国产侧倾碟瓣二尖瓣置换术117例患者15年随访研究

目的探讨影响国产侧倾碟瓣二尖瓣置换术患者近、远期临床疗效的因素。方法1983年3月至1990年9月117例患者应用国产侧倾碟瓣(25～29mm)施行二尖瓣置换术,对合并中、重度三尖瓣功能性关闭不全者行改良DeVega或Kay法环缩术。结果住院期间死亡9例(7.69%),低心排出量综合征、呼吸功能衰竭、人造瓣膜功能障碍等是早期死亡主要原因。平均随访时间为11.6年,存活5年以上106例,死亡的主要原因为心力衰竭、抗凝有关的并发症,以及风湿热复发。患者术后10年、15年生存率分别为78.3%和48.11%。抗凝过量出血与血栓栓塞并发症的发生率分别为1.86%患者·年与0.39%患者·年。生存15年以上的51例患者,心功能恢复I级34例、Ⅱ级13例、Ⅲ级4例。结论年龄较轻,心脏瓣膜病变较重,抗凝过量出血发生率较高是本组患者的三个特点;术中探查三尖瓣,凡有瓣环扩大的患者均应积极纠正;术后早期应重视预防风湿热复发,采用长效青霉素肌内注射3～5年;采用低强度抗凝治疗方案。     

Early cardiac valve replacement in infective endocarditis: a 10-year experience

Thirty one patients underwent early valve replacement for infective endocarditis during a 10-year period (between September 1973 and December 1983). Intractable heart failure, persistent infection and systemic emboli were the indications for urgent surgical intervention. Native valve endocarditis had been present in 22 patients (71%) and surgery was performed 14-105 (mean 51) days after the onset of symptoms. Nine patients (29%) had prosthetic valve endocarditis and surgery was performed within 6 to 51 (mean 28) days. The aortic valve was replaced in 22 patients (71%), the mitral valve in 5 patients (16%) and both valves in 4 patients (13%). Four patients (12.9%) died during hospitalization. There were no late deaths or reinfection in this series. The remaining 27 patients were discharged and after a mean follow-up period of 36 months, 25 patients were in NYHA functional class I or II. Only 9 patients (29%) underwent cardiac catheterization prior to surgery and the other patients were operated upon on the basis of echocardiographic data alone. The post-operative results with a survival rate of 87%, justify an aggressive surgical approach in order to prevent serious complications and cardiovascular deterioration. It appears that surgical decision-making can be made on the basis of echocardiography. The risk of cardiac catheterization can be avoided with the newer generation of echocardiographic equipment which allows a detailed and complete analysis of cardiac abnormalities and function.     

Aortic valve replacement with small-sized disc prostheses (medtronic hall)

BACKGROUND AND AIM OF THE STUDY: Several studies have demonstrated a worse performance of small prostheses in the narrow aortic root. However, modern low-profile mechanical prostheses have improved hemodynamic performance, are easy to implant, and have been used increasingly in elderly patients, where narrow roots are most frequently observed. We describe our experience in patients with aortic annuli >21 mm with the use of Medtronic Hall prostheses. METHODS: Between April 1988 and December 1997, a total of 332 patients (218 females, 114 males; mean age 59.3 +/- 9.8 years (range: 29-75 years) received Medtronic Hall size 20 (n = 140), 21 (n = 96) or 22 (n = 96) prostheses. The mean body surface area was 1.59 +/-0.12 m2 (range: 1.27-2.01 m2); 140 patients were in NYHA functional classes III/IV. There were no significant differences in clinical characteristics of patients in the three prosthesis-size groups. RESULTS: The mean preoperative systolic left ventricular/aorta gradient was 64.5 +/- 24.8 mmHg (no significant inter-group difference). After cardiopulmonary bypass, peak gradients through the aortic prostheses were 13.9 +/- 8.0 mmHg in size 20 valves, 14.0 +/- 8.1 mmHg in size 21, and 10.1 +/- 8.9 mmHg in size 22. Four patients died in hospital (mortality rate 1.2%); there were no significant inter-group differences in hospital morbidity. Follow up was complete for 97% of the patients (mean 4.3 years; range: 1-11 years). The late mortality rate was 9.3% (n = 31; 2.56% per pt-yr); of these patients, 20 (14.3%) had size 20 prostheses, seven (7.3%) size 21, and four (4.2%) size 22 (p = 0.01). Fourteen patients (4.2%) died from cardiac causes, and six (1.8%) from prosthesis-related causes. Preoperative older age and aortic regurgitation were the only independent predictors of late mortality. Eight patients had systemic thromboembolic events (0.66% per pt-yr), two had prosthetic thrombosis (0.17% per pt-yr) and five had hemorrhagic episodes (0.41% per pt-yr). Seven patients had prosthetic valve endocarditis (0.58% per pt-yr). Among survivors, 97% are currently in NYHA class I/II. CONCLUSIONS: The small (size 20, 21 and 22) Medtronic Hall prostheses have good hemodynamic performance and are an excellent option as valve substitutes in patients with narrow aortic roots.     

