合并心脏恶病质瓣膜病的围手术期处理

目的：探讨合并心脏恶病质瓣膜疾病的围手术期处理，提高对其外科治疗的成功率。方法：收集1992～2001年间符合心脏恶病质综合征诊断标准的风心瓣膜病24例。结果：二尖瓣置换术15例，主动脉瓣及二尖瓣置换术9例，同时三尖瓣成形术24例。术后并发症13例，包括低心排血量综合征、室性心律失常和多器官功能衰竭，死亡4例(17％)。结论：手术成功关键在于重视围手术期处理：调整全身及心功能达最佳状态，术中重视心肌保护及三尖瓣功能纠正，术后积极防治低心排血量和多器官功能衰竭。     

大心脏瓣膜置换术16例临床分析

目的探讨大心脏瓣膜置换术围手术期的处理,以提高外科治疗效果。方法回顾分析16例大心脏瓣膜置换术患者的临床资料。风湿性心脏病二尖瓣病变11例,二尖瓣并主动脉瓣病变2例;先天性心脏病室间隔缺损并主动脉瓣脱垂1例,退行性变主动脉瓣狭窄并关闭不全2例。术前心功能Ⅲ级12例,心功能Ⅳ级4例。术前平均心胸比0．82,左室射血分数（EF）0．46,左室舒张末期直径（EDD）71min。二尖瓣置换术（MVR）11例,主动脉瓣置换术（AVR）2例,双瓣置换术（DVR）2例,室缺修补术加主动脉瓣置换术1例。结果术后出现并发症5例,占本组31％,其中低心排4例,心律失常1例。死亡2例,占本组13．5％,1例为术后顽固性低心排,1例为术后心律失常、室颤。术后半年复查,心胸比、EDD较术前明显缩小,心功能明显改善。结论大心脏瓣膜置换术应重视围手术期的处理,术后应防治低心排及心律失常。     

肾功能不全患者心脏手术的围术期管理

目的:总结肾功能不全患者心脏手术围手术期管理的临床经验.方法:对1998年8月至2009年3月中国医科大学第一医院院收治的24例(其中18例为冠心病,4例为风湿性心脏病,1例为主动脉瓣病变合并冠心病, 1例为二尖瓣病变合并冠心病)合并肾功能不全患者心脏手术围术期治疗进行总结.结果:18例冠心病患者中10例在体外循环下完成手术,8例在非体外循环下完成手术.2例风湿性心脏病患者行双瓣置换术,2例行二尖瓣置换术.1例行冠状动脉旁路移植术加主动脉瓣置换术,1例行冠状动脉旁路移植加二尖瓣置换术.术后均进行连续性肾脏替代疗法(CRRT),透析6 h后患者心率、中心静脉压、肌酐和尿素氮较未透析时明显下降(P ＜ 0.05),而平均动脉压、动脉血氧分压较未透析时明显升高(P ＜ 0.05).围术期3例患者死亡, 3例患者放弃治疗, 其余18例患者中有5例改为内科规律透析治疗,10例患者肾功能恢复到术前水平出院后尿量恢复未再透析治疗,术后随访(28.5 ± 25.4)个月,心脏症状均消失,生存质量明显提高. 结论:CRRT是肾功能不全患者心脏术后围术期治疗的重要手段.     

风湿性心脏病二尖瓣置换术后三尖瓣返流的再手术治疗

目的分析风湿性心脏病二尖瓣置换术后再发三尖瓣返流（TR）患者的临床特点、外科手术方法和疗效,总结围手术期处理经验。方法2000年1月至2011年12月,17例风湿性心脏病二尖瓣置换术后再发三尖瓣返流的患者在我院接受单纯再次三尖瓣手术,行三尖瓣成形术10例,包括单纯DeVega成形术1例、瓣叶成形＋人工瓣环成形9例;行三尖瓣置换术7例,其中置换生物瓣4例,双叶机械瓣3例,回顾性分析其临床表现、诊治经过和预后情况。结果术后早期死亡1例（5．88％,1／17）,死于术后左心功能衰竭。术后发生低心排血量综合征3例,肾功能不全2例,呼吸功能不全2例,均成功救治。随访14例,随访时间3～9年,心功能I级2例,Ⅱ级8例,Ⅲ级4例。失访2例。结论对风湿性心脏病二尖瓣置换术后三尖瓣返流患者再手术治疗效果较好,合理掌握手术指征、手术时机和良好的围手术期处理是提高手术成功率的关键。     

