1000例心脏瓣膜替换术的临床经验

１９７６年６月～１９９４年１０月，作者为１０００例心脏瓣膜病患者施行了瓣膜替换术。术前心功能Ⅱ级９１例，Ⅲ级５２８例，Ⅳ级３８１例。手术方式：二尖瓣替换术（ＭＶＲ）６６０例（６６％）。主动脉瓣替换术（ＡＶＲ）１２８例（１２．８％），主动脉瓣及二尖瓣同期替换术（ＡＶＲ及ＭＶＲ）２０６例（２０．６％），三尖瓣替换术（ＴＶＲ）６例（０．６％）。术后早期并发症２４９例（２４．９％），早期死亡９５例（９．５％）。其中心功能Ⅱ～Ⅲ级者早期死亡３１例（４．４％），心功能Ⅳ级者早期死亡６４例（１６．８％），有非常显著的差异（Ｐ＜０．０１）。１９９１年以前手术的病人死亡８１例（１０．３％），１９９２年以后手术的病人手术死亡１４例（６．６％）。术后随访３个月～１８．６年，平均７．８年，晚期死亡１２７例（１．８％病人年），存活病人心功能明显改善。作者认为，选择适当的手术时机，完善和改进体外循环技术，加强术中的心肌保护，对适宜病例施行保留瓣下结构的二尖瓣替换手术（ＭＶＲＰ）及加强术后监护，及时处理早期并发症是提高手术疗效的重要措施。     

心脏人工瓣膜替换术252例临床分析

１９８４年１２月～１９９１年１２月施行心脏人工瓣膜替换术２５２例，术前心功能Ⅱ级占２．４％、Ⅲ级５３．６％、Ⅳ级４４．０％；心胸比率＞０．７０者４２．５％。行二尖瓣替换术１５４例，主动脉瓣替换术２０例，二尖瓣和主动脉瓣替换术７８例；同时行三尖瓣环成形术和／或三尖瓣交界切开术８７例。早期死亡２３例（９．１２％）。２２３例随访６～９０个月，晚期死亡１５例（６．７２％）。存活的２０８例中心功能Ⅰ级１６５例（７４．Ｏ％）、Ⅱ级３９例（１７．５％）、Ⅲ级４例（１．８％）。本文强调了重症患者的术前准备、手术时机的选择的重要性。     

二尖瓣闭式分离术后人工瓣膜置换术100例报告

自１９８６年１月～１９９６年１２月，对１００例二尖瓣闭式分离术后的病人行心脏瓣膜置换术。单独行二尖瓣置换术（ＭＶＲ）５４例，ＭＶＲ＋三尖瓣成形术（ＴＶＰ）２８例，ＭＶＲ＋主动脉瓣成形术（ＡＶＰ）２例，ＭＶＲ＋ＡＶＰ＋ＴＶＰ３例，ＭＶＲ＋主动脉瓣置换术（ＡＶＲ）１３例，ＭＶＲ＋ＡＶＲ＋ＴＶＰ４例；早期病死率２％，二尖瓣再狭窄时，腱索的增粗，融合，缩短均较严重，８７例（８７％）出现明显钙化，９２例（９     

心脏瓣膜置换术的体会（附21例报告）

为风湿性心脏瓣膜病人施行瓣膜置换术２１例，其中置换二尖瓣１２例、主动脉瓣６例、二尖瓣及主动脉瓣双瓣膜３例。２１例中男７例，女１４例。平均年龄３８岁。术前心功能Ⅱ级４例，Ⅲ级１３例，Ⅳ级４例。心胸比率０．５６～０．７７。手术死亡率４．７６％（１／２１）。作者对影响手术死亡原因如手术前、手术中及手术后的处理等问题进行探讨。     