Isolated mitral valve replacement with the Bj?rk-Shiley tilting disc prosthesis.

Between July 1970 and June 1977, 151 patients underwent isolated mitral valve replacement with the Bj?rk-Shiley valve. The follow-up period extended over 8 years to June 1978. Hospital mortality was 5.2% (8/151), late mortality 8.4% (12/143). Actuarial survival analysis predicts 84 (+/- 4) % of patients to be alive at 5 years and 80 (+/- 6) % at 8 years. Thirteen patients sustained 15 episodes of thromboembolic complications; actuarially 88 (+/- 4) % of patients were free from this complication at 5 years and 81 (+/- 8) % at 8 years. Other valve-related complications included paravalvular leak (7), prosthetion showed an improvement of at least one class in 84% of patients.     

Fatal hemolysis due to unidentified causes following mitral valve replacement with bileaflet tilting disc valve prosthesis

Summary Fatal hemolysis after mitral valve replacement with the St. Jude bileaflet tilting prosthesis is reported in two patients. Although one underwent re-replacement of the valve, both died from multiple organ failure and acute renal failure, respectively. Scanning electron microscopy revealed microthrombi adherent to a leaflet in one and irregular leaflet surfaces in the other. Such defects are rare but are possible causes of hemolysis in patients with the St. Jude mitral valve prosthesis.     

Blood rheology after cardiac valve replacement with mechanical prostheses or bioprostheses

Arterial thromboembolism is a serious complication in patients after heart valve replacement. Abnormalities in blood rheology may contribute to this complication. Therefore, the aim of this study was to compare various determinants of blood rheology in patients with substitute heart valves with those in healthy controls; furthermore, differences between patients with mechanical valves and those with bioprostheses should be investigated. The hemorrheologic determinants--fibrinogen, plasma viscosity, red cell aggregation, hematocrit and platelet aggregation--were studied in 92 patients with mechanical bileaflet valves, in 28 patients with bioprostheses and in 29 control subjects; the time since valve replacement was greater than or equal to 9 months. Fibrinogen, plasma viscosity, red cell and spontaneous platelet aggregation were found to be increased in all patients after heart valve replacement compared with normal subjects (fibrinogen: 348 +/- 87 vs 267 +/- 66 mg/dl, p less than 0.01; plasma viscosity: 1.71 +/- 0.1 vs 1.66 +/- 0.1 mPas, p less than 0.05; red cell aggregation: 9.9 +/- 2 vs 7.8 +/- 2 U, p less than 0.01; platelet aggregation: 22 +/- 15 vs 13 +/- 13%, p less than 0.01); among patients, fibrinogen, plasma viscosity and spontaneous platelet aggregation were higher in mechanical valves than in bioprostheses (fibrinogen: 359 +/- 95 vs 314 +/- 41 mg/dl, p less than 0.01; plasma viscosity: 1.72 +/- 0.1 vs 1.68 +/- 0.1 mPas, p less than 0.1; platelet aggregation: 23 +/- 15 vs 16 +/- 11%; p less than 0.05), whereas no difference could be found for red cell aggregation (9.7 +/- 2 vs 10.5 +/- 2%, p greater than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

