儿童心脏瓣膜置换术早期及中长期效果分析

目的评价儿童瓣膜置换术围术期及中长期疗效，探讨儿童瓣膜置换术适应证，分析术后抗凝特点及避免或减缓再次手术的方法。方法回顾性分析1991年12月至2006年8月，113例患儿128枚瓣膜置换术围术期疗效及中长期随访结果。结果住院死亡5例（4．4％），其中3例死于低心排综合征，1例死于心律失常，1例死于多器官衰竭。晚期死亡7例（6．5％），其中3例死于抗凝相关并发症。23例生物瓣膜置换患儿中有4例患儿需要行再次手术换瓣，随访的75例机械瓣置换患儿中有8例出现抗凝相关并发症。结论在严格掌握手术适应证的基础上，儿童人工心脏瓣膜置换术有较好的早期及中长期效果，但应尽量置人较大型号的瓣膜并选用相应的手术技巧，以保障儿童的成长，以避免或延缓再次手术，抗凝并发症是儿童瓣膜置换术后应该重视的问题。     

92例学龄前儿童心脏瓣膜成形术

目的 探讨学龄前儿童心脏瓣膜成形术的手术方法、效果。方法 回顾92例在中度低温体外循环下行心脏瓣膜成形术的各种心脏瓣膜病患儿的瓣膜病理改变、外科瓣膜处理方法。结果 术后早期死亡2例(占2．2％)。远期随访89例(占98．9％)，残留中度以上瓣膜返流6例(占6．5％)，心胸比、左房径均明显下降，无远期死亡。结论 学龄前儿童心脏瓣膜病可以采取瓣膜成形术，并能取得良好的术后效果。根据不同瓣膜病变，采用不同的手术方法，是学龄前儿童心脏瓣膜成形术取得满意效果的关键。     

瓣环扩大在儿童主动脉瓣膜置换术中的应用

目的总结6例儿童主动脉瓣膜置换术中主动脉瓣环扩大的经验，探讨儿童主动脉瓣置换时主动脉瓣环细小的外科处理方法。方法主动脉瓣膜置换术中进行瓣环扩大术6例，年龄7～14岁，平均（11．2±3．3）岁；体重20～41．5kg，平均（29．5±8．6）kg，体表面积0．8～1．35m^2，平均（1．08±0．23）m^2。术前测定主动脉瓣环直径13．5～18．7mm，平均（15．9±2.6）mm。术中主动脉瓣环扩大2例采用Manouguian法，4例采用Konno法。经瓣环扩大后，主动脉瓣环植入了平均直径（19．2±1．3）mm（17～21mm）的机械瓣膜。其他心脏畸形也在术中予以矫治。结果无住院死亡。随访时间3～89个月，无晚期死亡，无再次手术。NYHA心功能分级均为Ⅰ级。复查超声心动图2例存在跨瓣压差，分别为25mmHg和40mmHg。结论儿童主动脉瓣膜置换术中，采用主动脉瓣环扩大术，特别是Konno法，可有效扩大狭窄的主动脉瓣环，植入较大的人工瓣膜，提高手术的成功率，改善远期疗效。     

川崎病致心脏瓣膜病变的诊断及治疗

川崎病 (ＫＤ)是一种原因不明的全身性血管炎 ,主要影响婴幼儿 ,冠状动脉瘤 (ＣＡＡ)为其最严重的并发症 ,急性期ＣＡＡ的发生率约 2 0 %。心脏瓣膜病变为ＫＤ另一重要并发症 ,可导致充血性心力衰竭 ,甚至死亡。在日本、美国等国家 ,随着风湿热发病率进一步降低 ,ＫＤ已成为儿童后天性心脏瓣膜病变的一个重要原因[1,2 ] 。 1973年Ｈａｍａａｄａ等首先报道 3例ＫＤ患儿冠状动脉造影 (ＣＡＧ)时发现冠状动脉 (简称冠脉 )病变并二尖瓣返流 (ＭＲ)。此后 ,ＫＤ致心脏瓣膜病变受到广泛关注。Ａｋａｇｉ等[1] 对 12 15例ＫＤ患儿从急性期开始随访…     

