感染性心内膜炎伴瓣膜病变的外科治疗

自１９８９年９月～１９９３年７月对２０例感染性心内膜炎伴瓣膜病变病人施行瓣膜替换术，其中主动瓣替换术８例二尖瓣替换术６例，双瓣替换术６例，无手术死亡，随访３～３８个月疗效满意，作者认为瓣膜替换术对治疗感染性心内膜炎心瓣膜失功者，是一种有挽救生命方法，并对手术时机的选择及术前后抗生素应用进行讨论。     

降低心脏瓣膜替换术早期死亡率的探讨

作者分析了１９９０～１９９５年的１２１５例心脏瓣膜替换术后死亡４４例的原因,以求探讨降低术后早期死亡的有效措施。作者认为：（１）术前积极改善心功能,防治心律失常;（２）注意术野的充分显露和心肌保护,尤其是再手术患者;（３）主张使用膜肺;（４）及时纠正术后低心输出量综合征,使用血管活性药物或主动脉内球囊反搏;（５）积极防治术后心律失常;（６）加强术后监护及综合治疗措施等均为提高重症瓣膜手术成功率的诸因素。     

原发性感染性心内膜炎瓣膜损害的外科治疗

目的总结２２例原发性感染性心内膜炎（ＰＩＥ）致瓣膜损害的外科治疗经验。方法心脏瓣膜置换术２０例，主动脉瓣和肺动脉瓣病灶清除及瓣膜成形术１例，三尖瓣病灶清除及瓣膜成形术１例。结果手术死亡率１３．６％，早期人工瓣膜心内膜炎１例（４．５％）。随访１５例，随访率６８．２％，随访时间２～８９个月，平均３５．６个月；发生晚期人工瓣膜心内膜炎１例（６．６％），再次手术出院后半月猝死，死因不明。其余１４例情况良好。结论ＰＩＥ致瓣膜损害时应积极手术治疗。只要手术方法正确，抗菌素应用合理，则手术疗效满意     

儿童心脏瓣膜置换手术及其疗效

目的探讨儿童心脏瓣膜置换手术及治疗效果。方法1990年1月至2002年12月，45例14岁以下儿童施行了心脏瓣膜置换手术。其中男26例，女19例。年龄3—14岁，平均10．8岁；≤10岁15例，10～14岁30例。包括先天性心脏瓣膜病32例，风湿性瓣膜病6例，心内膜炎3例，部分型房室管畸形修补术后二尖瓣关闭不全3例，室间隔缺损修补术后主动脉关闭不全1例。行二尖瓣置换23例，其中2例为矫正型大动脉转位行解剖位三尖瓣置换，主动脉瓣置换9例；二尖瓣与主动脉瓣双瓣置换4例；三尖瓣置换9例。5例使用生物瓣膜或同种主动脉瓣，余40例均采用机械瓣膜，包括进口双叶瓣34枚，进口单叶瓣3枚，国产单叶瓣7枚。结果本组手术死亡(术后30d内)2例，死亡率4．4％，均死于手术当日，1例因顽固性心律失常，1例术后低心输出量综合征。生存者随访8个月-12年，平均4．9年。4例晚期死亡，晚期死亡率9．3％。置入机械瓣膜者均采用华法林抗凝治疗，未发生血栓栓塞及抗凝相关并发症，病儿术后心功能均Ⅰ-Ⅱ级。结论儿童瓣膜病病人，大多数可以置入合适的成人型号人工瓣膜，保证其术后生长发育，减少二次手术。采用华法林进行抗凝治疗，经过平均4．5年随访，无血栓栓塞或抗凝有关的出血并发症发生，治疗效果较为满意。     