Medico-surgical experience in dysfunction of heart valve prostheses. Report of 55 cases]

The medical and surgical outcome of 55 patients with prosthetic valve disfunction are reported (39 bioprosthesis and 16 mechanical). Fifty patients were operated and five had medical treatment. The group of patients with mechanical prosthesis had a functional class of 2.4 +/- .74 vs patients with bioprosthesis who had a functional class of 2.8 +/- .71. Forty eight patients (87%) had congestive heart failure, four systemic emboli and three infective endocarditis. Three cases with mechanical prosthesis in tricuspid position were subjected to thrombolysis with streptokinase and experienced clinical and echocardiographical improvement. Time elapsed from original implantation and valve disfunction was 66 +/- 56 months for mechanical prosthesis vs 108 +/- 37 months in bioprosthesis (p less than 0.01), three patients died at surgery and two during the waiting period. All deaths resulted from cardiogenic shock. All of them were previously on functional class IV.     

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。     

Heart valve prostheses in children with reference to 95 cases]

Over a 10 year period, 95 children aged 15 years and less underwent replacement of one or several of their heart valves, usually by a Starr-Edwards ball prosthesis. The predominant pathology was rheumatic heart disease and the most commonly affected valve was the mitral. Severe symptomatology, heart failure, cardiomegaly and high wedged-capillary and pulmonary arterial pressures were practically constant findings. Operative mortality was low (3.2%) and the long-term mortality was 10 patients. With an average follow-up of 40 months, results were excellent in the great majority of patients, with complete regression of symptoms, cardiomegaly and high capillary and pulmonary arterial pressures. Anticoagulant therapy was not systematic and only half the series were so treated. Thromboembolic complications were rare, 5.5% patients, but only affected those without anticoagulant therapy. The problems of evolving rheumatic disease and, above all, of tricuspid incompetence, the persistence of which after surgery on the mitral valve seems to be a sign of advanced myocardial damage, are discussed.     

Mitral valve replacement with the Bj?rk-Shiley monostrut prosthesis: a 4-year clinical experience

Mitral valve replacement with Bj?rk-Shiley monostrut prostheses was performed in 142 patients, aged 18 to 73 (mean age: 53.8). A group of 101 patients underwent isolated mitral replacement (group A), while both mitral and aortic (in one case tricuspid) valves were replaced in 41 (group B). In 19 of group A patients and in 9 of group B patients a tricuspid annuloplasty was added. Hospital mortality was one case in each group (group A: 1%; group B:2.4%). The cause of death was low output in both cases (i.e. not valve-related). Late mortality occurred in 4 cases (4%) in group A, and in 3 cases (7.3%) in group B (follow-up: 6 to 58 months; mean follow-up: 24 months). Actuarial survival was 93.79% in group A and 89.94% in group B one year after surgery; it was 93.79% in group A and 81.76% in group B after 3 years. All deaths from undetermined causes, as well as any new unexplained neurological deficit or peripheral emboli, were considered to be valve-related: 84.18% of group A patients, as well as 67.90% of group B, were event free after 3 year (actuarial). most valve-related events occurred in the first year after surgery. We observed thromboembolism in 3 cases for each group: one patient in group B had pannus formation over the prosthetic annulus; prosthetic valve endocarditis in 1 case of group A and 2 of group B; significant hemorrhage due to anticoagulant therapy in 1 (group A); one patient in each group died suddenly, 4 and 7 months postoperatively. One group A patient and 2 group B patients were reoperated: a new valve prosthesis was implanted in two patients. Mean transvalvular gradient, as determined by echocardiography, was 3.8 +/- 2.3 (SD) mmHg in the case of isolated mitral replacement. In conclusion, we believe these results are highly encouraging, especially in the isolated mitral replacement group. Bj?rk-Shiley monostrut prosthesis has been demonstrated to be a reliable valve substitute, with an acceptable incidence of complications. No Bj?rk-Shiley monostrut prosthesis structural deterioration was seen, and its hemodynamic behaviour may be considered satisfactory.     