同种带瓣管道治疗复杂先天性心脏病(附31例报告)

目的研究同种带瓣管道治疗复杂先天性心脏病的疗效。方法1997年12月～2003年4月，我科应用同种带瓣管道治疗复杂先天性心脏病31例。病种包括重症法乐氏四联症(TOF)14例，其中合并动脉导管未闭(PDA)1例，合并肺动脉闭锁(PA)、右肺动脉缺如(RPaA)各1例，PDA PA 1例，右冠状动脉畸形(RCaA)2例；右室双出口(DORV)8例，其中合并RCaA2例；三尖瓣闭锁(TA)1例；大动脉转位(L-TGA)并室间隔缺损(VSD)、肺动脉狭窄(Ps)3例；永存动脉干(PTA)2例；主动脉缩窄(CoA)并PDA 1例；VSD并PS、RCaA 1例；亚急性细菌性心内膜炎(SBE)1例。术式：主、肺动脉单瓣作右室流出道跨瓣补片术14例；Rastelli手术11例；右心室-肺动脉连接(RV-PA)3例；肺动脉瓣置换1例：Ross手术1例；改良Fantan手术1例。结果主、肺动脉单瓣作右室流出道跨瓣补片组14例，1例术后3d死于右心功能不全(7．14％)。存活13例，随访3～57月，超声心动图检查显示移植后瓣膜启闭功能良好，无增厚及粘连。同种带瓣管道移植矫治组17例，死亡7例(41．2％)，存活10例，随访9～57月，管道血流通过顺畅，管壁无变薄、钙化。结论同种带瓣管道具有管壁弹性好，易于缝合，术后排斥反应少等优点，可广泛应用于复杂先天性心脏病矫治术、左，右室流出道的重建。同种带瓣管道补片既能加宽右室流出道，且有良好抗反流作用，有利于术后患儿心功能恢复，使部分复杂的病例能够一次手术根治。     

学龄前儿童瓣膜成形术

目的 探讨学龄前儿童瓣膜疾患行瓣膜成形术的疗效。方法 总结１９９０年１月－１９９８年４月收治的学龄前儿童瓣膜疾患２８３例，男１３０例，女１５３例，年龄２个月－６岁，平均３．０５岁，其中≤１岁２２例（７．７７％）。≤３岁１７０例（６０．０７％）。体重３．１－２１．０ｋｇ，平均１１．８４ｋｇ，≤１０ｋｇ１０６例（３７．４６％）。主要瓣膜疾患包括：单纯瓣膜疾病９例（３．１８％），其中二尖瓣关闭不全（ＭＩ     

儿童感染性心内膜炎

儿童感染性心内膜炎（ＩＥ）是一种较为罕见的且与先天性心脏病相关的疾病。血流动力学改变造成内皮损伤及菌血症的发生导致了ＩＥ，怀疑ＩＥ时应进行血培养及超声心动图检查以明确诊断。ＩＥ需联合应用杀菌类抗生素治疗，对有手术适应证的患者需及时手术。具有高危因素的患儿进行侵入性操作前采取预防性的药物治疗，将减少ＩＥ的发生。     

抗凝药物华法林在儿童心血管疾病精准治疗的应用

<正>华法林(warfarin)是20世纪40年代在美国合成的临床最常用的防治血栓栓塞的口服抗凝药,因其具有抗凝和溶栓双重调节作用、疗效显著、作用持续时间长、服用方便、价格低廉而应用于心脏人工瓣膜置换术后、非瓣膜性心房纤颤或心房扑动、肺栓塞以及深静脉血栓抗凝的治疗。尽管华     

结构性心脏病介入治疗相关瓣膜损伤的防治北大核心CSCD

结构性心脏病是指以心脏和大血管结构异常为主要表现的一大类心脏病,既包括先天性疾病也包括后天获得性疾病,主要包括先天性心脏病、获得性心脏瓣膜病和心肌病。近年来,结构性心脏病的介入手术治疗已逐渐成熟并广泛应用于临床。由于患者心脏瓣膜及瓣膜相关组织较为脆弱或先天性发育不良,加之手术复杂,介入手术操作可引起相关瓣膜损伤并发症,该文就结构性心脏病介入治疗相关的瓣膜损伤原因及其防治措施进行介绍。     

