先天性二叶式主动脉瓣畸形所致主动脉瓣狭窄的外科治疗体会

目的总结先天性主动脉瓣二叶式畸形所致的主动脉瓣狭窄手术治疗的经验。方法1995年9月至2010年12月福建医科大学附属协和医院心外科共为46例二叶式主动脉瓣畸形所致主动脉瓣狭窄患者实施了瓣膜置换术。对这些患者的手术效果及其影响因素进行回顾性总结。结果术后随访3个月至12年,死亡1例（为猝死）,1例出现与抗凝有关的脑部并发症;心功能Ⅰ级36例,心功能Ⅱ级9例。术后超声心动图测得主动脉瓣跨瓣压差17～51（29．2±11．5）mmHg。结论主动脉瓣置换术是治疗先天性主动脉瓣二叶式畸形所致主动脉瓣的有效疗法,应尽可能选择有效瓣口面积较大的人造瓣膜,这样可以有效降低术后主动脉跨瓣压差,提高手术安全性和远期疗效。     

同种主动脉瓣在心脏外科的应用

目的总结同种主动脉瓣在心脏外科的应用,探讨其优越性。方法1995年1月至2000年12月,应用同种带瓣主动脉手术治疗先天性及后天性瓣膜疾病18例。其中完全性大动脉转位并右室双出口1例,行Rastelli手术;主动脉瓣狭窄及（或）关闭不全17例,先天性8例,风湿性9例,1例行Ross手术,余皆行主动脉瓣置换手术。结果早期死亡1例：Rastelli手术患者术后因严重低心排死亡;其余均顺利康复。随诊2～10年,1例主动脉瓣置换术后1年因同种瓣严重瓣损毁行二次手术置换机械瓣,术后18d死于多器官系统功能衰竭;其余患者术后生存状态均良好。结论同种主动脉瓣用于心脏瓣膜的置换及心室流出道的重建,可获得很好的临床效果。     

主动脉瓣四叶瓣畸形合并主动脉瓣病变的外科处理

目的 探讨主动脉瓣四叶瓣畸形对主动脉瓣功能的影响及其外科治疗.方法 2000年1月至2013年1月,我院通过经胸超声心动图和术中病理诊断主动脉瓣四叶瓣畸形13例.其中4例主动脉瓣的功能基本正常,9例合并主动脉瓣病变：重度关闭不全7例,重度关闭不全伴狭窄2例,合并二尖瓣中度关闭不全2例,三尖瓣中重度关闭不全1例.结果 13例患者中4例主动脉瓣功能正常者,继续随访中.9例合并主动脉瓣病变者,均行主动脉瓣置换术,同期行二尖瓣成形术2例、三尖瓣成形术1例.围术期无严重并发症及早期死亡,均康复出院.术后平均随访（6.34±5.17）年,心彩超提示主动脉瓣功能良好,无远期死亡.结论 主动脉瓣四叶瓣畸形是一种少见的先天性畸形,超声心动图有助于早期诊断.主动脉瓣功能正常时,可以随访;当合并主动脉瓣功能障碍时,应及时行主动脉瓣置换或修复,手术后可获得良好的远期效果.     

少年儿童的主动脉瓣替换

作者自1964年11月至1978年5月给26例4～12岁(平均9岁)儿童施行主动脉瓣替换术,属先天性心脏病者20例,主动脉囊性中层坏死者5例,风湿性心脏病者1例。在先天性病因中包括主动脉瓣二瓣化合并狭窄9例,主动脉瓣及瓣下狭窄     

