二尖瓣闭式扩张术后瓣膜替换的手术治疗

本文分析了自1988年至1991年,我院心外科收治的42例二尖瓣闭式扩张术后瓣膜替换的患者。36例二尖瓣替换,6例二尖瓣、主动脉瓣双瓣替换,术后早期死亡5例。结果表明:心包粘连是影响手术成功的关键因素之一。心包粘连的程度与术中渗血量、术后36小时引流量、手术死亡率及术中心肌保护有密切关系。选择合适的病例,二尖瓣闭式扩张术仍为治疗二尖瓣狭窄的有效方法。     

二尖瓣狭窄闭式扩张术后的瓣膜替换术

目的：介绍二尖瓣闭式扩张术后的瓣膜替换术经验。方法：我院自１９７７年１１月至１９９３年１２月期间共行二尖瓣闭式扩张术后瓣膜替换术２２９例（男１４８例，女８１例）。瓣膜替换时平均年龄４３．９５±６．６０岁。其中急诊手术５例，择期手术２２４例，两次手术间隔为１２．９６±６．７９年。均在低温体外循环下手术，其中二尖瓣替换术２０８例（９０．８３％）；二尖瓣及主动脉瓣双瓣替换术２１例（９．１７％）。结果：总手术死亡率７．４２％，１９８７年前死亡率为２３．６８％，而近３年死亡率仅０．８８％（１／１１３）。结论：掌握好手术时机；注重心肌保护；避免广泛游离心包粘连；采用右房、房间隔切口显露二尖瓣，连续缝合法替换二尖瓣，使手术时间缩短；以及正确的术后处理等，均是降低死亡率的重要因素。     

二尖瓣闭式扩张术后再狭窄瓣膜替换术的临床实践

二尖瓣闭式扩张术后,由于风湿性心脏炎症不断侵袭心脏瓣膜,可再次导致二尖瓣狭窄或/和关闭不全,主动脉瓣和三尖瓣亦常不同程度受累。由于目前体外循环心内直视手术安全性的大幅度提高,往往选择二尖瓣替换术来彻底解决心脏瓣膜疾患引起的血流动力学障碍。现报告26例此类手术体会。     

心脏瓣膜替换并冠状动脉旁路移植同期施行手术40例报告

目的:探讨心脏瓣膜替换并冠状动脉旁路移植同期手术指征、方法及围术期处理。方法:2003年1月至2008年12月我院同期施行心脏瓣膜替换并冠状动脉旁路移植手术40例,其中风湿性心脏瓣膜病并冠状动脉病变35例;冠心病并缺血性二尖瓣关闭不全2例,主动脉瓣退行性变3例;冠状动脉造影显示单支血管病变20例,双支12例,多支8例,施行二尖瓣替换29例,主动脉瓣替换7例,二尖瓣替换+主动脉替换4例,同期施行三尖瓣成形10例,左心房血栓清除6例,室壁瘤切除3例。结果:全组病例无早期死亡,术后发生低心排出量综合征6例,呼吸衰竭3例,脑栓塞3例,肾功能衰竭1例。术后随访30例,随访时间1~60个月,除1例术后5年死于肝癌外,其余心功明显改善。结论:心脏瓣膜替换并冠状动脉旁路移植同期手术可获得良好效果。彻底解除瓣膜病变,充分心肌再血管化,良好的心肌保护和术后处理是获得手术成功的关键。     

