北京B-N型牛心包瓣膜替换术23例总结

我院自1983年11月至1988年4月,应用北京BN型牛心包瓣膜为23例风心病患者施行二尖瓣替换术。其中二尖瓣和主动脉瓣双瓣膜替换术2例,二尖瓣替换术并主动脉瓣成形术1例。术后近期效果较好。临床资科本组23例,男9例,女14例。年龄20～46岁,平均35岁。均为风心病,病史1～20年,平均7年。术前心功能(按NYHA分级):Ⅲ级21例,Ⅳ级2例。房颤19例。心胸比率0.50～0.71,平均0.62。均无动脉栓塞史。     

重症感染性心内膜炎的外科治疗

目的 评价重症感染性心内膜炎手术治疗效果.方法 回顾性分析2003年1月至2007年6月手术治疗的复杂性心内膜炎患者33例临床资料,均为原发性心内膜炎,其中感染侵犯二尖瓣16例、主动脉瓣11例、二尖瓣和主动脉瓣6例.术中发现瓣叶严重毁损27例、主动脉瓣周脓肿1例、均有瓣膜赘生物形成.脓肿清除后遗留残腔采用间断褥式缝合1例、主动脉瓣替换术11例,二尖瓣替换术16例,主动脉瓣及二尖瓣双瓣替换术6例.结果 早期无死亡,术后3个月心功能(NYHA分级)恢复Ⅰ级33%(11/33)、Ⅱ级66%(22/33).结论 重症心内膜炎瓣膜及瓣环受损重,积极手术,彻底清除赘生物,病灶创面的恰当处理是影响手术本身能否成功以及术后近期效果的关键.     

先天性主动脉瓣狭窄的外科治疗

我院自1984年7月至1995年3月共收治48例先天性主动脉瓣狭窄患者，其中30例行外科治疗，占62．5％。22例主动脉瓣替换术（73．3％）中，同种动脉瓣13例，机械瓣9例。主动脉瓣交界切开术8例。术后随访1月至9年，每半年一次。治疗效果：术后早期死亡2例，死亡率6．7％；晚期死亡1例，术后1年死于感染性心内膜炎，占33％；27例随诊良好。结合先天性主动脉瓣狭窄的临床征象，对其诊断及外科治疗进行讨论。     

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。     

44例原发性心脏肿瘤的诊断与治疗

目的总结44例原发性心脏肿瘤的发生部位、肿瘤性质、诊断及外科治疗方法。方法2006年1月至2007年12月44例原发性心脏肿瘤患者接受手术治疗，男性12例，女性32例，年龄25～69（37．6±11．9）岁；其中良性肿瘤42例、恶性肿瘤2例。所有病例均经超声心动图诊断并在体外循环下行手术切除治疗。结果手术死亡1例，其余43例术后随访6个月至2年，1例恶性肿瘤于术后6个月死亡，2例黏液瘤分别于术后10、20个月后复发。结论原发性心脏肿瘤良性以黏液瘤多见，彻底切除肿瘤是防止复发的关键。心脏恶性肿瘤手术近远期效果差。     

感染性心内膜炎的诊断与外科治疗

目的探讨感染性心内膜炎的诊断与外科治疗特点，分析术后近、中期效果。方法1995年1月至2007年6月期间52例感染性心内膜炎患者在我院接受手术治疗，通过对临床资料的分析，总结外科治疗经验。通过对门诊及电话随访资料的分析，总结手术后近、中期效果。结果术后早期死亡4例（7．7％），术后随访6个月至12年，出院患者死亡5例，生存患者中心功能Ⅱ级34例、Ⅲ级9例。结论早期明确诊断、选择合适的手术时机及内、外科综合治疗，是提高感染性心内膜炎治愈率的关键。     

心脏左房肿瘤39例外科治疗分析

目的总结发生在左房的心脏肿瘤的临床特征及治疗结果。方法回顾性分析39例原发性心脏左房肿瘤患者的临床资料。结果39例全为良性肿瘤,其中左房粘液瘤37例;左房脂肪瘤2例。临床表现为心悸、气短;系统栓塞及发热。39均行手术治疗且完整切除。其中2例同期行二尖瓣成形术,2例行二尖瓣置换术,2例行三尖瓣成形术。术后随访9个月～9年其中一例复发,其余恢复良好。结论原发性心脏左房肿瘤中以左房粘液瘤最常见。外科治疗良性肿瘤手术效果好,预后令人满意。     