118例再次或多次心脏瓣膜替换手术

对１１８例再次或多次心脏瓣膜替换术病人行１３５次手术，替换了１４５个人工瓣膜。其中男４８例、女７０例，年龄７～７４岁。初次手术以风湿性瓣膜病居多（８３．９％）。再次手术以人工瓣膜失功为多（７１．７％）。结果示１１８例中早期死亡２９例，晚期死亡１例，总死亡率２５．４２％。其中因手术并发症死亡２３例，占手术死亡人数的７７％。７６例生存者平均随访７．３年，效果良好。结论：掌握手术时机、减少手术并发症是提高手术效果的重要环节     

股浅静脉瓣膜包窄术治疗原发性下肢深静脉瓣膜功能不全

目的：探讨下肢深静脉瓣膜包窄术的临床应用价值。方法：回顾性分析25例28条肢体用股浅静脉瓣膜包窄术治疗原发性下肢深静脉瓣膜功能不全的临床资料。结果：28条肢体术后患肢症状明显消失或改善，7例溃疡植皮后2周后创面愈合。9例术后3－6个月溃疡愈合，2条肢体溃疡1年后复发，结论：本手术操作简便，合理选择手术适应证及包窄材料是取得理想疗效的关键。     

非缺血性心脏瓣膜疾病合并冠心病同期手术治疗的临床分析

目的 总结非缺血性心脏瓣膜疾病合并冠心病同期手术患者的临床特征和手术效果,以提高手术疗效. 方法 2000年1月至2007年6月同期手术治疗105例非缺血性心脏瓣膜疾病合并冠心病患者,年龄36～79岁(61.96±7.61岁),其中风湿性心瓣膜疾病59例,退行性二尖瓣病变24例,老年性钙化性主动脉瓣病变13例;其它主动脉瓣病变9例.术前行冠状动脉造影明确诊断98例,术中探查发现冠心病7例.全组均行冠状动脉旁路移植术,共移植血管216支(2.06支/例),同期行二尖瓣置换术36例,二尖瓣成形术15例,主动脉瓣置换术43例,双瓣膜置换术11例. 结果 术后住院死亡6例(5.7%,6/105).死于严重低心排血量3例,肾功能衰竭2例,术后心脏骤停并发多器官功能衰竭1例.术后随访93例,随访时间1个月至7年,失访6例.无晚期死亡患者.心功能分级(NYHA)Ⅰ级25例,Ⅱ级53例,Ⅲ级10例,Ⅳ级5例.1例患者活动后仍有心绞痛存在. 结论 非缺血性心脏瓣膜疾病合并冠心病患者绝大多数无典型的心绞痛症状,50岁以上的患者必须行冠状动脉造影检查,对有冠心病易患因素者,应积极作冠状动脉造影检查;冠心病所致的心肌缺血可明显加重心脏瓣膜疾病所引起的心肌损害,术中心肌保护尤为重要;正确评价术前左心功能低下的患者是选择手术治疗的难点,更是影响手术效果的关键因素.     

原发性心脏瓣膜肿瘤1O例临床分析

目的 分析原发性心脏瓣膜肿瘤的临床特征和外科治疗的远期效果。方法回顾性总结1983年11月至2002年11月在阜外心血管病医院行原发性心脏瓣膜肿瘤手术治疗的10例患者的临床经验和远期结果。结果本组原发性瓣膜肿瘤占心脏肿瘤的2．65％(10／378)，其手术约占所有心脏手术的1／4000。10例中男性5例、女性5例，年龄2～66岁，平均30岁。所有患者均有症状，临床表现为活动后心慌、气促7例，脑血管栓塞症状2例，紫绀1例。术前超声心动图检查确诊8例，术中确诊2例。均在全麻、低温体外循环下行肿瘤切除。良性肿瘤8例，恶性肿瘤2例。术后早期恢复均顺利，晚期死亡3例。死亡病例中，1例为三尖瓣囊性畸胎瘤患者，术后2个月死于电解质平衡紊乱所致的心律失常；2例为二尖瓣恶性肿瘤，其中1例术后11个月死于肿瘤局部复发所致的心功能衰竭，另1例术后12个月死于肿瘤脑转移。长期生存的7例均为瓣膜良性肿瘤患者，随访8个月～19年，平均随访5．7年。所有患者活动量恢复正常，心功能均为I级。最后一次超声心动图检查均未见肿瘤局部复发。结论瓣膜良性肿瘤手术切除后近、远期结果良好。恶性瓣膜肿瘤的预后很差。     