严重钙化性主动脉瓣病变的手术策略及治疗效果观察

目的探讨严重钙化性主动脉瓣病变手术治疗效果。方法对13例严重钙化性主动脉瓣病变患者行手术治疗,其中同时行二尖瓣置换术3例,冠状动脉旁路移植术1例,升主动脉成形术2例,Bentall术1例,三尖瓣成形术2例。结果围手术期死亡3例,1例术后出现Ⅲ°房室传导阻滞,其余术后均顺利恢复,无其他严重并发症。结论严重钙化的主动脉瓣病变手术死亡率高,术中应加强心肌保护,对钙化部分合理处理,能有效防止并发症,降低手术死亡率。     

心脏二次手术疗效分析

目的　探讨心脏二次手术的经验及围术期处理要点。方法　 1998年 1月至 2 0 0 2年 7月 ,我院对 2 7例心脏病患者行第二次手术治疗。第一次手术类型 :二尖瓣闭式扩张术 2 0例 ,二尖瓣球囊扩张术 2例 ,二尖瓣生物瓣置换术 2例 ,左心房黏液瘤摘除术 2例 ,室间隔缺损修补术 1例。第一、二次手术间隔时间 2～ 18(平均 10± 7)年。二次手术方式为 :单纯二尖瓣置换术 2 0例 ,二尖瓣并主动脉瓣置换术 4例 ,部分房间隔切除并黏液瘤摘除术 2例 ,室缺残余漏直接修补 1例。结果　术后二次开胸止血 3例 ,住院死亡 6例 ,其余病例均康复出院。结论　心脏二次手术术前应充分改善病人一般情况 ,术中强调心肌保护及彻底止血 ,术后使用必要的血管活性药物等对于提高疗效均十分重要。     

65岁以上老年心脏瓣膜病的外科治疗

目的:总结分析206例65岁以上老年人心脏瓣膜置换术的近期疗效。方法:从1994年1月至2006年7月,我院共为206例65岁以上(65～80岁)老年患者施行瓣膜置换术,其中行二尖瓣置换术(MVR)97例,主动脉瓣置换术(AVR)58例,三尖瓣置换术(TVR)3例,二尖瓣及主动脉双瓣置换术(DVR)43例,二尖瓣及三尖瓣置换术(MVR TVR)1例,主动脉带瓣人造血管置换4例,同期行二尖瓣整形(MVP)21例,三尖瓣整形(TVP)66例,冠状动脉旁路移植术(CABG)32例,左心房血栓清除26例,左心耳接扎34例。其中采用人工机械瓣23枚,生物瓣227枚。结果:本组早期死亡16例(7.8%),其余190例痊愈出院。结论:随着手术技巧和围术期处理的成熟和完善,高龄老年瓣膜置换术是安全有效的;高龄老年换瓣术后并发症的处理关键在于预防。     

心脏瓣膜置换术后80例护理体会

心脏瓣膜置换术是治疗心脏瓣膜病变所致心功能不全的重要手段[1-7]。由于术后患者管道多,手术创伤大,病情变化迅速,易发生各种并发症。所以,术后监护要分清主次,同时又要注意联系整体。现就我院2007年3月～2009年6月80例心脏换瓣术后监护体会总结如下。1临床资料本组80例,男32例,女48例。年龄5～64岁。单纯二尖瓣病变22例,主动脉瓣病变17例,二尖瓣及主动脉联合病变20例,二尖瓣或主动脉瓣联合三尖瓣病变21例。术前心功能二级15例,三级53例,四级12例。行二尖瓣置换术28例,主动脉瓣置换术15例,双瓣置换术18例,二尖瓣或主动脉瓣置换联合三尖瓣成形术19例。2结果术后呼吸机辅助时间1     