二尖瓣膜退行性变外科治疗38例

二尖瓣粘液退行性变致二尖瓣脱垂是单纯二尖瓣返流的最常见病因 ,发病有增加的趋势。其临床表现虽与风湿性心脏病二尖瓣关闭不全相似 ,但有自身的超声心动及病理特点 ,外科治疗以二尖瓣替换及成形术为主。我院 1990 - 0 7～2 0 0 1- 0 7共 3 8例二尖瓣脱垂患者施行治疗 ,报道如下。1　对象和方法　患者 3 8(男 2 9,女 9)例 ,年龄 13～ 64 (平均2 6)岁。临床诊断均为二尖瓣脱垂 ,2例伴马凡综合征 ,2例伴病毒性心肌炎 ,1例伴感染性心内膜炎 ,2例伴冠心病。病程10 d～ 9年 ,平均 8.5月 ,突发者 18例 ,反复心衰者 5例。心尖区均可闻及收缩期 ～…     

术中经食管超声心动图监测行二尖瓣成形术

目的　评价术中经食管超声心动图在二尖瓣成形术中的作用。方法　 1993年 3月至 2 0 0 3年 3月 ,6 2例二尖瓣关闭不全病人在经食管超声心动图监测下行二尖瓣成形术 ,男 2 4例 ,女 38例 ,平均年龄 (31 3± 7 5 )岁。病因为退行性变 4 2例 ,先天性 2 0例。重度二尖瓣关闭不全 5 9例 ,中度 3例。根据二尖瓣病变的特征进行相应的成形手术。结果　全组无一例手术死亡 ,8例改行二尖瓣替换术。术后超声心动图检查二尖瓣无返流 3例 ,轻度返流 4 9例 ,中度返流 2例。结论　经食管超声心动图在术中能即时判断二尖瓣成形术的效果 ,并找出失败原因 ,从而指导进一步成形术。     

肥厚型梗阻性心肌病13例的外科治疗

目的探讨肥厚型梗阻性心肌病(hypertrophic obstructive cardiomyopathy,HOCM)患者的外科治疗、手术疗效及经验,为基层医院开展此类手术提供经验。方法回顾性分析2006年1月至2016年10月高州市人民医院13例外科治疗的HOCM患者的临床资料,其中男8例、女5例,年龄29.3(1~47)岁。术中、术后用食道超声心动图评估左心房、左心室、左心室流出道流速及压差、左心室射血分数、二尖瓣关闭情况。13例患者均采用改良Morrow手术疏通左心室流出道,同时对二尖瓣成形或二尖瓣置换不予处理,并矫正心内合并的其他畸形。结果 1例因出现低心排血量综合征,术后2 d死亡。其余患者手术效果满意,无近期或中期死亡及相关并发症,住院时间8.4(7~13)d。术后左心室流出道压差比术前明显降低[(14.3±8.3)mmHg vs.(85.3±40.5)mmHg(1 mmHg=0.133 kPa)]。术后食道超声提示收缩期前向运动(systolic anterior motion,SAM)征消失。2例术前二尖瓣中-重度反流,行二尖瓣成形效果欠佳而改行二尖瓣机械瓣置换。2例二次转机行左心室流出道疏通。术后12例随访,随访率100%,主要以门诊及电话随访,随访1个月~10年,患者症状明显改善,纽约心脏协会心功能在I~II级,无远期死亡、其他并发症或再次手术。结论充分疏通左心室流出道及妥善处理二尖瓣,外科治疗HOCM是安全、有效的。     

双孔成形术治疗二尖瓣关闭不全

目的总结双孔二尖瓣成形术治疗二尖瓣关闭不全的经验。方法诊断为二尖瓣关闭不全接受此手术治疗30例，男12例，女18例，年龄14～52（33±17）岁。心功能Ⅱ级5例，Ⅲ级23例，Ⅳ级2例，用超声心动图对瓣膜进行评价。结果全组术前二尖瓣反流面积（9．8±3．5）cm^2，术后为（0．72±0．31）cm^2。全组无术后死亡，痊愈出院。随访1～48个月，效果满意，心功能为Ⅰ～Ⅱ级。结论双孔二尖瓣成形术是一种简单有效的手术方法。     