1 137例三瓣膜病变的外科治疗

目的 总结三瓣膜病变的外科治疗经验。方法 回顾性分析1985年5月至2005年5月1137例施行三瓣膜手术病人的临床及随访资料。统计分析术后早、晚期病死率、死亡原因、并发症以及影响疗效的危险因素等。结果 早期死亡98例（8．62％），死因包括心力衰竭、多脏器功能衰竭、肾功能衰竭、呼吸功能衰竭、顽固性心律失常、纵隔感染、颅内出血、人工瓣膜心内膜炎或左心室破裂等。晚期死亡81例，死因主要是慢性心衰和抗凝相关性并发症。术后5、10与15年累计生存率分别为89％、84％与65％。84％的病人心功能（NYHA）恢复至Ⅰ～Ⅱ级。结论 随着手术技术的进步和心肌保护方法的改善，三瓣膜手术的疗效已经显著改善。虽然早期病死率偏高，但只要维持术后心功能的良好状态和规律服用抗凝药物，术后远期病人心功能改善显著。     

心脏瓣膜病再次手术221例临床分析

目的总结既往有二尖瓣闭式扩张术、瓣膜成形术、瓣周漏及生物瓣失功能等的患者再次瓣膜手术的经验。方法自1998年1月至2005年8月,实施心脏瓣膜病再次手术221例,其中急症手术8例。其中二尖瓣闭式扩张后再狭窄105例,二尖瓣或主动脉瓣成形术后复发性瓣膜病变37例,瓣周漏29例,生物瓣衰败18例,其他瓣膜再发病变11例,人工瓣膜机械功能障碍9例,Ebstein畸形矫治术后三尖瓣关闭不全7例,人工瓣膜心内膜炎5例。再次手术方式包括二尖瓣置换、二尖瓣和主动脉瓣双瓣置换、主动脉瓣置换、三尖瓣置换。两次手术间隔时间1～21年。结果全组术后死亡19例,占8．6％。早期死亡主要原因为术后低心排综合征、恶性心律失常、多脏器功能衰竭与肾功能衰竭,其中急症手术8例中死亡3例,术前心功能Ⅳ级者手术死亡9例,病死率为14．5％（9／62例）。结论瓣膜病再次手术危险因素包括急症手术、术前心功能差、合并其他重要脏器功能不全、体外循环时间和主动脉阻断时间长等。针对这些因素积极防治,可以进一步降低这类患者手术病死率和并发症发生率。     

Prediction of postoperative hepatic dysfunction after cardiac surgery in patients with chronic congestive heart failure

Objective  Chronic congestive liver dysfunction in advanced valvular disease remains an important co-morbidity in open heart surgery. The objective of this study was to explore the prognostic value in patients with severe valvular disease associated with congestive liver dysfunction. Methods  From 1997 to 2004, a total of 63 patients who had valvular disease with moderate or severe tricuspid regurgitation were studied. In addition to the indocyanine green retention rate at 15 min (ICG15) and the Child-Pugh score, we measured serum total bilirubin (T-bil), asparate aminotransferase (AST), alanine aminotransferase (ALT), cholinesterase (ChE), albumin (Alb) concentration, and prothrombin time. We compared these preoperative factors with postoperative liver dysfunction and mortality and attempted to develop a new liver function score. Results  There were eight in-hospital deaths (13%). Seventeen patients had postoperative liver dysfunction. The univariate analysis indicated there were significant differences in preoperative T-bil, Alb, ChE, ICG15, and Child-Pugh score between the patients with and without liver dysfunction. Multivariate logistic regression analysis also identified preoperative T-bil as a significant indicator of postoperative liver dysfunction and preoperative ChE as a predictor of mortality. Based on these findings, we introduced a liver function score to predict postoperative dysfunction and death. Conclusion  In addition to preoperative ChE, T-bil and Alb appeared to be valuable for producing obtainable prognostic information regarding postoperative liver dysfunction in patients with severe valvular disease. A new liver score, including T-bil, ChE, and Alb, is proposed for predicting postoperative hepatic dysfunction and outcome.     