结构性心脏病介入治疗相关瓣膜损伤的防治

结构性心脏病是指以心脏和大血管结构异常为主要表现的一大类心脏病,既包括先天性疾病也包括后天获得性疾病,主要包括先天性心脏病、获得性心脏瓣膜病和心肌病。近年来,结构性心脏病的介入手术治疗已逐渐成熟并广泛应用于临床。由于患者心脏瓣膜及瓣膜相关组织较为脆弱或先天性发育不良,加之手术复杂,介入手术操作可引起相关瓣膜损伤并发症,该文就结构性心脏病介入治疗相关的瓣膜损伤原因及其防治措施进行介绍。     

Valve replacement in children under 15 years with rheumatic heart disease

Summary From 1967 through 1984, single- or double-valve replacement for rheumatic heart disease (RHD) was undertaken in 184 children (aged 4 to 15 years) in Tunis. At the time of operation most patients were in an advanced state of cardiac disability, but most of them were still in sinus rhythm. A total of 222 valves were inserted. The most commonly used replacement valve was the Starr—Edwards caged-ball prosthesis, with 12 hospital deaths (6.5%). There were no hospital deaths among 19 children who had a (glutaraldehyde-treated porcine) xenograft replacement valve; however, a much higher rate of valve failure occurred later, owing to valve calcification (14 to 19 replacements, 11 requiring reoperation). There were 24 episodes of clinical thrombo-embolism in 21 children after insertion of a prosthetic valve, but only one in a child with a xenograft valve. Two thirds of the patients with prosthetic valves were on anticoagulants, but fewer than half of them had effective levels because of low compliance. For the group with prosthetic valves, the 10-year survival rate was 70%.     

法洛四联症根治术后肺动脉瓣置换术研究进展

随着法洛四联症(tetralogy of Fallot,TOF)手术方法越来越成熟,TOF患儿存活率得到较大提升,然而TOF术后的远期并发症成为影响预后的重要因素,其中最常见的为肺动脉瓣反流(pulmonary regurgitation,PR),可以导致右心室功能不全、运动耐力下降以及心律失常,甚至猝死。肺动脉瓣置换术(pulmonary valve replacement,PVR)是治疗PR的有效手段,手术方式包括传统外科肺动脉瓣置换术(surgical pulmonary valve replacement,SPVR)、经皮肺动脉瓣置换术(percutaneous pulmonary valve replacement,PPVR)及镶嵌治疗。对于肺动脉瓣的替代物,生物瓣膜仍然为大多数医生的首要选择,随着抗凝方案的完善,机械瓣膜也有其特定的适应人群,PVR术后的抗凝方案也不尽一致。现对TOF根治术后PVR的手术指征、肺动脉瓣替代物的选择与术后抗凝方案以及临床治疗进展进行综述。     

Late Pulmonary Valve Replacement in Congenital Heart Disease Patients Without Original Congenital Pulmonary Valve Pathology

Many congenital heart defects with pulmonary valve pathology are repaired or palliated in childhood. It is anticipated that these patients will need subsequent pulmonary valve replacement due to the pulmonary regurgitation or right ventricular dilation/failure that results from their original operation. Interestingly, some patients with prior congenital heart surgery and no congenital pulmonary valve pathology require pulmonary valve replacement in adulthood. The current study analyzed this subset of patients. The pediatric and adult congenital cardiac surgical databases at a large academic center were reviewed from 2001 to 2008 for pulmonary valve replacements. Patients without congenital pulmonary valve disease were identified. Preoperative, operative, and postoperative data were analyzed. Between 2001 and 2008, five patients with congenital heart disease but no pulmonary valve pathology underwent late pulmonary valve replacement. The initial congenital diagnoses were coarctation/ventricular septal defect (n = 3), complete atrioventricular septal defect (n = 1), and anomalous left coronary artery from the pulmonary artery (PA) (n = 1). All five patients had undergone main PA manipulation during their previous operations. Four of these patients had received PA banding and debanding, and one had received a Takeuchi tunnel repair and revision. All the patients underwent pulmonary valve replacement secondary to pulmonary regurgitation and right ventricular dilation. The average time from the last previous operation to the time of pulmonary valve replacement was 20.8 ± 9.1 years. Bioprosthetic valves were used for all the pulmonary valve replacements, and there were no mortalities. Patients who have undergone previous PA manipulation, regardless whether congenital pulmonary pathology is present, may be at risk for pulmonary valve replacement in adulthood. This report describes five cases of patients with a history of congenital heart surgery but no congenital pulmonary valve pathology who required pulmonary valve replacement due to the consequences of prolonged pulmonary regurgitation. Although pulmonary regurgitation may be well tolerated for many years, it is further evidence for the importance of close follow-up assessment and monitoring of young adults with congenital heart disease.     