Doppler echography in the evaluation of mitral valve function following Carpentier's valvuloplasty

In the present study Doppler-echocardiography was used to evaluate the quality of mitral valve regurgitation (MVR) repair by Carpentier valvuloplasty. Between January, 1984 and June, 1987, this operation was performed in 51 patients (39 men, 12 women; mean age 58 +/- 10.9 years) presenting with mitral valve regurgitation; 25 were in class III and 14 in class IV of the NYHA classification. Two patients died soon after the operation and 2 others some time later. The 47 survivors were followed up for a mean period of 20.5 +/- 11.2 months: 3 of them required mitral valve replacement for residual MVR or mitral stenosis, one developed cerebral embolism. At the latest control, 18 patients were in NYHA class I and 26 in NYHA class II. Doppler velocimetry showed no or little mitral valve dysfunction; the residual MVR was below grade 1 in 37 of the 44 survivors who were not reoperated upon. Mitral function was satisfactory after Carpentier valvuloplasty, with a mean transmitral gradient of 3.3 +/- 1.3 mmHg and a mean mitral valve area of 2.9 +/- 0.98 cm2. In 3 patients an intraventricular gradient of 10 to 20 mmHg, reflecting moderate ventricular obstruction, was detected by Doppler velocimetry. These data obtained with the combined Doppler-echocardiographic method confirm that the quality of mitral function is excellent after Carpentier mitral valvuloplasty.     

再次心脏瓣膜手术285例临床分析

目的:总结再次心脏瓣膜置换手术的病因及诊疗体会。方法:回顾分析自2007年3月至2013年10月,在第三军医大学新桥医院施行心脏瓣膜再次手术的285例患者的临床资料。其中男性92例(32.3%),女性193例(67.7%),年龄2~72岁,收集患者术前合并症,术前心功能状态,初次手术方式,再次手术的原因及手术方式,围手术期死亡情况等相关临床资料,通过多因素Logistic回归分析再次心脏瓣膜病围手术期死亡的相关危险因素。结果:本组患者再次手术的原因为二尖瓣闭式扩张术后再狭窄、生物瓣毁损、机械瓣功能障碍或其他病因;全组围手术期死亡18例,病死率6.31%,主要原因为低心排出量综合征(低心排),恶性心律失常,呼吸衰竭,心力衰竭,多器官衰竭。多因素Logistic回归分析结果显示,患者术前合并其他系统疾病(OR=3.530,P=0.049),术前心功能IV级(OR=4.025,P=0.025),术中主动脉阻断时间120min(OR=5.748,P=0.004),术后呼吸机支持时间24h(OR=4.770,P=0.025),是患者围手术期死亡的独立危险因素。结论:再次心脏瓣膜手术难度大,手术风险较高,准确的把握手术时机,术中注意心肌的保护,术后加强心肺肾等重要器官的监护和处理,再次心脏瓣膜手术有较高的手术成功率。术前合并其他系统疾病,术前心功能IV级,主动脉阻断时间较长是再次心脏瓣膜手术围手术期死亡的危险因素。     

通讯作者：修宗谊,Email:13504909539@163.com

目的：提高再次人工心脏瓣膜置换患者的生存率及生活质量。方法：总结2006年5月～2014年5月中国医科大学附属第一医院心脏外科住院再次心脏瓣膜手术患者69例。置换二尖瓣瓣膜31个,修复17个;置换主动脉瓣15个,修复10个;三尖瓣置换3个。术前心功能分级( NYHA)II级22例,III级31例,IV级16例。结果：住院期间死亡5例,死亡率：7.24%(5/69)。术后随访49例(随访率:76.56%),随访时间7个月-8年;随访中再手术6例,死亡7例;存活患者42例,心功能：III级1例,II级12例,余心功能正常。结论：对瓣膜置换术后任何原因导致的重度瓣膜功能障碍,早期诊断、及时采取正确的手术方法将有利于提高患者的生存率。外科手术联合药物治疗是提高术后生存质量的关键。     