先天性左心室流出道梗阻的外科治疗

目的 :总结先天性左室流出道梗阻 (LVOTO)的外科治疗经验。方法 :分析我科 1998年 1月至 2 0 0 3年 7月 33例先天性LVOTO接受手术治疗的患者临床资料。年龄 1～ 5 5岁 ,平均 (14 9± 10 2 )岁。其中主动脉瓣膜狭窄 10例 (30 3% ) ;主动脉瓣下狭窄 18例 (5 4 5 % ) ;主动脉瓣上狭窄 3例 (9 1% ) ;复合狭窄 2例 (6 1% )。有合并畸形者 2 3例 (6 9 7% ) ,心内膜炎 2例 (6 1% )。主动脉瓣置换 7例 (2 1 2 % ) ,升主动脉加宽 3例 (9 1% ) ,主动脉根部和升主动脉加宽 2例 (6 1% )。对主动脉瓣换瓣的患者常规华法令抗凝治疗 ,并监测凝血酶原时间和国际标准指数。结果 :全组无早期死亡 ;随访 3～ 4 1个月 ,平均 (13 2± 6 8)个月 ,4例患者残留轻度梗阻 (12 2 % ) ;晚期死亡 1例 (3 0 % )术后 18个月死于感染性心内膜炎 ;其余患者恢复良好。结论 :对不同类型的先天性LVOTO选择合适的手术方式、同期处理合并畸型、加强术后随访是提高先天性LVOTO外科治疗疗效的关键。     

过渡性经皮球囊主动脉瓣成形术治疗危重主动脉瓣狭窄的早期效果

目的 探讨过渡性经皮球囊主动脉瓣成形术(PBAV)治疗暂时不宜行外科主动脉瓣置换术和经导管主动脉瓣置入术(TAVR)危重主动脉瓣狭窄患者的早期临床结果.方法 回顾性分析2011年3月至2014年1月在阜外心血管病医院行过渡性PBAV的20例危重主动脉瓣狭窄患者的临床资料,患者年龄(72 ±8)岁.观察手术相关并发症及疗效,并在术后对患者进行随访.结果 所有患者均完成PBAV,主动脉瓣瓣口面积从术前的(0.55±0.09) m2增大至(0.77±0.15)m2,主动脉瓣跨瓣压差从术前的(49.5±15.0) mmHg(1 mmHg =0.133 kPa)降至术后的(31.7±12.0) mmHg(P＜0.001),左心室射血分数从术前的(31.7±9.0)％增加至术后的(39.0±11.0)％ (P =0.018),肺动脉收缩压从术前的(55.1±18.0)mmHg降至术后的(38.7±11.0)mmHg(P =0.025),主动脉瓣反流分级手术前后差异无统计学意义(P=0.854).术后发生低血压4例,一过性左束支传导阻滞5例,术后24 h和30 d分别死亡1例和3例患者.术后30 d内,5例患者实施外科主动脉瓣置换术,1例实施TAVR,5例等待TAVR.结论 对于不宜行外科主动脉瓣置换术和TAVR的危重主动脉瓣狭窄患者,PBAV可取得良好的早期临床结果,有望成为一种安全的过渡性治疗手段.     

感染性心内膜炎的外科治疗

目的：探讨感染性心内膜炎（ＩＥ）的诊断及外科治疗。方法：我院从１９８６年１１月至１９９６年５月，外科治疗感染心内膜炎患者１６例，其中男性１２例，女性４例。手术方法：全麻低温体外循环急诊换瓣手术７例（主动脉瓣替换５例，主动脉瓣＋二尖瓣替换１例，主动脉瓣替换＋膜部心室间隔缺损涤沦补片修补１例）；择期换瓣手术９例（主动脉瓣替换７例，二尖瓣替换２例）。切除瓣周感染组织，对散在于心室间隔和腱索上难以切除的微小赘生物电灼，术毕抗生素溶液冲洗心腔。结果：全组１６例。急诊手术７例，其中术后死亡１例（死亡率１４．３％），死亡原因为多器官衰竭；择期手术９例，无手术死亡。结论：反复多次血培养结合超声心动图检查，可使ＩＥ诊断阳性率大大提高。尽早手术是对部分ＩＥ患者治疗的基本原则，无法控制的感染和心力衰竭是尽早手术治疗的最佳适应证。     

新中心组建团队经心尖入路经导管 主动脉瓣置换术4例经验

目的 总结经心尖入路经导管主动脉瓣置换术治疗外科高危的主动脉瓣狭窄、主动脉瓣关闭不全患者围术期效果及并发症处理经验。方法 回顾性分析2019年8~12月我院经心尖主动脉瓣置换术4例,其中主动脉关闭不全为主者2例,主动脉瓣狭窄为主者2例。结果 4例均顺利完成手术,2例轻度瓣周漏,1例心包积液,1例卒中,1例术后14 d死亡。经妥善处理瓣周漏减轻、心包积液治愈,卒中好转。术后1个月复查心功能好转。结论 虽然经心尖入路经导管主动脉瓣置换术围术期并发症较多,但经处理部分可好转,心脏功能近期改善满意,同时其在外科高危的无钙化风湿性主动脉瓣狭窄及单纯主动脉瓣反流患者有着无可替代的作用,远期结果有待进一步随访观察。     