心脏瓣膜替换术影响手术死亡率因素探讨

我们自１９８７年４月对１９９７年３月进行心脏瓣膜替换术１７３例，其中重症心脏瓣膜替换术７６例，本组病列包括二尖瓣及主动脉瓣替换术２４例，二尖瓣，主动脉瓣替换及三尖瓣Ｄｅｖｅｇａ成形术１０例；二尖瓣闭式扩张后再次换瓣术３例，生物瓣衰败失功后再次换瓣术３例。本组术后死亡１１例，死亡率主６．３％，其中重症心脏瓣膜替换术后死亡１０例，死亡率为１３．１％，手术死亡率以多瓣膜替换术及再次手术组偏高分别为１８％     

原位心脏移植手术的体外循环(5例报告)

我院于１９９５年８月、１９９７年３月、４月、１１月及１９９８年１月先后为５例扩张型心肌病终末期的患者施行改良经典式原位心脏移植手术,其中４例存活（第１例已存活３年多）,１例手术后早期死亡。现将与手术有关的体外循环的处理和体会报告如下。１临床资料１．１...     

108例二尖瓣闭式扩张术后再狭窄的外科治疗

目的 总结108例二尖瓣闭式扩张术后再狭窄病人的再手术治疗围术期处理经验。方法 108例二尖瓣闭式扩张术后再狭窄病人首次术式经左径扩张94例,右径12例,左右径2例。术前心功能Ⅱ级42例,Ⅲ级52例,Ⅳ级14例。再次手术行二尖瓣置换（MVR）67例,MVR＋三尖瓣成形（TVP）22例,二尖瓣主动脉瓣双瓣置换（DVR）13例,DVR＋TVP3例,MVR并其它术式3例。结果 术中死亡3例,术后早期死亡6例,占8．3％;术后发生并发症26例,占24．1％。术前心功能Ⅲ－Ⅳ级的死亡与并发症的发生率较心功能Ⅱ级者有明显差异（P＜0．01）。结论 二尖瓣闭式扩张术后狭窄病人需尽早行手术治疗;术前正确评价和改善心肺功能,术中加强心肌保护及术后积极防治并发症是保证治疗成功的关键。     

人工心脏瓣膜置换术后瓣周漏的外科治疗

目的：探讨人工心脏瓣膜置换术后瓣周漏的治疗经验。方法：２１例瓣周漏患者,主动脉瓣瓣周漏１１例,二尖瓣瓣周漏１０例。对其中４例无明显症状和体征者行内科保守治疗,１７例有贫血和（或）心力衰竭者行外科手术治疗。手术直接修补瓣周漏漏口４例（术后２例复发）;另１３例及２例复发者手术时重新换瓣。结果：术后早期残废例（１１．８％）。长期生存的１９例随访３个月至１５年,晚期死亡２例;余１７例中,心功能Ⅰ、Ⅱ级者１     

心脏瓣膜置换术后感染性心内膜炎

人工心脏瓣膜心内膜炎（ＰＶＥ）是瓣膜置换术后的严重并发症。我科１９８０年８月～１９９６年３月施行瓣膜置换术１２６例，发生ＰＶＥ３例，现报告如下。１临床资料例１，女，２６岁。因风湿性心脏病二尖瓣狭窄用２５＃Ｇ－Ｋ瓣行二尖瓣置换术。因心包纵隔引流液多达２...     

心脏瓣膜置换术心内操作方法再探讨

１９９４年１月至１９９６年１２月我们为１４９例心脏瓣膜病患者行置换术，置换心脏瓣膜１６２枚，其中二尖瓣１４１枚，主动脉瓣２１枚。二次手术１０例。术中保留二尖瓣后瓣及瓣下结构３５例，三尖瓣行Ｄｅｖｅｇａ成形术７例。术后早期死亡９例，总死亡率６％，初次手术死亡率４．３％，二次手术死亡率３０％。与我们１９９２年的报告相比，手术成功率有明显的提高。作者认为心脏瓣膜置换术心内操作方法的改进，是提高手术治疗效果的关键。     