95例再次人工机械瓣置换术

目的:总结95例再次人工机械瓣置换术的外科治疗经验。方法:自2000年1月至2010年4月共行心脏瓣膜置换术3235例,其中95例行再次人工机械瓣置换术。本组95例第一次手术均是行人工机械瓣置换术后的患者,其中机械瓣功能障碍65例,瓣周漏19例,机械瓣心内膜炎11例,手术均在全麻体外循环心脏停跳下进行,其中急诊手术35例,限期手术20例,择期手术40例。其中二尖瓣置换74例,主动脉瓣置换12例,双瓣置换9例,同期行三尖瓣置换13例,三尖瓣成形45例。结果:围术期死亡7例,病死率7.37%,其中有3例是术中无法脱离体外循环机,2例因术后出现严重低心排出量综合征(低心排)及多脏器功能衰竭死亡,1例死于术后心室颤动(室颤),1例死于术后脑出血、脑疝,其余88例痊愈出院。随访3个月至4年,晚期死亡4例,存活患者心功能均明显改善。结论:掌握好手术时机、手术技术及术后处理,是再次机械瓣置换术成功的重要因素。     

风湿性心脏瓣膜置换术1 061例临床分析

目的:对1061例风湿性心脏病瓣膜置换术进行早期疗效观察及临床分析。方法:对2000年1月～2005年12月入院施行瓣膜置换术的风湿性心脏瓣膜病例进行回顾总结。结果:1061例中,术后早期病死率1.32%(14例),主要死亡原因为低心排血量综合征(3例)和心室颤动(3例)。术后早期并发症发生率6.41%(68例),其中低心排血量综合征13例、严重心律失常12例,两者占36.76%。结论:术前改善心功能、术中加强心肌保护和改进手术方法、积极处理术后并发症是提高风湿性心脏病瓣膜置换术疗效的重要措施。     

Six years clinical experience with the Omniscience cardiac valve

Clinical data on the Omniscience valve prosthesis were obtained from 194 patients (92 mitral valve replacements, 65 aortic valve replacements, 11 tricuspid valve replacements and 26 multiple valve replacements). Follow-up was 98% complete for a total of 443 patient-years with a mean of 2.6 years and maximum of six years. The mean age of patients was 50.3 +/- 14.5 years, with a range of two months to 75 years. Seventy-five percent of patients were in NYHA functional class III-IV preoperatively; postoperatively, over 93% of patients were in class I-II. Hospital mortality was 12.4% and late mortality was 3.2% per patient-year. The linearized rates for complications were as follows (per patient-year): thromboembolism 2.9%; valve thrombosis 0.7%; anticoagulant bleeding 2.7%; endocarditis 0.9%; pannus formation 0.2%; periprosthetic leak 0.5%. All significant valve related complications occurred at a rate of 5.9% per patient-year. The complications were fatal at a rate of 1.1% per patient-year and the risk of reoperation on the valve site was 1.1% per patient-year. Actuarial survival at six years was 84.8% +/- 5% for the whole group (88.6 +/- 5.7% for aortic, 84.3 +/- 9.4% for mitral valve replacement, 86.0 +/- 5.5% for single valve replacement and 77.1 +/- 10.2% for multiple valve replacements). Based on the duration of the study and absence of restrictive selection criteria, these clinical data demonstrated a reliable degree of safety and performance for this prosthesis.     