复发性心脏瓣膜病再次外科治疗效果及其相关因素

目的:回顾性分析对二尖瓣闭式扩张术、瓣膜成形术、瓣周漏、人工机械瓣功能障碍、生物瓣衰坏等原因引起的复发性瓣膜病变进行再次手术的效果和相关因素。方法: 复发性瓣膜病患者331（男143,女188）例,年龄12～73(46±12)岁,两次手术间隔时间2月～25(17±8)年。其中二尖瓣闭式扩张术后再狭窄143例,二尖瓣或主动脉瓣成形术后瓣膜病变复发53例,生物瓣衰坏32例,瓣周漏26例,换瓣术后其它瓣膜病21例,人工瓣膜替换或瓣膜成形术后心内膜炎17例, Ebstein畸形矫治术后三尖瓣关闭不全15例,人工瓣膜机械功能故障9例,室间隔缺损修补术并行瓣膜成形术后心内膜炎7例,完全或部分性心内膜垫缺损和矫正性大动脉转位术后二尖瓣或三尖瓣关闭不全6 例,二尖瓣球囊扩张术2例。再次手术方式为二尖瓣替换术,主动脉瓣替换术,二尖瓣和主动脉瓣替换术,三尖瓣替换术,瓣周漏修补术及三尖瓣成形术等。结果: 全组共死亡27例,占8.2％,早期主要死亡原因为低心排出量综合征、室性心律失常、多脏器功能衰竭、左心室破裂、感染性心内膜炎、肾功能衰竭。随访259例,随访期6月～21（10±7）年,心功能恢复至Ⅰ～Ⅱ级189例。复发性心脏瓣膜病再次手术的危险因素包括术前心功能差、重要脏器功能不全、急诊手术、主动脉阻断时间和体外循环时间长等。结论: 针对再手术相关的危险因素进行积极防治,适时而妥善的外科手术和围手术期处理仍可获良好效果。     

二尖瓣闭式扩张术后瓣膜置换术临床分析

目的总结二尖瓣闭式扩张术后瓣膜置换术的经验及提高治疗效果的措施.方法分析上海长海医院自2001年8月至2002年7月二尖瓣闭式扩张术后瓣膜置换术34例,二尖瓣闭式扩张术至瓣膜置换术间隔平均时间为4～29(12.5±6.73)年.其中,二尖瓣置换术2例(5.9%),二尖瓣置换 三尖瓣成形术16例(47.1%),二尖瓣置换 主动脉瓣置换术2例(5.9%),二尖瓣、主动脉瓣双瓣置换 三尖瓣成形术14例(41.2%).并与同期风湿性心脏病瓣膜置换术患者有关临床资料对照分析.结果二尖瓣闭式扩张术后瓣膜置换术患者与同期风湿性心脏病瓣膜置换术患者在性别、年龄、心功能、手术方式、体外循环时间、主动脉阻断时间以及手术后早期死亡率等方面比较差异无统计学意义.结论对二尖瓣闭式扩张术后复发或病情加重的患者应尽早行瓣膜置换,加强围手术期合理治疗、有限分离心包粘连、术后加强血流动力学监测、注意心功能支持及呼吸支持等措施,可进一步提高手术效果.     

心肺血管病杂志2005年(第24卷)索引

文题索引(文题关键词以汉语拼音为序)A爱波斯坦异常降低Ebstein心脏畸形手术早期死亡率的探讨(韩宏光)(1):8X综合征X综合征患者血管内分泌功能和内皮依赖性舒张功能(张增堂)(2):81B白质脑病显性遗传性脑动脉病伴皮层下梗死和白质脑病1例报告(冯立群)(2):116瓣膜置换术保留整个二尖瓣和瓣下结构的人工瓣膜置换手术43例临床总结(赵国芳)(2):87闭式二尖瓣扩张术闭式二尖瓣扩张术后心脏瓣膜替换52例(褚衍林)(3):155并发症超高龄患者永久心脏起搏器植入围手术期常见并发症及处理(郝蓬)(1):29C超声检查X综合征患者血管内分泌功能和内皮依赖性舒…     

Bjork-Shiley单柱瓣替换心脏瓣膜的临床及血流动力学结果

1983年5月至1986年4月,作者应用Bjork-Sh-iley单柱瓣为318名患者施行了心脏瓣膜替换。患者平均年龄52岁(11至69岁);男性168人(52％);心功能分级(NYHA)Ⅲ～Ⅳ者119人(69％),43人有心脏瓣膜手术史(26例为闭式二尖瓣分离术、17例直视二尖瓣手术)。主动脉瓣替换(AVR)组136例:瓣膜狭窄、关闭不全及狭窄伴关闭不全(混合型)者分别为84例、41例及11例;二尖瓣替换     