危重瓣膜病的围术期治疗

目的:总结对因重症心脏瓣膜病行瓣膜置换患者围手术期的治疗经验。方法:156例患者行二尖瓣置换术(MVR)52例,主动脉瓣置换术(AVR)50例,MVR AVR54例;术中同时行DeVega或Kay氏三尖瓣成形术89例,左房折叠术 MVR43例,术中保留二尖瓣后瓣65例,保留全部二尖瓣装置23例,行多支冠状动脉搭桥术6例,AVR同时行左乳内动脉和左前降支吻合2例,术中平均搭桥(1.8±0.9)根。结果:156例患者中有8例早期死亡。存活的148例患者中有112例经术后随访6～12个月,无晚期死亡,心功能I～Ⅲ级。结论:合理的手术方式和术后处理是治疗重症心脏瓣膜病的关键。     

心脏瓣膜置换术围手术期处理

目的　探讨心脏瓣膜置换术围手术期血流动力学变化及其手术处理方法。方法　选取 4 3例重症心脏瓣膜病患者 ,均为风湿性二尖瓣和 /或主动脉瓣病变 ,分别行单瓣或双瓣置换术。围手术期采用Swan Ganz四腔气囊漂浮导管监测中心静脉压、右房压、肺动脉压、肺毛细血管楔压 ,并计算心排血量、心脏指数和周围血管阻力。结果　 4 3例患者均安全度过围手术期 ,无早期死亡。结论　对重症心脏瓣膜病 ,维持血流动力学稳定和有效的心肌保护是围术期管理的关键。     

Valvular heart disease. Identifying and managing mitral and aortic lesions

Evaluation and treatment of valvular heart disease (table 1) are in evolution. Echocardiography is the principal diagnostic tool. In general, mitral and aortic stenotic lesions warrant surgical treatment when symptoms appear. Such intervention is also indicated in symptomatic patients with a regurgitant mitral or aortic lesion. Some patients with regurgitant lesions require surgical treatment even before the onset of symptoms, such as when left ventricular dysfunction or dilatation supervenes. Surgical treatment of valvular lesions consists of repair or replacement, except in the case of mitral stenosis, where PBMC is a reasonable alternative. In general, medical therapy has a very limited role in the treatment of valvular heart disease. Severe aortic insufficiency is an exception. In such cases, afterload reduction has proved beneficial in the long-term prognosis.     

Minimally invasive repair of the mitral valve: Technological and clinical developments

Abstract

The present article will review new technology in the invasive approach to mitral valvular disease. Mitral valve pathology continues to present an important challenge to the cardiac surgeon and interventionalist. From the early days of closed mitral valvular commisurotomy, a number of new approaches to this valve have been developed. Mitral stenosis was previously approached through a minimally invasive beating heart surgical approach, but may now be treated with either catheter-based or open surgical techniques. Regurgitation, which has become the leading pathology of the mitral valve in the developed world, may be approached through traditional cardiac surgery or through catheter-based techniques. New imaging techniques and device innovation will cause drastic changes in therapy for mitral valvular disease in the foreseeable future.     

经食管实时三维超声心动图在二尖瓣病变中的应用价值

目的初步探讨经食管实时三维超声心动图（RT3D—TEE）在二尖瓣病变术前诊断、术中监测及术后评价中的临床应用价值。方法应用RT3D—TEE对31例二尖瓣病变患者进行术前、术中及术后检查,并与外科手术结果对比。结果RT3D—TEE清晰显示23例风湿性瓣膜病变患者的二尖瓣病变情况、累及瓣膜情况,并指导手术成功完成;准确显示7例二尖瓣脱垂患者的病变部位并量化病变情况;准确诊断1例二尖瓣人工机械瓣置换术后再狭窄患者的病因。31例患者均获得满意的RT3D—TEE图像。结论RT3D—TEE能在二尖瓣病变术前、术中及术后提供真实准确的评价信息。     

Multivalvular vegetations in a patient with enterococcal endocarditis diagnosed by echocardiography.