老年人心脏瓣膜置换围术期处理（附123例分析）

目的总结老年人心脏瓣膜置换围术期处理经验。方法对本院123例接受心脏瓣膜置换60岁以上老年患者围术期处理的特点进行回顾性分析。结果二尖瓣置换66例,主动脉瓣置换39例,二尖瓣＋主动脉瓣置换15例,三尖瓣置换2例,同期进行其他手术共105例,早期死亡率8.9%（11/123）,并发症出现率41.5%（50/123）,晚期死亡3例,其中与心脏有关死亡1例,死于反复心力衰竭。随访6个月～14年,96例存活,失访13例,随访率88.4%（96/112）。结论重视老年人心脏瓣膜置换围术期的处理措施,合理的手术方法和心肌保护,可以减少围术期并发症,降低手术围术期的死亡率。     

Aortic and mitral valve replacement with retrograde perfusion in the beating heart

Objective To estimate the value of aortic valves and combined mitral valve replacement wit h retrograde perfusion in beating hearts.Methods Continuous retrograde coronary sinus perfusion with beating hearts was used in 8 3 patients undergoing aortic valve or aortic valve combined with mitral valve re placement, without application of cardioplegia. After aortic valve replacement, the retrograde perfusion was changed to antegrade perfusion for mitral valve re placement or correction of the other deformities (group A). Cold blood cardiopl egia solution (15℃) was infused at intervals in 20 cases (group B). The follow ing parameters were tested: lactate, ET, CTn-T and MDA in blood; myocardial ult ra-structure; and cardiac rhythm and cardiac output (CO).Results All biochemical values increased after cardiopulmonary bypass (P<0.05-0.01 ). Empty and beating heart sinus rhythm was maintained in group A. Myocardial ultrastructure did not change significantly. The pump was stopped smoothly as t he surgical procedure finished. No postoperative low cardiac output syndrome or arrhythmia was observed. Eight-one patients recovered smoothly, two died from renal failure or infective shock. When the pump stopped, all patients in group B were supported by 5-10 μg·kg(-1)·min(-1) dopamine. Transie nt pacing was used in 9 patients. One patient died from low cardiac output synd rome. Conclusion This method is a good myocardial protection which simulates physiologic status. It is applicable to aortic valve and combined mitral valve replacement of patie nts with large heart or heart failure and long time aortic cross-clamping. Ide al clinical effect can be achieved.     

心脏跳动中巨大心脏二尖瓣置换术远期疗效

目的 :评价在浅低温体外循环心脏跳动中巨大心脏病人二尖瓣置换术的远期疗效。方法 :对 131例巨大心脏患者在心脏跳动中施行二尖瓣置换术 ,早期死亡 5例。术后随访到 111例 ,失访 15例 ,随访率 88.1% ,随访时间 0 .5～ 9.0年。随访方法是对病人采用信访、电话随访和门诊复查相结合进行长期随访。结果 :远期死亡 9例 ,死亡原因为心衰 5例、心律失常 2例、瓣周漏 1例、原因不明 1例。 3、6、9年累积生存率为 92 .3%、84 .1%、79.5 %。随访结果与术前及术后早期结果进行统计学处理 ,左室收缩末直径、左室舒张末直径及心功能等指标差异均有统计学意义 (P <0 .0 5 )。左房型及右室型远期疗效较好 ,全心型及左室型效果较差。结论 :在心脏跳动中行巨大心脏的二尖瓣置换手术切实可行 ,安全有效 ,心肌保护效果良好 ,远期效果满意。随访期间加强心功能支持和室性心律失常防治 ,有助于提高巨大心脏二尖瓣置换术的远期疗效     