先天性主动脉瓣下狭窄的外科治疗

本文报告我院自１９８４年６月到１９９５年６月手术治疗先天性主动脉瓣下狭窄２３例。局限型２２例（纤维膜样狭窄１４例，纤维肌隔样狭窄８例），隧道型１例；对于局限型行狭窄膜切除术１５例，加左室肌肉切除术７例，对隧道型行左室流出道疏通术；局限型无手术死亡，隧道型术后２１个月复发再次手术死于低心排综合症；全组随访６～１３２个月，平均４１个月，ｌ例死亡，６例失访，随访率７２．７％。手术效果：术前左室到主动脉收缩压差平均９．７７±４．９４ｋＰａ（７３．２７±３７．００ｍｍＨｇ），术后２．９４±２．２０ｋＰａ（２２．０５±１６．５２ｍｍＨｇ）（Ｐ＜０．００１），症状明显改善，但对术前已有的主动脉瓣关闭不全无改善。结果表明：先天性主动脉瓣下狭窄呈进展性，其压差与合并主动脉瓣关闭不全的情况病理进程和年龄密切有关，应尽早手术。     

过渡性经皮球囊主动脉瓣成形术在治疗危重主动脉瓣狭窄患者的临床应用——单中心经验

目的:探讨过渡性经皮球囊主动脉瓣成形术(PBAV)治疗危重主动脉瓣狭窄患者的临床应用经验。方法:回顾性分析2011-03至2017-03在阜外医院行PBAV的37例暂不适宜行瓣膜置换术的危重主动脉瓣狭窄患者,年龄(74±12)岁。观察患者临床及解剖特点、手术有效及安全性,并进行随访。结果:本组患者基线外科风险高心功能差,二叶式主动脉瓣占比约50%,瓣叶钙化程度重[钙化体积CT值850(HU850)=(856.0±658.2)mm3]。术中参考瓣环上平均内径选择球囊,术后7天主动脉瓣瓣口面积从(0.37±0.10)cm2增大至(0.87±1.10)cm2,主动脉瓣平均跨瓣压差从(55.1±22.9)mm Hg(1 mm Hg=0.133 k Pa)降至(44.8±17.8)mm Hg(P0.001),左心室射血分数从(35.8±14.3)%增加到(41.0±12.2)%(P0.001)。术后住院期间发生死亡4例,1例安装永久起搏器,1例主动脉瓣重度反流。术后平均随访(16.5±11.1)个月,共有13例(35.1%)患者过渡到外科或经导管瓣膜置换术治疗。结论:对于暂不宜行外科主动脉瓣置换术和经导管主动脉瓣置换术(TAVR)的危重主动脉瓣狭窄患者,PBAV可取得良好的早期临床结果,有望成为过渡性治疗手段,对于中国二叶式主动脉瓣比例高,瓣叶钙化重特点,采用瓣环上内径选择较小球囊安全有效。     

Operated aortic stenosis. Evaluation of the long-term prognosis using clinical and hemodynamic parameters in a series of 249 cases]

The long-term results and the prognostic factors in aortic valve replacement for aortic stenosis were assessed from a series of 249 operated cases (comprising 199 pure or dominant stenosis and 50 mixed aortic lesions) followed up for a maximal period of 9 years. The postoperative survival rate, 71% at 5 years, 62,6% at 8 years, including the operative mortality, is better than in a comparable series of pure chronic aortic incompetence (58% at 5 years) despite a higher average age. In the same age group the difference is significant at the 6th year. However, no difference was observed between mixed aortic disease and aortic stenosis. Irreversible myocardial dysfunction is relatively rare (6,6% of survivors at 1 month, 24% of poor results or late deaths) and much less common than in aortic incompetence of which it represents the main cause of failure. Even in these cases, prolonged symptomatic improvement may be observed. 3 prognostic factors affect the operative and late mortality. They act to variable degrees and independantly of each other. They are : age, cardiomegaly and heart failure. The actuarial 5 year survival is: 81,77% and 53% for under 50, 50 to 65 and over 65 years age group respectively; 88%, 78% and 48% for cardiothoracic ratios of less than 0,50, between 0,50 and 0,58 and greater than 0,58 respectively; 83%, 65% and 47% for patients without signs of heart failure, with a history of pulmonary oedema, and with a history of congestive cardiac failure respectively. These results encourage a liberal attitude towards surgery, even in old patients with severe valvular lesions.     

