心脏瓣膜术后心室辅助治疗

Objective An increasing number of patients requiring ventricular assist devices (VAD) have had previous valvular corrections,including valve repair,and valve replacement with mechanical or bioprosthetic valves.The operative and peri-operative management of these patients has been varied.Methods A retrospective study of VADs between Jan 1994 and June 2008 revealed 10 patients with previous prosthetic valves requiring management during and after VAD placement.Three patients were supported post-cardiotomy after valve surgery.Two patients were supported due to cardiogenic shock postopera-tively.Four patients were supported as a bridge to transplantation.One patient was supported as a destination therapy.Results The mitral valve was left untreated during VAD implantation regardless of valve repair or replacement.For aortic valves,the mechanical aortic valve was replaced with tissue valve in two patients and left untreated in one case.One patient had tricuspid valve repair previously and was left untouched.All patients with prosthetic valves in aortic,mitral and tricuspid position during VAD support received anticoagulation therapy.There were 4 deaths,and 4 went on to transplantation.One patient weaned from VAD and discharge from hospital.One patient received HeartMate Ⅰ as destination therapy.The most common causes of death were multisystem organ failure and sepsis.One patient had a thromboembolic event.Conclusion The survival rate of 60% is encouraging when compared to overall survival rates.The most common cause of death was multisystem organ failure.Patients with prosthetic valves may be safely managed during VAD support.     

心脏瓣膜术后心室辅助治疗

Objective An increasing number of patients requiring ventricular assist devices (VAD) have had previous valvular corrections,including valve repair,and valve replacement with mechanical or bioprosthetic valves.The operative and peri-operative management of these patients has been varied.Methods A retrospective study of VADs between Jan 1994 and June 2008 revealed 10 patients with previous prosthetic valves requiring management during and after VAD placement.Three patients were supported post-cardiotomy after valve surgery.Two patients were supported due to cardiogenic shock postopera-tively.Four patients were supported as a bridge to transplantation.One patient was supported as a destination therapy.Results The mitral valve was left untreated during VAD implantation regardless of valve repair or replacement.For aortic valves,the mechanical aortic valve was replaced with tissue valve in two patients and left untreated in one case.One patient had tricuspid valve repair previously and was left untouched.All patients with prosthetic valves in aortic,mitral and tricuspid position during VAD support received anticoagulation therapy.There were 4 deaths,and 4 went on to transplantation.One patient weaned from VAD and discharge from hospital.One patient received HeartMate Ⅰ as destination therapy.The most common causes of death were multisystem organ failure and sepsis.One patient had a thromboembolic event.Conclusion The survival rate of 60% is encouraging when compared to overall survival rates.The most common cause of death was multisystem organ failure.Patients with prosthetic valves may be safely managed during VAD support.     

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。     

经导管心脏瓣膜研究进展

经导管主动脉瓣置换术已成为治疗严重主动脉瓣狭窄的主要方式,目前市售瓣膜主要包括球囊可膨胀瓣膜和自膨胀瓣膜。新一代球囊可膨胀瓣膜由SAPIEN XT和SAPIEN 3瓣膜组成,最新自膨胀瓣膜为可重新定位的Evolut Pro系统。本文对经导管心脏瓣膜研究进展进行综述。     

5066例瓣膜手术的围术期临床回顾

目的回顾分析安贞医院1993～2004年5066例心脏瓣膜手术围术期资料，探讨我国瓣膜外科围术期临床特点。方法利用自行研发的心外科专业数据库，将所有病例资料依据手术种类、心脏大小、心功能及EF值变化、手术相关数据（体外循环时间、主动脉阻断时间、呼吸机带管时间、ICU时间、术后住院并发症）、病死率、并发症分布等进行分组，应用t检验和X^2检验来比较各组间的差异。结果全组手术后围术期并发症发生率为18．2％，总病死率4．6％。统计显示，病人平均年龄逐年升高；风湿性心脏病仍是病因的构成主体，但近5年来退行性病变、黏液性病变比例明显增加；围术期病死率近年来已稳定在3％～4％。结论瓣膜外科年龄构成有明显的上升趋势；围术期应针对老年病人特点进行管理；EF值在不同病理改变的瓣膜病中，对围术期病死率的影响意义并不相同；应重视瓣膜成形技术的开展；应加强对专业数据库系统的开发和应用。     