A patient with enterococcal endocarditis of 11 months' duration is presented, and the role of surgery and echocardiography is reviewed. Echocardiography revealed vegetations of the aortic and mitral valves. After appropriate antibiotic therapy the patient had successful aortic and mitral valve replacement with porcine heterografts. Enterococcal endocarditis is increasing in frequency and is likely to infect young women of childbearing age, elderly men who have had genitourinary tract manipulation, and abusers of intravenous drugs. Aortic and mitral valves are most frequently affected, cardiac failure is common, and often no evidence of underlying heart disease can be found. The use of echocardiography in this patient provided accurate diagnosis of valvular vegetations and assessment of the hemodynamic severity of the lesion, thus preventing the need for cardiac catheterization and its potential risk of septic embolization.     

高龄心脏瓣膜置换术62例分析

目的总结62例高龄患者心脏瓣膜病的手术治疗及结果。方法2012年2月至2013年1月心脏大血管外科施行的〉60岁高龄患者心脏瓣膜手术的病例,其中行二尖瓣置换31例,主动脉瓣置换23例,二尖瓣联合主动脉瓣置换8例。同期行房颤射频消融术24例,左房血栓清除15例,三尖瓣成形术29例,左房折叠31例。共置换瓣膜70枚,生物瓣59枚、机械瓣11枚。结果术后早期死亡2例,病死率3．22％（2／62）。术后并发症：低心排血量综合征4例,呼吸功能不全8例,心律失常19例,急性肾功能不全8例,精神症状3例,无并发脑血管意外、切口愈合不良、精神症状,治疗后均痊愈出院。对其中52例患者随访3至8个月。结论只要掌握好手术指证,细致的手术操作,加强围手术期管理,高龄患者心脏瓣膜置换术可以取得良好的效果。     

术中经食管实时三维超声心动图在心脏瓣膜疾病中的应用价值

目的 探讨术中经食管实时三维超声心动图(RT-3D-TEE)在心脏瓣膜疾病诊治中的应用价值.方法 应用Philips iE33型超声诊断仪,X7-2t经食管多平面实时三维探头,对32例拟行手术治疗的心脏瓣膜病患者,在手术室分别于术前及术后即刻行RT-3D-TEE检查,对二尖瓣脱垂患者运用QLAB 7.0分析系统进行定量分析.结果 RT-3D-TEE能够实时、直观、清晰地显示心脏瓣膜的三维立体结构及功能状态,在评价病变部位、性质及程度上与术中直视所见基本一致.经RT-3D-TEE检查后补充诊断2例,调整手术方案3例,实施补救性手术1例.结论 RT-3D-TEE成像清晰,在术前诊断、手术方案制定及手术效果评价方面均具有独特优势,在心脏外科手术中应用前景广阔.     

Diet drug-related cardiac valve disease: the Mayo Clinic echocardiographic laboratory experience