Ten years' experience in aortic valve replacement with homografts in 389 cases

BACKGROUND AND AIM OF THE STUDY: Aortic valve replacement using homografts is an accepted alternative to the use of other replacement devices, and has been established at the authors' institution for more than 10 years. METHODS: Since 1992, a total of 389 homografts was implanted, and 332 patients (mean age 54 years, 72% males) were followed up. The initial patients (n = 75) had subcoronary implantation, all subsequent patients had root replacement. Both aortic grafts (AG) and pulmonary grafts (PG) were used. Follow up was conducted with regard to the factors 'graft origin', 'implantation technique' and 'gender', and included clinical examination, ECG and transthoracic echocardiography on an annual basis. RESULTS: Overall 30-day mortality was 5.4% (AG patients 3.9%, PG patients 13.5%; p = 0.09). Among late deaths (n = 22), six were valve-related (all prosthetic infection). Four minor thrombembolic events were recorded due to amaurosis fugax and transient ischemic attacks (TIA). Freedom from reoperation was 86.5%. Indication for graft replacement was greater after subcoronary implantation than after root implantation (p = 0.04). Reoperation was necessary in 24 patients due to restenosis (n = 4), regurgitation grade >II (n = 5), paravalvular leak (n = 2) and prosthetic infection (n = 13). At the latest echocardiographic follow up, mean peak pressure gradient was 15.60 +/- 11.76 mmHg, homograft regurgitation grade was 0.82 +/- 0.66, left ventricular end-diastolic diameter (EDD) was 49.1 +/- 7.54 mm, and mean aortic root diameter was 30.54 +/- 5.48 mm. When comparing parameters at a mean of five years postoperatively, the pressure gradient increased from 10.26 to 15.02 mmHg, regurgitation grade increased from 0.53 to 0.81, and EDD decreased from 52.3 to 50.4 mm. Other variables showed no significant differences. CONCLUSION: The present results confirmed good midterm-results for aortic valve replacement with homografts. These prostheses are vulnerable to infection, and root replacement was superior to the subcoronary implantation technique.     

Twenty-two-year experience with aortic valve replacement. Starr-Edwards ball valves versus disc valves

From 1965 through 1986, 817 patients underwent aortic valve replacement at our institution. Six hundred forty-five patients received Starr-Edwards ball valves, including 286 Silastic ball valves (Models 1200/1260), 165 cloth-covered caged-ball prostheses (Models 2300/2310/2320), and 194 track-valve prostheses (Model 2400). In contrast, 172 patients received disc-valve prostheses, including 126 St. Jude Medical aortic bi-leaflet disc valves, 32 Lillehei-Kaster pivoting disc valves, and 14 Bj?rk-Shiley valves (6 convexoconcave and 8 monostrut). With respect to preoperative data, the 2 groups were comparable, with the following differences. The Starr-Edwards group included 1) more men (77% versus 51%; p < 0.0001); 2) a significantly older patient population (59 +/- 10 years versus 56 +/- 15 years; p < 0.0001); 3) more patients in New York Heart Association functional class III or IV (72% versus 65%; p < 0.01); 4) fewer patients with angina pectoris as a limiting symptom (20% versus 36%; p < 0.0001); and 5) patients who tended to receive larger prostheses (26 +/- 2 mm versus 23 +/- 3 mm, p < 0.0001). The overall 10-year survival rate +/- standard error was 59% +/- 2% for patients receiving Starr-Edwards valves and 63% +/- 6% for those with disc valves. The linearized complication rates (expressed as percentage per patient-year +/- standard error) for the Starr-Edwards and disc-valve groups, respectively, were 2.0% +/- 0.2% and 1.4% +/- 0.5% for thromboembolism, 2.1% +/- 0.2% and 3.9% +/- 0.8% for Coumadin-related hemorrhage, 0.5% +/- 0.1% and 0.3% +/- 0.2% for endocarditis, 0.3% +/- 0.1% and 0.7% +/- 0.3% for other prosthesis-related complications, and 4.8% +/- 0.1% and 6.4% +/- 1.0% for all complications together. There were no instances of thrombotic occlusion or mechanical failure. After the 6th postoperative year, no thromboembolic events were encountered in patients with a Silastic ball valve; the 15-year freedom from thromboembolic events was 89%. Cox regression analysis showed that 1) a prosthetic orifice diameter of 15 mm or less was associated with an increased mortality; 2) disc valves entailed an increased rate of hemorrhage and prosthesis-related complications considered as a whole; 3) and Lillehei-Kaster valves led to an increased rate of prosthesis-related complications other than thromboembolism, hemorrhage, and endocarditis. Neither the type of prosthesis nor the size influenced the rate of thromboembolism, endocarditis, or prosthesis replacement. Because of their proven durability and relatively low price, we advocate the continued use of Starr-Edwards Model 1260 Silastic ball valves that have an orifice diameter of 16 mm or more.