Continuous Wave Doppler Echocardiographic Evaluation of St. Jude Prosthetic Mitral Valves in Children

The function of 9 St. Jude prosthetic mitral valves in 8 children was evaluated by continuous wave Doppler (CWD) echocardiography 28±22 months after implantation. All valves were apparently functioning normally on clinical examination. Peak flow velocity, mean flow velocity, pressure half-time and mean pressure gradient were determined from the transmitral flow velocity curve by CWD echocardiography. For comparison, the same parameters were examined in 15 normal children and 14 adults who had undergone mitral valve replacement. All measured values were greater in adults and children who had undergone valve replacement than in normal children. There were no differences in any parameter in adults or children in whom prostheses 25 mm or larger had been implanted. Although 3 children in whom prostheses 23 mm or smaller had been implanted had greater values for each parameter than those who received 25 mm or larger prostheses, there were no symptoms or signs of mitral stenosis. These data may be useful as guidelines for normal Doppler characteristics for St. Jude mitral valves in children. In an asymptomatic child whose prosthetic valve developed obstruction by granulation tissue overgrowth, each parameter significantly worsened as the heart rate increased. The changes in these parameters in 2 normally functioning St. Jude valves during atrial pacing were insignificant. The fluctuation of Doppler characteristics with changes in heart rate is useful for differentiating normally functioning prosthetic valves from impending stenosis.     

Tissue engineering: Relevance to neonatal congenital heart disease

Congenital heart disease (CHD) represents a large clinical burden, representing the most common cause of birth defect-related death in the newborn. The mainstay of treatment for CHD remains palliative surgery using prosthetic vascular grafts and valves. These devices have limited effectiveness in pediatric patients due to thrombosis, infection, limited endothelialization, and a lack of growth potential. Tissue engineering has shown promise in providing new solutions for pediatric CHD patients through the development of tissue engineered vascular grafts, heart patches, and heart valves. In this review, we examine the current surgical treatments for congenital heart disease and the research being conducted to create tissue engineered products for these patients. While much research remains to be done before tissue engineering becomes a mainstay of clinical treatment for CHD patients, developments have been progressing rapidly towards translation of tissue engineering devices to the clinic.     

Cell seeded tissue engineered cardiac valves based on allograft and xenograft scaffolds

An ideal heart valve substitute should possess the following requirements: absolute biocompatibility, long-term durability, nature-like biomechanical properties, no thrombogenicity, no teratogenicity, sufficient availability in all common sizes, and moreover, particularly for pediatric patients the growth potential is crucial. The use of current available biological cardiac prostheses such as glutaraldehyde fixed xenovalves and aortic or pulmonary homografts is unfortunately limited by several reasons. Further developments towards the alternative biological valves prostheses based on biological cell-free matrices as ideal valve substitute using methods of tissue engineering would potentially abolish the known disadvantages of current valve prostheses.Tissue Engineering is a complex science which combines both: basic research and clinical disciplines. Its main concept includes the usage of biological or/and artificial scaffolds which form the shape of the organ structures for subsequent tissue replacement.This review describes the current status in the development of tissue engineering of semilunar heart valves, including the usage of different types of biological scaffolds and characterization of several types of cells and cell sources for reseeding, as well as specific issues relating their cultivation on the matrices under dynamic conditions in especially designed bioreactor systems.Tissue engineered heart valve represents a viable tissue with the ability to grow, which is a strong argument to further evaluate this concept especially for clinical application in pediatric cardiac surgery.     