Less invasive cardiac surgery via partial sternotomy

BackgroundLess invasive cardiac surgery is widely adopted nowadays. Upper or lower partial sternotomy is an approach for less invasive cardiac surgery. We report results of less invasive cardiac surgery via partial sternotomy.MethodsFrom August 1, 2009 to September 30, 2010, 35 patients underwent cardiac surgery via upper or lower partial sternotomy. The preoperative characteristics, operative variables, mortality, and morbidity were reviewed retrospectively.ResultsThirty-five patients underwent cardiac surgery via partial sternotomy during the study period. Eleven patients (31%) were female. The mean age was 66 ± 11 years (range 38 to 88). Seven patients underwent aortic valve replacement via upper partial sternotomy. Simultaneous mitral valve replacement was done in one patient. Lower partial sternotomy was done in 28 patients. Sixteen patients received mitral valve replacement. Three patients underwent mitral valve repair. Concomitant tricuspid valve repair was done in eight patients. Two patients received aortic valve replacement. One patient had replacement of aortic and mitral valve replacement. One patient had repair of tricuspid valve. Two patients received LIMA anastomosis to the LAD. Two patients underwent emergent repair of the right ventricle. One patient had resection of myxoma in the left atrium. Direct cannulation of the aorta and right atrium was used for cardiopulmonary bypass in 15 patients (48%). Both antegrade and retrograde administration of cardioplegia solution was used routinely for myocardial protection. There was no mortality. Two patients developed respiratory failure. One patient suffered unstable sternum. One patient required conversion to full sternotomy. No patient suffered mediastinitis or groin wound infection.ConclusionUpper or lower partial sternotomy provides adequate exposure for various kind of cardiac surgery. Conventional cardiopulmonary bypass and cardioplegia solution administration can be used. The immediate preliminary outcome was acceptable.     

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。     

心脏瓣膜置换术后早期死亡病例分析

目的：探讨瓣膜置换手术后早期死亡病例的相关因素．方法：回顾分析1092例瓣膜置换手术中21例死亡病例的术前心脏功能情况、手术方式、体外循环和阻断主动脉时间、死亡原因以及心肌损伤标志物等相关资料．结果：手术早期死亡21例（1、93％,21／1092）,其中,心脏停跳手术组死亡9例（2．03％,9／444）,心脏不停跳手术组早期死亡12例（1．85％,12／648）,两组间差异不明显（P〉0．05）．二尖瓣置换手术死亡率最低为0.85％（6／694）,二尖瓣和主动脉瓣双瓣膜置换手术死亡率最高为3、89％（12／308,P〈0．05）;和存活病例相比较,死亡病例的体外循环和阻断主动脉时间更长,CK和CK-MB明显增加（P〈0．01）;术前左心室射血分数、短轴缩短率在死亡病例和存活病例问无统计学差异（P〉0,05）;死亡原因中,低心排综合征死亡最高达12例（57.2％）,心脏骤停、室颤、呼吸衰竭和多脏器功能衰竭也是死亡的重要原因．结论：双瓣膜置换术在瓣膜置换手术中死亡率较高,并多发生在体外循环转流时间过长、心肌损伤标志物增加非常明显的患者;死亡原因以低心排综合征最常见．     

保留后瓣及全瓣下结构的老年二尖瓣置换术

目的：探讨老年患者二尖瓣置换术中保留后瓣及全瓣下结构的临床经验和效果。方法：对15例老年患者（年龄〉65岁）施行保留后瓣及全瓣下结构的瓣膜置换术,分析对比其术前、术后X线胸片、超声心动图资料及手术效果。结果：本组无手术死亡病例。术后心胸比率明显缩小（P〈0.01）,左心室舒张末径显著缩小（P〈0.05）,平均左心室射血分数明显降低（P〈0.05）,心功能明显改善,手术效果良好。结论：保留后瓣及全瓣下结构应用于老年二尖瓣置换术安全、可靠,能有效保护进而改善左心功能,减少手术并发症。     

冠状动脉搭桥同期行心脏瓣膜替换术35例的体会

目的回顾总结35例冠状动脉搭桥术（CABG）同期行心脏瓣膜替换手术的方法及疗效,分析手术死亡的危险因素,提高手术的成功率.方法 2005年1月至2010年3月,共行CABG＋心脏瓣膜替换术35例,共移植血管105支,平均每例移植血管2.86支.同期行二尖瓣替换术16例,主动脉瓣替换术12例,双瓣膜替换术5例,本特氏手术例,升主动脉替换1例（替换机械瓣28例、生物瓣7例）.结果术后早期死亡2例,术后平均住院时间17.2d.主要死亡原因：急性肾功能衰竭1例、心室颤动致心脏骤停1例.相关危险因素分析：术前有心肌梗塞病史、心功能差、射血分数低、肾功能不全等与早期死亡有关.术后发生并发症包括内出血、严重室性心律失常、神经系统并发症、切口感染等,经相应的治疗均痊愈.随访12例（34.2%）,随访时间6～12个月,心绞痛和心力衰竭症状、体征均明显改善.结论 CABG联合心脏瓣膜替换术是治疗冠心病合并心脏瓣膜病变的有效方法,术前积极改善心肺功能、有效控制血糖、术中加强心肌保护、缩短主动脉阻断和心肌缺血时间以及尽可能的心肌再血管化能有效地提高手术成功率。     