The role of intraaortic balloon counterpulsation in patients undergoing cardiac operations.

Intraaortic balloon counterpulsation (IABC) was used to assist 60 patients undergoing cardiac operations for reasons of acute left ventricular failure (18 patients) or electively for indications in high-risk coronary and valvular heart disease (42 patients). Nine of 18 patients achieved hemodynamic stability when treated for acute perioperative or postoperative cardiogenic shock. Four of these died from problems unassociated with postoperative left ventricular failure and 5 were long-term survivors, indicating a potential salvage of 50%. In 42 high-risk patients, IABC was used electively to control preinfarction angina before operation (21 patients) and prophylactically to prevent postoperative low-output failure in another 21 patients with severe coronary and valvular heart disease. Thirty-nine, or 93%, of these patients survived. There were no deaths in the preinfarction angina group, 1 death in the group with coronary disease and ejection fractions less than 30%, and 2 deaths in those with valvular heart disease and congestive failure. Seven patients developed thrombotic or ischemic complications, but no permanent damage resulted. IABC is an important form of assistance for any patient with preoperative, intraoperative, or postoperative left ventricular failure and adds safety and hemodynamic stability for the high-risk patient with preinfarction angina or poor ventricular function.     

Effect of Treprostinil on the Early Postoperative Prognosis of Patients with Severe Left Heart Valvular Disease Combined with Severe Pulmonary Hypertension

Objective: To investigate the effect of treprostinil on the early postoperative prognosis of patients with severe left heart valvular disease combined with severe pulmonary hypertension (PAH).Methods: A retrospective study including 55 patients with severe left heart valvular disease combined with severe PAH who underwent left heart valve replacement in our hospital between January 2019 and May 2019 was conducted. Patients were divided into two groups (treprostinil group and control group), and the clinical data of patients in the two groups were compared and analyzed.Results: Compared with the preoperative status, the mean postoperative pulmonary artery pressure (mPAP) in both groups was significantly lower. Compared with the control group, the treprostinil group had a significantly lower mPAP. Moreover, the postoperative mechanical ventilation time, intensive care unit (ICU) stay, and hospital stay of the treprostinil group were significantly shorter than those of the control group. There were no serious drug-related side effects in either group.Conclusions: Treprostinil can improve the early postoperative prognosis of patients with severe left heart valvular disease combined with severe PAH undergoing prosthetic valve replacement.     

心脏瓣膜手术后呼吸衰竭相关危险因素分析

目的探讨影响心脏瓣膜手术后呼吸衰竭发生的相关危险因素。方法回顾性分析2001年1月至2010年11月兰州军区兰州总医院618例心脏瓣膜疾病患者的临床资料,其中男339例,女279例;年龄10～74(44.01±13.95)岁;风湿性心脏病387例,非风湿性心脏病231例;根据术后是否发生呼吸衰竭分为呼吸衰竭组(74例)和非呼吸衰竭组(544例),采用单因素及多因素logistic回归方法分析术后呼吸衰竭发生的危险因素。结果心脏瓣膜术后早期住院死亡率6.1%(38/618),呼吸衰竭发生率12.0%(74/618)。呼吸衰竭组住院死亡率为17.6%(13/74),非呼吸衰竭组住院死亡率4.6%(25/544),两组差异有统计学意义(χ2=18.994,P=0.000)。单因素分析显示,年龄>65岁(P=0.005)、心功能分级(NYHA)Ⅳ级(P=0.014)、射血分数(EF)<50.0%(P=0.003)、体外循环时间>3 h(P=0.001)、主动脉阻断时间>2 h(P=0.008)、复合手术(同期CABG、主动脉根部置换或射频消融迷宫手术P=0.000)、二次手术(P=0.012)、术后并发症(P=0.000)、输血量>2 000 ml(P=0.000)是心脏瓣膜手术后呼吸衰竭发生的潜在危险因素;多因素logistic回归分析结果显示,复合手术(P=0.003)、二次手术(P=0.010)、术后并发症(P=0.000)、输血量>2 000 ml(P=0.012)是心脏瓣膜手术后呼吸衰竭发生的独立预测因素。结论重视心脏瓣膜术后呼吸衰竭发生的危险因素,加强围手术期处理,缩短体外循环时间,减少并发症,以减少呼吸衰竭的发生,降低病死率。     