人工瓣膜功能障碍的外科治疗

目的 总结41例人工心脏瓣膜功能障碍(PHVD)的临床特点、外科治疗方法 及围术期处理经验.方法 手术均在全麻低温体外循环下进行;1例采取股动脉插管左侧开胸,40例均经原切口,主动脉、上下腔静脉插管建立体外循环.38例行瓣膜置换术,使用机械瓣35枚(二尖瓣位23枚,主动脉瓣位11枚,三尖瓣位1枚),生物瓣6枚(二尖瓣位3枚、主动脉瓣位2枚、三尖瓣位1枚);2例行瓣膜角度矫正术;1例行异物清除术.急诊手术13例,择期手术28例.结果 全组气管插管5.1～243.0 h,平均63.3 h,中位时间15.3 h;气管切开5例.全组死亡6例,病死率14.6%,均发生于急诊手术后,死因为低心排血量综合征3例、多器官衰竭2例及恶性心律失常1例.并发症包括感染性心内膜炎、顽固性呃逆及切口感染各1例.结论 对急性PHVD,无论是生物瓣或机械瓣,均应立即进行急诊手术.对慢性PHVD亦应强调及早再次手术.     

生物瓣膜失功能原因分析

目的对植入人体内1年以上损坏的生物瓣膜作损坏原因的临床分析。方法1993年6月至2004年6月,共41例(47只)生物瓣膜失功能病人行再次手术换瓣。两次换瓣间隔时间1~16年,平均(9.7±4.1)年。对失功能生物瓣膜进行标本观察及病理学检测。结果47只带支架生物瓣膜中,瓣架无一损坏,42只瓣膜发生瓣叶撕裂或穿孔,35只有不同程度的钙化现象,且在瓣环表面和瓣脚周围有纤维组织增生,2只瓣膜有赘生物及血栓形成;47只生物瓣膜中损坏较重的瓣膜送病理学检查发现大量吞噬细胞和单核细胞浸润。结论生物瓣膜早期损坏以破损撕裂为主,晚期以钙化和破损撕裂等多种因素的复合病损结果出现。     

人工瓣膜功能障碍的外科治疗

Objective To review our clinical experience with 41 reoperatioas of prosthetic heart valve dysfunction be-tween October 1996 and October2008. Methods There were 16 malas and 25 females with an average age of (44.5±12.6)years. All 41 patients underwent reoperation under hypothermic cardiopulmonary bypass, including 38 heart valve replace-ments, 2 disc rotations and cut of the excessive knot in 1 case. There were 13 emergency and 28 elective procedures. Results The median time for extubation was 15.3 hours and tracheostomy was needed in 5 cases. There were 6 deaths, all of which occurred in emergency cases, with a mortality rate of 15.4%. No death occurred in patients implanted with a bioprosthetic valve previously. Postoperative complications included 1 infective endocarditis, 1 intractable hiccup and 1 wound infection. Conclusion Prosthetic heart valve dysfunction is catastrophic. Early diagnosis and reoperation is mandatory.     

人工瓣膜功能障碍的外科治疗

Objective To review our clinical experience with 41 reoperatioas of prosthetic heart valve dysfunction be-tween October 1996 and October2008. Methods There were 16 malas and 25 females with an average age of (44.5±12.6)years. All 41 patients underwent reoperation under hypothermic cardiopulmonary bypass, including 38 heart valve replace-ments, 2 disc rotations and cut of the excessive knot in 1 case. There were 13 emergency and 28 elective procedures. Results The median time for extubation was 15.3 hours and tracheostomy was needed in 5 cases. There were 6 deaths, all of which occurred in emergency cases, with a mortality rate of 15.4%. No death occurred in patients implanted with a bioprosthetic valve previously. Postoperative complications included 1 infective endocarditis, 1 intractable hiccup and 1 wound infection. Conclusion Prosthetic heart valve dysfunction is catastrophic. Early diagnosis and reoperation is mandatory.     