Secundum atrial septal defect repair: long-term surgical outcome and the problem of late mitral regurgitation.

This study examines the clinical and surgical outcome of a group of 55 patients (mean age 33 years) with secundum atrial septal defect who underwent surgical repair of this defect between 1981 and 1990. A group of 25 of these patients underwent late echocardiographic follow-up. Fifty-two patients underwent repair by direct suturing and three by patch closure. Surgical mortality was nil. There was one late death of a 58 year old who died from cardiac failure 4 years after surgery. Late postoperative morbidity consisted of two patients; one, age 63 at the time of surgery, required mitral and tricuspid valve replacement 6 years later and one, age 77 at surgery, developed cardiac failure 3 years later. Atrial fibrillation persisted in the six patients who had the rhythm before surgery and developed postoperatively in two patients aged 54 and 58. Two patients aged 49 and 57 developed immediate postoperative sinus node dysfunction requiring permanent pacing. The mean age at surgery of those six patients who suffered cardiac morbidity was 60 years. The patients with preoperative angiographic evidence of mitral valve prolapse were significantly older (P < 0.001) and had higher mean pulmonary artery pressures (P < 0.001) than patients with normal valves. There was no significant relationship between shunt size and mitral valve prolapse. Echocardiographic follow-up showed persistent mitral valve prolapse in all nine patients who developed the condition preoperatively. Five patients developed mitral valve prolapse with mitral regurgitation postoperatively, one of whom needed subsequent mitral and tricuspid valve replacement. These five patient were on average older (mean age 54) but the group was too small to prove significance. The follow-up data illustrate the current low mortality and morbidity associated with surgical closure of atrial septal defects. Late postoperative echocardiography had revealed not only that mitral valve prolapse persists in those patients who developed the condition pre-operatively but that new cases of mitral valve prolapse with mitral regurgitation can occur after atrial septal defect closure.     

30对左心瓣膜置换术后三尖瓣重度关闭不全11例外科治疗

目的探讨左心瓣膜置换术后三尖瓣重度关闭不全的机理及外科治疗选择及效果.方法1998年1月～2004年10月,对11例左心瓣膜置换术后三尖瓣重度关闭不全的病人行外科治疗,曾行二尖瓣置换术4例;主动脉瓣置换术1例;主动脉及二尖瓣置换术6例.其中7例病人第1次手术时曾行三尖瓣成形术.术后1～20年发生重度三尖瓣关闭不全,肝大、腹水、右心衰竭,心功能Ⅳ级.11例病人均再次手术,8例行三尖瓣成形术,3例行三尖瓣置换术.结果手术死亡1例,成活10例.术后随访1～4年,2例三尖瓣置换病人恢复良好;5例三尖瓣成形术心功能恢复良好,只有极轻度或轻度三尖瓣关闭不全;2例出现中度三尖瓣关闭不全,1例出现重度三尖瓣关闭不全.结论左心瓣膜置换术后包括部分同期行三尖瓣成形术病人,远期发生三尖瓣关闭不全,可能与以下原因有关:(1)风湿性病变持续发展;(2)左心瓣膜病变未纠正;(3)原三尖瓣成形术失败;(4)持续性肺动脉高压;(5)心房纤颤等因素.对重度三尖瓣关闭不全,发生右心功能衰竭者,应再次外科手术治疗.首选三尖瓣成形术,只有瓣膜严重破坏,成形术无法恢复瓣膜功能时,才考虑作三尖瓣置换术.