, but only hypertensive patients had higher relative expression of collagen type I vs III. In hypertensive patients TIMP2 expression was up-regulated and correlated with higher baseline left ventricular mass index (r = 0.61; p = 0.020).

Conclusions

In aortic stenosis, hypertension impairs mass regression one year after valve replacement, independently of total afterload. Differences in the expression of extracellular matrix remodeling genes might contribute to this finding.     

Physical training and occupational rehabilitation after aortic valve replacement

Forty-four patients were tested 2, 6 and 12 months after anisolated aortic valve implantation in order to evaluate theinfluence of training and vocational assistance on physicalwork capacity and the rate of reemployment. They were randomlyallocated to a training group (A) or a control group (B). Trainingwas carried out from the eighth to the twelfth week after operationand the socio-occupational status was evaluated. Training increasedphysical work capacity, expressed as cumulated work (CW), by58 per cent (P <0.001), decreased the rate–pressureproduct (RPP) by 13 per cent (P <0.001) and the rate of perceivedexertion (RPE) by 13 per cent (P<0.001) at the highest comparablework load. The CW was 38 per cent higher in the training thanthe control group after 6 (P<0.02) and 37 per cent after12 months (P<0.025). After one year 81 per cent in groupA and 65 per cent in group B were working (NS). Reemploymentcorrelated significantly with the CW and inversely with theduration of sick leave prior to operation. Thus, physical trainingshortly after aortic valve operation rapidly and persistentlyimproves physical work capacity while return to work is lessinfluenced by training and socio vocational assistance.     

Physical training and occupational rehabilitation after aortic valve replacement

Forty-four patients were tested 2, 6 and 12 months after anisolated aortic valve implantation in order to evaluate theinfluence of training and vocational assistance on physicalwork capacity and the rate of reemployment. They were randomlyallocated to a training group (A) or a control group (B). Trainingwas carried out from the eighth to the twelfth week after operationand the socio-occupational status was evaluated. Training increasedphysical work capacity, expressed as cumulated work (CW), by58 per cent (P <0.001), decreased the rate–pressureproduct (RPP) by 13 per cent (P <0.001) and the rate of perceivedexertion (RPE) by 13 per cent (P<0.001) at the highest comparablework load. The CW was 38 per cent higher in the training thanthe control group after 6 (P<0.02) and 37 per cent after12 months (P<0.025). After one year 81 per cent in groupA and 65 per cent in group B were working (NS). Reemploymentcorrelated significantly with the CW and inversely with theduration of sick leave prior to operation. Thus, physical trainingshortly after aortic valve operation rapidly and persistentlyimproves physical work capacity while return to work is lessinfluenced by training and socio vocational assistance.