Prevention of atrial fibrillation after cardiac valvular surgery by epicardial, biatrial synchronous pacing.

OBJECTIVE: Postoperative atrial fibrillation (AF) after cardiac surgery is a frequent complication after valvular surgery (30-60%). The purpose of this prospective, randomized study was to determine if biatrial synchronous pacing reduces postoperative AF after cardiac valvular surgery as compared to conventional therapy. METHODS: Eighty patients subjected to valvular surgery (52 men, age 66 +/- 10 years) were randomized to one of two groups: one group was treated with biatrial, synchronous pacing (BAP) for 72 h postoperatively (n=40) the other group received no atrial pacing (controls; n=40). All patients had one pair of epicardial wires attached to the right atrium. An additional electrode was placed to the left atrium in the BAP group. These patients were continuously paced at a rate of 10 beats per minute higher than the intrinsic rate starting immediately after surgery. All patients were monitored with full disclosure telemetry or Holter monitors to identify onset of AF. RESULTS: Eighteen of the 40 patients in the control group (45%) developed AF within the first 3 days postoperatively as compared to eight patients (20%) in the BAP group (P=0.02). No complications occurred associated with the placement, maintenance and removal of the atrial pacing electrodes. CONCLUSIONS: Temporary, biatrial synchronous pacing during the first 3 postoperative days is safe and has a significant rhythm-stabilizing effect in patients undergoing valvular cardiac surgery.     

SF-36量表评估心脏瓣膜病患者术后生活质量的研究进展

生活质量评估是从患者主观感受角度评估患者病情,近半个世纪来,逐渐成为临床评价治疗效果的一项重要指标.生活质量评估量表众多,SF-36健康调查简表(the 36-Item Short Form Health Survey,SF-36)是目前应用最广泛的量表.近年来,SF-36量表逐渐应用于探索影响心脏瓣膜病患者术后生活质量的危险因素,为临床医生提供了更多的术前评估方法,提高了手术治疗效果.但目前SF-36用于评估心脏瓣膜病患者生活质量刚刚起步,受样 ,本量、随访时间、地域、文化等因素的影响,结论有一定分歧.为此,我们对目前用SF-36量表评估心脏瓣膜病患者术后生活质量的研究进展进行综述,以更好地应用SF-36量表.     

Surgical management of valvular disease in patients requiring left ventricular assist device support

BACKGROUND: Success with long-term implantable left ventricular assist devices (LVAD) has led to increased use in patients previously thought to be unsuitable for mechanical circulatory assistance. Patients with preexisting or newly diagnosed valvular disease have been traditionally excluded from device placement. The purpose of this study was to review our experience with LVAD support in patients with valvular disease and to develop a management algorithm for these difficult patients. METHODS: We reviewed the clinical records of 199 consecutive patients who received the ThermoCardiosystems, Inc, HeartMate Pneumatic or Vented Electric LVAD. There were 18 patients (9%) who required surgical management of native or prosthetic valvular disease during LVAD implantation. RESULTS: Suture or patch closure of the aortic valve was performed in 6 patients, aortic valve plication and repair in 1 patient, mitral valve repair in 4 patients, and tricuspid valve annuloplasty in 5 patients. Two patients with mechanical mitral valve prostheses were treated with postoperative warfarin anticoagulation. Fifteen of the 18 patients with valvular pathology survived the immediate postoperative period (17% mortality). Eleven patients have either undergone transplantation or continue to be supported with an LVAD (61%). Operative mortality in LVAD patients without concomitant valve repair was 18% (n = 33) with a late mortality of 7% (n = 13). Seven of these late deaths occurred in patients who received a device as destination therapy. In the remaining 6 patients, the cause of death was sepsis (n = 2), multisystem organ failure (n = 2), driveline rupture (n = 1), and massive gastrointestinal bleed (n = 1). CONCLUSIONS: Preexisting native or prosthetic valve pathology does not increase the immediate perioperative risk of LVAD insertion; however, these patients continue to pose a challenge for postoperative management while awaiting transplantation.     