OBJECTIVE: To describe the prevalence of diet drug-related valvular disease among our referral population and the association of valvular disease with duration of exposure to fenfluramine and phentermine in combination and to dexfenfluramine alone. PATIENTS AND METHODS: In this retrospective review of clinical and echocardiographic data, charts of patients referred for treatment of toxic effects of diet drugs were reviewed, and telephone interviews were conducted. RESULTS: Between June and December 1997, 191 patients (164 women, 27 men; mean age, 47 years) were referred for possible diet drug-related valvular disease. Twenty-eight (28%) of the 99 asymptomatic patients and 40 (43%) of the 92 symptomatic patients had abnormal echocardiographic findings. Valvular lesions among the 68 patients with abnormal echocardiographic findings included mild (or greater) aortic regurgitation in 55 patients (81%), moderate (or greater) mitral regurgitation in 12 (18%), and moderate (or greater) tricuspid regurgitation in 7 (10%). The Food and Drug Administration case definition of diet drug-related valvulopathy was noted in 31 % of this referral population. Of patients with valvulopathy, mean duration of therapy with fenfluramine and phentermine in combination and dexfenfluramine alone was 9 months and 5 months, respectively. Duration of therapy was not associated with presence or absence of disease. Five patients had surgical intervention for severe valvulopathy: 3 had mitral valve repair, 1 had mitral valve replacement, and 1 had aortic valve replacement. Pulmonary hypertension (>40 mm Hg) was found in 24 patients (13%), and 17 (71 %) had pulmonary hypertension in association with valvulopathy. CONCLUSION: This study demonstrated a 31% (60/191) prevalence of valvulopathy in patients with a history of diet drug exposure who were referred for echocardiographic evaluation. The most common finding was mild aortic regurgitation. Twenty-eight percent of asymptomatic patients had abnormal echocardiographic findings. This study emphasizes the spectrum of diet drug-related cardiac disease and the potential for valvulopathy in asymptomatic patients.     

Evaluation of the aortic and mitral valves with cardiac computed tomography and cardiac magnetic resonance imaging

Cardiac computed tomography (CT) produces high-quality anatomical images of the cardiac valves and associated structures. Cardiac magnetic resonance imaging (MRI) provides images of valve morphology, and allows quantitative evaluation of valvular dysfunction and determination of the impact of valvular lesions on cardiovascular structures. Recent studies have demonstrated that cardiac CT and MRI are important adjuncts to echocardiography for the evaluation of aortic and mitral valvular heart diseases (VHDs). Radiologists should be aware of the technical aspects of cardiac CT and MRI that allow comprehensive assessment of aortic and mitral VHDs, as well as the typical imaging features of common and important aortic and mitral VHDs on cardiac CT and MRI.     

Radionuclide quantification of mitral and aortic regurgitation

Abstract. Gated equilibrium bloodpool scintigraphy was used to obtain the ratio of left and right ventricular stroke counts (end-diastolic minus end-systolic counts within ventricular areas of interest), the radionuclide equivalent of stroke volumes. This ratio or stroke count index (SCI) should be unity in normal subjects and increased in patients with aortic or mitral regurgitation, when left ventricular stroke output rises to compensate for regurgitant flow. Results of this non-invasive method were compared with semiquantitative angiographic grading of mitral (1 to 4+) or aortic (1 to 3+) regurgitation in ninety-seven patients. We found a SCI of 1.15 ± 0.18 (SD) in thirty-six control subjects without evidence of mitral or aortic regurgitation at cardiac catheterization. Subsequently, a ratio of 1.50 was chosen as the upper limit of normal for the analysis of thirty-seven patients with mitral regurgitation and twenty-four patients with aortic regurgitation. Clearly, elevated SCI values were obtained in the presence of grade 3 and 4 mitral regurgitation (eighteen out of twenty patients) and of grade 2 and 3 aortic regurgitation (seventeen out of eighteen patients). Only two out of seventeen subjects with grade 1 or 2 mitral incompetence had an elevated SCI, while none of six subjects with grade I aortic regurgitation had an abnormal SCI. If these lesser degrees of valvular incompetence are considered of minor significance, overall sensitivity of the radionuclide method in our patient population was 92%, specificity 95%. Occasional discrepancies between SCI and angiographic severity of left-sided valvular regurgitation are probably a result of methodological limitations. We could not demonstrate any relation with global left ventricular function as measured from the radionuclide ejection fraction. We conclude that the SCI may be used as a non-invasive tool for diagnosis and management of patients with valvular heart disease, both before and after interventions.