Balloon Aortic Valvuloplasty in the First Year of Life

Between February 1988 and September 1993 balloon aortic valvuloplasty was attempted in 33 consecutive patients in the first year of life: 20 patients (61%) were younger than J month. Major associated anomalies such as mitral stenosis, coarctation, and hypoplastic left ventricle were found in 11 cases (33%). The balloon dilation of the aortic valve was accomplished through the right carotid cut-down approach in neonates and patients with body weight < 5 kg, through a percutaneous femoral approach in the others; the procedure was completed in all. The peak systolic gradient across the aortic valve measured at catheterization fell from 80 ± 33 mmHg (range 25–165) before the dilation to 27 ± 17 mmHg (range 0–65), afterwards (P < 0.0001). The left ventricular ejection fraction increased from 44%± 26% to 61%± 17%, 24–48 hours after the procedure (P < 0.0001). Aortic insufficiency developed in 17 cases, being moderate in 2, mild in 6, and trivial in 9. Seven patients (21%), all in the first month of life, died within 30 days from the valvuloplasty; major associated anomalies were present in six; the death was due to a procedure related complication in one. No mortality was observed among the patients undergoing valvuloplasty beyond the first month of life. On follow-up (6 months to 6 years) aortic restenosis occurred in 3 cases; 1 was treated by surgical valvotomy, 2 by repeat balloon valvotomy; in another 2 cases, a subvalvular aortic obstruction developed and was relieved by surgical resection. There was no late mortality. Thus, balloon valvuloplasty appears to be an effective palliation for critical aortic stenosis in infancy. Early mortality is mainly related to associated anomalies.     

Aortic valve replacement for patients with mild to moderate aortic stenosis undergoing coronary artery bypass surgery

Aortic valve replacement (AVR) is not normally recommended in asymptomatic patients, even if aortic stenosis is severe. However, as the population ages, an increasing number of patients with mild or moderate aortic stenosis will require coronary artery bypass grafting (CABG). In these cases, risk of "prophylactic" AVR needs to be weighed against risks of subsequent worsening of the mildly or moderately diseased aortic valve. If unoperated, aortic stenosis will worsen at an average of 6-8 mmHg per year (-0.1 cm2/year valve area), and one-quarter of such patients will require late AVR with a high operative mortality (14-24%). If AVR is performed at the time of CABG, operative risk is increased only slightly (from 1-3% to 2-6%), as are late mortality (1-2% per year) and morbidity (1-2% per year), mainly from hemorrhagic complications. Intrinsic gradients of most prosthetic valves are sufficiently low that even patients with low aortic valve gradients are likely to derive hemodynamic benefit from AVR. Thus, if there is a measurable (>20-25 mmHg) gradient across the aortic valve in a patient who requires CABG, the patient is at considerable risk for developing symptomatic aortic stenosis prior to reaching the end of expected benefit from CABG; in this case AVR should be considered. It may be reasonable in patients with very mild gradients (<25 mmHg) to defer aortic valve surgery; however, it should be noted that aortic stenosis progression is generally more rapid when the initial gradient is small.     

The Treatment of Aortic Stenosis: Is Valvuloplasty Ever an Alternative to Surgery?

The desire to extend the principle of balloon angioplasty to cardiac valve disease is Understundable and commendable. Aortic valvuloplasty is associated, however, with an excessive complication rate, as reported by the Mansfield Scientific Aortic Valvuloplasty Registry (20.5% overall, including a 4.9% death rate within 24 hours and an additional 2.6% rate within 7 days for a 7.5% 1-week mortality). In contrast, the operative mortality for aortic valve replacement now ranges from 3%-5%, with periopercitive complications far less than the one in five associated with valvuloplasty. Even if the two procedures had equivalent morbidity arid mortality rates, the high incidence of resteriosis (30%-60% range at 6 months) for the balloon technique precludes its widespread use for aortic stenosis. Despite the poor mid- and long-term results for balloon valvuloplasty, the procedure may have limited application in some clinical situations. Indeed, there are patients with concomitant systemic illnesses or advanced age (> 80 years) who would not be good surgical candidates. In particular, valvular balloon dilation may be useful in bridging a seriously ill patient to a condition more favorable for replacement therapy. With few exceptions, however, valve replacement remains the gold standard, for treatment of adult aortic stenosis.     