二尖瓣位置入GK双叶瓣应用体会——附684例早期临床分析

目的:评估二尖瓣置换术中应用GK瓣的早期疗效。方法:回顾分析2007年1月至2013年6月间,二尖瓣位应用GK瓣的684例患者的临床资料:男性256例,女性428例,年龄(46.70±13.54)岁,病程(13.17±8.29)年;术前心功能分级(NYHA):II级141例,III级369例,IV级174例,其中,再次手术41例,感染性心内膜炎53例,急诊手术75例,合并心房颤动509例。结果:死亡7例,病死率1.02%。早期并发症为:严重低心输出量综合征(低心排)30例,转化为多脏器功能衰竭6例;恶性心律失常11例;呼吸衰竭12例;肾功能严重损害6例。随访6个月至3年,恢复良好,6个月时心脏超声检查心脏功能和二尖瓣跨瓣压差满意。出院1个月后,发生瓣膜血栓1例,该患者合并三尖瓣置换,再次手术见人工三尖瓣和二尖瓣均有血栓,再次置入GK瓣,术后恢复较好;出院后4个月发生瓣周漏1例,再次换瓣手术,恢复好。结论:二尖瓣位应用GK瓣安全,缝合环柔软,入座自然,早期疗效好。     

Long-term follow-up of partial atrioventricular septal defect repair in adults

Patients presenting with partial atrioventricular septal (PAVC) defects in adulthood are rare. Eight adult patients with this congenital heart defect who had surgical repair are described, along with their long-term postoperative follow-up data. Average age at operation was 48 years, and average follow-up was 13.4 years. There was no operative mortality. All but one patient were in NYHA functional class 1 or 2 postoperatively. Three patients had suffered late onset of progressive mitral regurgitation leading to severe congestive heart failure 15 to 25 years postoperatively. The number of adult patients with repaired PAVC defects who have eventual mitral valve deterioration may be higher than estimated in the current literature. Because of the unpredictability of mitral valve function, lifelong follow-up should be stressed in these patients.     

Is measurement of plasma brain natriuretic peptide levels a useful test to detect for surgical timing of valve disease?

BACKGROUND: The optimal timing of valve surgery is very important. In patients who are severely symptomatic, the marked improvement in symptomatic status observed following successful valve surgery. However, in patients with no or only mild symptoms, the decision is more difficult. The aim of this retrospective study was to determine whether the measurement of plasma brain natriuretic peptides (BNP) levels is useful to decide surgical timing for valve disease. METHODS: Fifty-one patients with valve disease underwent single valve surgery (mitral stenosis, MS, 13; mitral regurgitation, MR, 16; aortic stenosis, AS, 14; aortic regurgitation, AR, 8 patients). Blood samples, echocardiographic and cardiac catheterization data were obtained before operation and echocardiographic examination were performed after 1-year of operations. RESULTS: In patients subjected to single heart valve surgery, plasma BNP mean levels were 214.6+/-48.5 pg/ml. In plasma BNP levels, there was only significant difference between MS and AS group (MS 67.5+/-9.7 vs. AS 314.3+/-112.0 pg/ml, P=0.04). There were no relationships between plasma BNP levels and pre-operative cardiac functions. After 1-year of the valve surgery, NYHA functional class was reduced in 36 patients (70.6%) and plasma BNP levels before the surgery significantly correlated with post-operative NYHA functional class. CONCLUSIONS: In this retrospective study, patients with high plasma BNP levels significantly impaired the improvement of clinical symptoms after surgery. We have suggested that plasma BNP levels is useful for detecting asymptomatic valvular disease, and is a clinical marker useful in determining the optimal surgical timing.     

Percutaneous balloon dilatation of the mitral valve in critically ill young patients with intractable heart failure.

OBJECTIVE--To assess the outcome of percutaneous balloon dilatation of the mitral valve in critically ill young patients with intractable heart failure. DESIGN--Retrospective analysis of all such patients presenting over a period of 4 years. PATIENTS--Of 432 consecutive patients undergoing percutaneous balloon dilatation of the mitral valve, 12 (mean age 29 years) with intractable heart failure were identified. Nine had severe pulmonary oedema and three had pulmonary oedema with severe right heart failure and hypotension. Three patients were pregnant and three required mechanical; ventilatory support. PROCEDURE--Percutaneous balloon dilatation of the mitral valve was performed using the Inoue balloon technique. The procedure was shortened by excluding full right study, cardiac output measurement, and left ventriculography. The mitral valve morphology and mitral valve area were determined before and after percutaneous balloon dilatation using cross sectional Doppler echocardiography. RESULTS--The procedure was technically successful in all patients. The mean (SD) echocardiographic value of the mitral valve area increased from 0.7 (0.1) to 1.4 (0.2) cm2 with a concomitant reduction in pulmonary artery systolic pressure (Doppler) from 81 (17) to 50 (7) mm Hg. There was a significant clinical improvement in all patients. The mean (range) fluoroscopy time for the procedure was 6.9 (1.7-14.1) min. During follow up (mean 10 months) nine patients were in New York Heart Association (NYHA) functional class I, one was in class II, one under NYHA elective mitral valve replacement, and one, who refused elective surgery, died suddenly at home. CONCLUSION--Percutaneous balloon dilatation of the mitral valve can be performed as a life saving procedure in critically ill patients with mitral stenosis, as even a modest increase in valve area in these patients produces gratifying clinical improvement.     