用无支架生物瓣膜行主动脉瓣置换术的早期临床经验

目的探讨无支架生物瓣的置入技术及其早期临床效果.方法对12例平均年龄65岁的主动脉瓣病变病人,选用St.Jude公司提供的TorontoSPV瓣膜,行主动脉瓣置换术.结果全组手术死亡1例,平均主动脉阻断时间(95.0±12.3)?min,其中单纯主动脉瓣置换者为(74.0±9.2)?min.术后1个月随访超声心动图显示均无主动脉瓣反流,跨瓣压差明显较其他人工瓣膜小,左心室舒张末期内径明显缩小,无栓塞、出血等并发症.结论尽管无支架生物瓣膜置入有一定难度,但其优良的血液动力学性能,提示其能提高病人的远期疗效.     

心脏瓣膜置换术后中远期疗效分析

目的　分析探讨心脏瓣膜置换术的中远期疗效。方法　 1978年至 2 0 0 1年 12月 ,行瓣膜置换手术 2 14 1例 ,同期随访 16 81例 ,计 80 2 1 1人·年 ,平均 4 77人·年。通过回顾病因、手术方式、瓣膜类型等因素 ,观察术后病人心功能改善情况 ,病死率及并发症等 ,采用t检验 ,多因素回归等统计学方法分析。结果　 92例死亡。总体生存率 5年为 (92 3± 2 2 ) % ,10年生存率为 (90 1± 2 7) %。并发症有血栓栓塞、机械瓣膜功能障碍、瓣周漏、溶血、机械瓣膜感染性心内膜炎。术后心功能 (NYHA)与术前比较有明显的提高。结论　 1.机械瓣置换术后中远期疗效满意 ,病死率及并发症均较低 ;与术前心功能和手术种类直接相关 ;2 .使用保留瓣下结构及三尖瓣成形术对术后心功能恢复有明显效果 ;3.术中良好心肌保护是提高手术成功率的关键。     

国人机械瓣膜置换手术后远期随访和抗凝治疗现状

目的　通过对 4 5 0 5例人工机械瓣膜置换病人的远期临床结果随访 ,全面评价国人人工机械瓣膜置换手术的远期疗效和人工机械瓣膜置换手术后抗凝治疗现状 ,以指导临床工作。方法　 1976年 5月至 1997年 5月实施人工机械瓣膜置换手术 4 5 0 5例 ,共置换人工机械瓣膜 5 72 9枚。总随访率为 87% ,平均随访 5 5 6年 ( 0 80～ 2 0 17年 ) ,随访总人年数为 2 0 882 4 7病人 年。结果　 30d死亡 173例( 3 84 % )。 5 8例发生血栓形成及血栓栓塞 ( 0 2 8%病人 年 ) ,2 73例 ( 1 31%病人 年 )发生出血事件 ,5例再手术 ( 0 0 2 %病人 年 )。远期随访死亡 15 2例 ( 0 73%病人 年 ) ,5年生存率 ( 96 4 9± 0 33) % ,10年 ( 92 6 9± 0 75 ) % ,15年 ( 90 78± 1 5 4 ) %。 88 8%病人了解换瓣术后服用抗凝药物的必要性 ,11 2 %病人不了解抗凝治疗的必要性。抗凝知识的掌握、抗凝治疗检测等与病人文化水平和地区分布有密切关系。结论　远期随访结果表明 ,国人人工机械瓣膜置换术后具有良好远期生存率。部分病人不了解抗凝治疗的重要性 ,抗凝治疗方面存在地区差异。     