A 13-year follow-up study of rheumatic valvular diseases

A 13-year follow-up study was performed in 301 patients with rheumatic heart disease (RHD). Of these patient, 223 cases, 78 men (average age 59.3 years) and 145 women (average age 60.4 years), survived. Seventy-eight cases including 38 men (mean age of death 72.5 years) and 40 women (mean age of death 64.8 years) died. RHD consisted of 51% mitral valvular diseases, 40% combined valvular diseases and 9% aortic valvular diseases. The mean mortality for all patients with RHD was 25.9%. Seventy percent of the deaths were due to severe, chronic heart failure, sudden death and cerebral emboli. Atrial fibrillation was observed in 50% of the patients. Cerebral emboli occurred frequently in patients with mitral stenosis (MS), mitral stenoregurgitation (MSR) and combined valvular disease (CVD), which were associated with atrial fibrillation. However, cerebral emboli were rarely found in cases with MSR, CVD and aortic valvular disease with sinus rhythm. The mortality of cardiac surgery was low, 13.3%.     

Late results after operations for left ventricular outflow tract obstruction

The late results were evaluated of operations for the relief of left ventricular outflow tract obstruction in young patients, 1 to 18 years old, from the National Heart Institute who were followed up for at least 5 years and from recently reported studies with an average follow-up duration of 5 or more years. The operative mortality rate for the combined series was low: 1.9 percent of 522 patients with valvular aortic stenosis, 6.0 percent of 222 patients with fixed subvalvular aortic stenosis and 5.5 percent of 18 patients with hypertrophic subaortic stenosis. From the National Heart Institute series, gradients early postoperatively were decreased to less than 50 mm Hg in 88 percent (30 of 34) of patients with valvular, in 68 percent (15 of 22) of patients with subvalvular and in 88 percent (8 of 9) of patients with hypertrophic subaortic stenosis. Late survival rates for patients in the combined series were 90 percent (472 of 522), 86 percent (190 of 222), and 82 percent (14 of 17) in the three respective groups after mean follow-up periods of 5 to 14.4 years. All late survivors in the current series have had symptomatic improvement; 95 percent (58 of 61) are asymptomatic. However, actuarial analysis in these patients predicts that 50 +/- 8 percent of those with valvular and 44 +/- 10 percent of those with subvalvular aortic stenosis after 10 years will be free from the adverse postoperative events of residual or recurrent left ventricular outflow tract obstruction, clinically significant aortic regurgitation, reoperation, endocarditis or late death. With use of the same adverse postoperative events to determine satisfactory late results from the combined series, it was found that 54 percent (281 of 522) of those operated on for valvular, 54 percent (120 of 222) of those operated on for subvalvular and 78 percent (14 of 18) of those operated on for hypertrophic subaortic stenosis had satisfactory late results 5 to 14 years after operation. Of the patients having unsatisfactory late results, major hemodynamic abnormalities were detected in 55 percent (23 of 42) within 1 year postoperatively. Thus it appears that operations for many children with left ventricular outflow tract obstruction are palliative. These patients should have early postoperative assessment and continuing long-term follow-up evaluation during childhood, adolescence and adulthood.     

Rescue “valve in valve” implantation after late onset corevalve cusp rupture leading to acute massive aortic insufficiency

Transcatheter aortic valve implantation (TAVI) has emerged as a feasible and effective alternative to aortic valve replacement in patients at high surgical risk, and is associated with a lower risk of death at 1 year follow‐up when compared with standard therapy. In a recent large study, enrolling 663 high risk patients with symptomatic severe aortic stenosis TAVI with the use of CoreValve system has been associated with early and sustained clinical and hemodynamic benefits, with a cumulative mortality of 15.0% at 1 year follow‐up. This study has shown that paravalvular aortic regurgitation after successful TAVI is a frequent finding, being of mild entity in the vast majority of cases, whereas valvular regurgitation is almost entirely absent or mild. Of note, no cases of structural valve deterioration were reported. We report a case of a successful implantation of a CoreValve that complicated with late onset massive intravalvular aortic regurgitation, due to CoreValve cusp rupture, leading to low output state with acute pulmonary edema, which was successfully treated with “valve in valve” implantation. © 2011 Wiley Periodicals, Inc.     