不同保留瓣下结构方法行二尖瓣置换术的对比研究

目的:总结不同保留瓣下结构方法在二尖瓣置换术中的临床应用和体会,提高临床治疗效果,降低术后病死率和并发症发生率。方法:回顾性分析2005年5月至2013年7月,102例以二尖瓣病变为主的患者,实施了保留二尖瓣瓣叶及瓣下结构的瓣膜置换术(均置换的机械瓣膜),其中男性48例,女性54例,年龄22~67岁,平均(46±10.1)岁,术前诊断二尖瓣狭窄为主22例,二尖瓣狭窄合并关闭不全56例,二尖瓣关闭不全为主24例,合并三尖瓣中度以上关闭不全38例,合并心房颤动35例,合并左心房血栓3例。术前射血分数(EF)33%~65%,平均(52±8.2)%。心功能分级(NYHA分级)Ⅱ级7例、Ⅲ级76例、Ⅳ级19例。同期选择行保留后叶及瓣下结构以及不保留瓣膜和瓣下结构的二尖瓣置换术的患者各102例作为对照组。三组患者术前情况比较,差异无统计学意义(P0.05)。结果:保留全瓣组无围手术期死亡;保留后叶组术后早期死亡2例(1.96%),1例死于严重低心排出量综合征(低心排),1例死于肺部感染;不保留组术后早期死亡5例(4.90%),3例死于左心室后壁破裂,2例死于严重低心排。术后6个月心脏超声随访结果显示保留全瓣组术后左心室射血分数(LVEF)、左心室舒张末期内径(LVEDD)、左心室收缩末期内径(LVESD)均较保留后叶组和不保留组有改善,其中LVEF和LVESD的差异有统计学意义(P0.05)。结论:保留全瓣及瓣下结构的二尖瓣置换术近期效果优良,适合各种类型的二尖瓣病变,主要是以二尖瓣关闭不全为主的病变。该方法操作上较为复杂,适合经验丰富的外科医生。保留后叶适合二尖瓣狭窄为主,瓣环偏小的患者。     

Mitral Valve Repair for Isolated Mitral Valve Regurgitation: A Plea for Early Operation

Although mitral valve repair is a recognized method to surgically treat mitral valve regurgitation, the ideal timing of the operation still is controversial. The goal of this study was to study the long-term results of mitral valve repair focusing on symptomatic versus nonsymptomatic patients. From October 1988 to June 1994, 262 patients (mean age = 57.4) with isolated mitral regurgitation underwent mitral valve repair. Seventy-nine patients (group I) were nonsymptomatic (NYHA Class I or II) and 184 (group II) were severely symptomatic (NYHA III or IV). The surgical techniques have been mainly those described by Alain Carpentier. All patients but three had an annuloplasty with a Carpentier ring. Mean follow-up was 4.02 ± 0.1 years and total follow-up, 972 patient-years. There was one operative death (0.4%). Postoperative Doppler echocardiography showed satisfactory mitral valve function in 97% of the patients and two cases of systolic anterior motion (1%). At 7 years, actuarial survival was 80%± 9%, 95%± 5%, 75%± 11% for the total group, group I, and group II, respectively. At 7 years, freedom from thromboembolic or bleeding complications and reoperation was 96%± 4%, 93%± 8%, and 94%± 3%, respectively. Mitral valve repair for isolated mitral valve regurgitation provides satisfactory survival at 7 years. The long-term survival is better when patients are operated at an early stage when they are still nonsymptomatic.