Reassessment of usefulness of porcine heterografts in mitral position in children

Summary The use of porcine heterograft valves in children is restricted because of valve calcification and dysfunction at follo-up. Because of inability to monitor the anticoagulant status or of desire of some teenage girls to get married and get pregnant, several pediatric patients received porcine heterografts. The purpose of this paper is to examine the issue of heterografts in children, based on our experience with children and adolescents aged 1 to 20 years, who underwent left heart valve replacement during a 7-year period ending April 1985. Ninety-four percent of the lesions were rheumatic in origin, 4% congenital, and 2% infectious. Of 168 mitral valves replaced, 54 (32%) were porcine heterografts and 114 (68%) were mechanical valves. These were divided into four groups, based on type of valve implanted and age at implantation: mechanical (M), age >15 years (M>15), 49 cases; heterografts (H) age >15 years (H>15), 34 cases; mechanical, age <-15 years (M<-15), 65 cases; and heterografts, age <-15 years (H<-15), 20 cases. None of the patients with heterografts received anticoagulation. Five-year actuarial valve survival was 86% for M>15, 96% for H>15, 82% for M<-15, and 60% for H<-15. The respective 9-year valve survival was 86%, 72%, 75%, and 18%. The valve survival data indicate that heterograft valves in patients older than 15 years are comparable (p=0.97) to mechanical valves, while heterografts in children less 15 years do poorly (p=0.015). Based on 8- to 10-year follow-up data, heterografts should not be inserted into children <-15 years of age. Heterografts may be used in children over 15 years of age with the expectation of valve survival comparable to that of mechanical valves and with little or no threat of thromboembolic complications.     

Late infective endocarditis after transcatheter tricuspid valve-in-valve implantation: A pediatric case report

In patients with congenital heart diseases, new procedures, such as transcatheter valve replacement, have been associated with a non-negligible incidence of infective endocarditis (IE): up to 4% patient–year IE incidence. Prosthetic IE after percutaneous tricuspid valve replacement (PTVR) has been scarcely reported. We report the first pediatric case of IE after percutaneous tricuspid Melody™ valve-in-valve implantation in a boy who was diagnosed with Eisenmenger syndrome, related to patent ductus arteriosus. This first pediatric case of late IE (4 years) after PTVR is added to eight previously reported cases of IE from the valve-in-valve international database registry (VIVID registry).     

小儿先天性心脏病介入治疗并发症的外科处理

目的 探讨先天性心脏病介入治疗后出现并发症而进行外科手术的适应证和手术时机.方法 1997年6月至2007年6月我院有28例先天性心脏病的患儿在介入治疗后出现并发症而需要外科手术治疗,其中男12例,女16例,年龄为8个月～14岁,平均为(8.9±3.4)岁,体重为9～43kg,平均为(22.7±2.1)kg;房间隔缺损12例,室间隔缺损8例,动脉导管未闭8例.介入治疗并发症包括有:堵闭器脱落12例,单纯残余分流10例(其中残余分流合并溶血3例),Ⅲ度房室传导阻滞4例,堵闭器脱落合并心包填塞1例,堵闭器被三尖瓣腱索缠绕1例.有23例在介入手术后当天进行急诊外科手术,5例于术后48h内手术.外科手术中,堵闭器取出术20例,房间隔缺损修补12例,室间隔缺损修补8例,动脉导管未闭缝闭术8例.结果 无住院死亡病例,经外科治疗后所有患儿均痊愈出院.术后复查心脏彩超无残余分流,而术前为Ⅲ度房室传导阻滞的4例患儿中,有3例恢复为窦性心律,1例转为Ⅱ度房室传导阻滞.结论 介入治疗术前必须有准确的诊断,并且选择合适的病例进行;出现并发症后应及时外科手术;对出现Ⅲ度房室传导阻滞的病例,经保守治疗无效后尽快选择外科手术.