Congenital aortic valve stenosis. Long-term results after valvulotomy

The cases of 73 patients undergoing valvulotomy for congenital valvular aortic stenosis between 1957 and 1982 were reviewed. Data was updated after recalling patients to the outpatient clinic and/or analysis of the results of a questionnaire sent to the patient's family doctor or cardiologist. Babies less than 12 months old at the time of surgery were excluded from the study. Operation consisted of valvulotomy under direct control with few associated procedures as the valvular lesion was isolated in 89 p. 100 of cases. 5 patients died in the first 30 postoperative days, an operative mortality of 5,4 p. 100. The follow-up period ranged from 1 to 25 years, with 15 patients having been followed up for over 10 years. 6 patients were reoperated with no operative mortality. 2 of whom have since undergone a second reoperation. Of the 59 patients not re-operated, 54 were class I and 5 class II of the NYHA. Of the latter group, 4 are candidates for aortic valve replacement for significant aortic regurgitation. The actuarial survival graph shows a 92.82 p. 100 probability of survival at 5 years, and 86.83 p. 100 at 10 years. Aortic valvulotomy remains a palliative operation which does not protect the patient from subsequent sudden death.     

Aortic valve replacement in patients 70 years and older

BACKGROUND: Aortic valvular disease is the most common valvular lesion among elderly patients. Because of changing demographics, it has become increasingly frequent. Aortic valve replacement (AVR) is the only effective treatment for aortic valvular disease. HYPOTHESIS: This study was undertaken to evaluate the results of AVR in an elderly population. METHODS: Data were retrospectively analyzed in 117 consecutive patients (mean age 73.8 years) who underwent AVR between 1991 and 2002. RESULTS: Pure or predominant severe aortic stenosis was present in 108 patients. Nine patients had severe aortic regurgitation. Before valve replacement, 62.4% of the patients were in New York Heart Association (NYHA) functional class III-IV. A bioprosthesis was implanted in 62.4% of the patients, and 37.6% received a mechanical valve. Concomitant cardiac surgical procedures were performed in 25 patients (coronary artery bypass graft in 22, mitral valve replacement in 3). There were 17 deaths, giving a perioperative mortality rate of 14.5%. Multivariate logistic regression showed that repeat surgery for bleeding, prolonged cardiopulmonary bypass time, postoperative respiratory failure, and postoperative acute renal insufficiency were significant independent predictors of operative mortality. Of the 100 hospital survivors, 78 were followed for a mean of 42.9 months. There were six deaths during follow-up; only two of these were cardiac related. Five-year actuarial survival for all patients and for hospital survivors were 70 and 91.1%, respectively. One year post surgery, all patients were in NYHA functional class I-II. CONCLUSION: In a selected patient population, AVR in the elderly is associated with acceptable mortality and morbidity. The outlook for hospital operative survivors is excellent with improved quality of life and an expected survival normal for this particular age.     

Eleven year experience of aortic valve replacement with antibiotic sterilized homograft valves in Southampton

Aortic valve replacement with an antibiotic-treated aortic valve homograft was performed in 200 patients between April 1973 and December 1984. In all cases, a two-layered freehand technique of valve implantation was used. Tailoring of the annulus was performed in 39 cases and a gusset in the non-coronary sinus was used to maintain the shape of the aortic root in 67 patients. There were 6 early deaths (3%) and 14 late deaths (7.2%); 4 of these were related to homograft regurgitation. The 11 years survival rate on actuarial analysis was 83%. The overall incidence of early diastolic murmurs was 27.3%; being significantly higher in those with tailored roots (P less than 0.001). Severe homograft aortic valve incompetence requiring re-operation developed in 3.1%. Anticoagulant therapy was not used routinely, and there was no major thromboembolic episode in those who had isolated homograft aortic valve replacement. There was one case of miliary tuberculosis but pyogenic and fungal endocarditis were not encountered. No hemolysis, valvular calcification or stenosis was observed.