国产人工双叶机械瓣置入绵羊肺动脉瓣位的实验研究

目的　探讨国产人工双叶机械瓣用于绵羊肺动脉瓣位的功能状况及其长期在体内的各项性能。　方法　于 2 0 0 1年 10～ 11月 ,在体外循环并行下维持心跳对 6只成年绵羊经主肺动脉行肺动脉瓣国产人工双叶机械瓣置换术 ,长期观察术后绵羊生存时间、机械瓣的功能情况及病理变化。　结果　术后 6只绵羊全部存活 ,平均存活 (2 2 1± 2 0 8)d ,按计划将其中 2只绵羊分别于术后4 1d和 71d处死 ,处死前绵羊状况良好 ,病理检查 :机械瓣功能良好 ,无血栓形成 ,无瓣周漏 ,无组织过度生长 ;1只绵羊于术后 15 8d时停用抗凝药物 ,1周后 (16 5d)死于白色血栓形成导致的机械瓣功能障碍 ,病理检查示瓣周缝合缘纤维组织轻度增生 ;2只绵羊分别于术后 196和 2 34d死于重度贫血 ,尸检未见其他异常 ;1只绵羊迄今仍存活 (>6 17d) ,并分别于术后 4 38d和 4 79d行彩色超声多普勒检查 ,提示机械瓣在肺动脉瓣位功能正常。　结论　在绵羊肺动脉瓣位应用新型国产人造双叶机械瓣 ,可取得良好的长期效果。     

经导管植入国产自膨式主动脉瓣膜治疗老年性主动脉瓣狭窄(附3例报告)

正75岁以上的老年人退行性心脏瓣膜病发病率高达4.6%~([1])。老年性主动脉瓣狭窄(aortic valve stenosis,AS)发病率越来越高。目前外科主动脉瓣膜置换术(surgery aortic valve replacement,SAVR)仍是治疗重度AS的首选方法,但30%~50%的患者因存在严重合并症、无法承受外科手术而出现心力衰竭和心源性猝死。2002年Cribier等~([2])采用经导管主动     

左心瓣膜置换术后远期三尖瓣关闭不全的外科处理

目的探讨左心瓣膜置换术后远期三尖瓣关闭不全(TR)发生的可能机制以及外科治疗方法的选择和结果.方法 56例左心瓣膜置换术后远期发生TR行再次瓣膜手术的病人,10例人工瓣膜功能正常(A组)者中行二尖瓣置换(MVR)4例,主动脉瓣、二尖瓣双瓣置换(DVR)6例;46例人工瓣膜功能障碍(B组)者中MVR 36例,主动脉瓣置换(AVR)4例, DVR 6例.在A、B两组中,46例第1次手时三尖瓣未见明显异常,10例第1次手术时已行DeVega三尖瓣成形(TVP),第2次手术时发现缝线断裂3例,缝线撕脱7例.56例TR病人再次手术时9例行三尖瓣替换(TVR),其中6例三尖瓣呈风湿性改变;47例行TVP.结果 TVP和TVR各死亡1例,病死率3.6%.54例获随访,随访时间6～132个月,平均(79.4±34.8)个月.8例TVR病人术后心功能恢复良好,46例TVP者40例为轻度TR,5例出现中度TR,仍需强心、利尿药维持,1例再次出现重度TR.结论左心瓣膜置换术后远期TR可能与持续肺动脉高压、右心室不可逆损害、三尖瓣风湿性病变、左心功能的恢复情况以及持续心房纤颤有关.重度功能性TR和三尖瓣风湿性病变者行TVR的疗效可靠.随访发现部分TVP病人功能性TR仍有逐渐加重趋势.     

胸腔镜主动脉瓣和二尖瓣双瓣膜置换术的动物实验研究及临床应用

目的探讨胸腔镜下二尖瓣和主动脉瓣双瓣膜置换术的可行性。方法实验动物组(16只犬)和临床组(1例临床病例)股动脉、股静脉插管建立体外循环。右胸壁做一个4~5 cm小切口和2个1.5 cm小孔,用自行设计的腔静脉阻断器阻断上下腔静脉,升主动脉插冷灌针灌注停跳液保护心肌。间断缝合人工机械二尖瓣膜和主动脉瓣膜。结果实验动物组:体外循环时间104~196 m in,(143.2±46.5)m in;升主动脉阻闭时间58~128 m in,(82.4±26.1)m in。术后取出心脏标本检查,人工二尖瓣及主动脉瓣,缝合确切,无松线及周围组织撕裂。临床组1例:体外循环时间157 m in,升主动脉阻闭时间112 m in;术后呼吸机辅助时间10 h,术后胸腔引流液150 m l,术后住院时间10 d;术后随访9个月,未发现瓣周漏及其他术后并发症;心脏超声示人工瓣膜活动良好,无瓣周漏。结论胸腔镜二尖瓣和主动脉瓣双瓣膜置换术技术上可行。