Surgical treatment of active valvular infective endocarditis

A review is presented of 20 patients consecutively operated on for acute valvular endocarditis. The diagnosis was established from at least two of the criteria: (a) typical clinical features, (b) two blood cultures positive for the same causal microorganism, and (c) echocardiographic evidence of vegetations. In all cases there was histologic evidence of active infection in the surgical specimen. Only three of the 20 patients had no previous cardiac disease. The most common causal agent was Staphylococcus aureus. The indications for surgery were refractory cardiac failure or infection (18 and 2 cases, respectively). Aortic valve replacement was performed in 16 of the 20 cases, suggesting that aortic valvulopathy aggravates the course of infective endocarditis and increases the risk of heart failure. The overall mortality rate was 30%. All surviving patients were infection-free at postoperative bacteriologic follow-up. Surgery is considered to be the management of choice in active valvular, therapy-resistant bacterial endocarditis with or without cardiac failure.     

Mitral Stenosis: Factors Influencing Long-term Survival Rates after Closed Valvulotomy

The 10-year survival rates of 165 consecutive patients with mitral stenosis subjected to closed valvulotomy are reviewed. While patients operated on for mitral stenosis appear to live longer than medically treated patients, their survival rates are less than those of the general population. Factors with significantly adverse influence upon postoperative survival are pre-operative heart failure, severe disability, atrial fibrillation, mitral regurgitation, mitral valvular calcification, and severe mitral stenosis with marked changes of the valves. The prognostic significance of operative restoration of normal valvular function, as indicated by postoperative catheteri-zation studies, is clearly demonstrated in the present material.     

An experience with transthoracic echocardiography after heart surgery]

OBJECTIVE: In order to determine if routine use of transthoracic echocardiography (TTE) shortly after heart surgery could have a role in postoperative management, we carried out TTE in postoperative patients operated on for CABG or valvular repair. PATIENTS AND METHODS: For a 3 months period, we prospectively enrolled 51 patients for TTE. We performed a TTE using a Hewlett Packard Sonos 1500 and a 2.5 MHz probe. Feasibility, left ventricular kinesis, valve function, intracardiac thrombi, and pericardial effusion were noted for each patient. Patients have been divided into 2 groups: patients with or, without haemodynamic disturbance (HD, mean arterial blood pressure < or = 80 mmHg). RESULTS: Nine TTE were impossible for bad acoustic images. Feasibility was about 82% (42 TTE/51 patients). Two ETT views were easily obtained: the apical 4-chambers (75%) and the subcostal (30%) views. TTE examination induced treatment change in 12 patients for hypovolaemia (ten patients), left ventricular dysfunction (one patient), and systolic anterior motion of mitral valve (one patient). In patients without HD (41 patients) only hypovolaemia was found (three patients) and TTE returned to normal with fluid challenge. In patients with HD (ten patients), one patient returned to the operating room for valvular replacement, one patient was treated with dobutamine for left ventricular dysfunction, seven patients with hypovolaemia recovered with fluid challenge. CONCLUSION: TTE can guide postoperative management of patients operated on for heart surgery especially in patients with haemodynamic disturbance. Because of its safety and easiness, TTE may be the first-line examination in these patients before any invasive evaluation.