急诊心脏瓣膜替换25例报告

目的:探讨急诊心脏瓣膜替换手术时机和围手术期处理措施。方法:1995年1月至2009年5月,对急性心脏瓣膜功能障碍致急性心肺功能衰竭施行急诊瓣膜置换25例,其中男性15例,女性10例,年龄12～64岁,术前心功能均为Ⅳ级。二尖瓣病变17例,其中二尖瓣机械瓣替换术后血栓形成致人工瓣膜功能障碍7例,人工瓣膜性心内膜炎并瓣周漏4例,感染性心内膜炎致急性二尖瓣腱索及乳头肌断裂并二尖瓣重度关闭不全5例,二尖瓣关闭不全并预激症1例。主动脉瓣病变8例,其中感染性心内膜炎并主动脉穿孔致急性心力衰竭(心衰)3例,血栓形成致人工瓣功能障碍2例,主动脉关闭不全并主动脉窦瘤破裂致急性心衰2例,外伤性主动脉瓣撕裂致主动脉瓣重度关闭不全1例。二尖瓣替换18例,其中再次心脏瓣膜替换11例,同时施行三尖瓣成形9例,异常传导束旁路切断1例。主动脉瓣替换8例。置入机械瓣22例,生物瓣3例。主动脉阻断时间34～80 min,转流时间70～160 min。结果:早期死亡1例,死于术后严重低心排综合征(低心排),其余病例术后恢复顺利,随访1～13年,心功能恢复良好。结论:及时、准确诊断,果断抉择手术时机,合理选择术式及良好围术期处理是进一步提高手术疗效的关键。     

心脏瓣膜手术前后血浆血小板因子4和β血小板球蛋白改变的临床研究

对３０例心脏瓣膜患者手术前后血浆血小板因子４（ＰＦ４）和β血小板球蛋白（βＴＧ）浓度测定显示，术前心房颤动病例的ＰＦ４和βＴＧ浓度高于窦性心率病例，瓣膜替换病例术后ＰＦ４和βＴＧ高于单纯二尖瓣闭式扩张病例。本文提出，术前心房颤动病例及瓣膜替换术后病例的体内血小板处于活化状态，具有血栓形成倾向，并对ＰＦ４和βＴＧ升高的成因及其临床意义进行讨论。     

重症心脏瓣膜替换175例报告

目的 :探讨对重症心脏瓣膜病外科诊断标准和总结治疗经验。方法 :1980年 1月至 1998年 2月 ,对重症心脏瓣膜病施行瓣膜置换 175例 ,其中男性 80例 ,女性 95例 ,年龄 12～ 6 6岁 ,术前心功能Ⅲ级 40例 ,Ⅳ级 135例。二尖瓣置换 111例 ,其中 40例为再次手术 ,主动脉瓣置换 2例 ,二尖瓣 +主动脉瓣置换 6 2例。全组置入瓣膜均为机械瓣。同时施行三尖瓣成形 32例 ,左房血栓清除 17例 ,左房成形12例 ,冠状动脉搭桥、经主肺动脉内关闭未闭动脉导管及异常传导束切割各 1例。结果 :早期死亡 10例(5 6 % ) ,低心排出量综合征、呼吸衰竭及室颤为最常见原因。结论 :注重术前准备 ,适当选择手术时机 ,合理纠正病变 ,避免手术不当并发症及加强术后并发症处理可进一步提高外科疗效     

Outcome probabilities and life history after surgical mitral commissurotomy: implications for balloon commissurotomy

From 1967 to 1988, 339 patients with mitral stenosis underwent surgical commissurotomy, 103 with a closed and 236 with an open technique. The 1 month and 1, 5, 10 and 20 year overall survival rate was 99.7%, 99%, 95%, 87% and 59%, respectively, and the technique (open versus closed) was not a risk factor. Technique was also not a risk factor for a second mitral commissurotomy, subsequent mitral valve replacement, thromboembolism or poor functional status. Risk factors were older age at commissurotomy, black race, higher pulmonary vascular resistance, mitral leaflet calcification, left ventricular enlargement and postcommissurotomy mitral incompetence. The closed technique was a risk factor for mitral incompetence immediately after commissurotomy, but important incompetence developed in only 2 of the 103 patients undergoing closed commissurotomy. Mitral valve replacement was not required within 10 years in 78% of patients and within 20 years in 47%. Despite some increased prevalence of postcommissurotomy mitral incompetence and particularly in view of the considerable long-term likelihood of mitral valve replacement, initial therapy for most patients with mitral stenosis should probably be surgical closed (or percutaneous balloon) mitral commissurotomy. The equations developed in the present study can be used to predict and compare outcome probability after percutaneous balloon commissurotomy with that after surgical commissurotomy and to compare these with outcome probability after mitral valve replacement.     

Reoperations in valve surgery. Apropos of 194 cases

Between 1970 and 1985, 194 patients underwent one or several reoperations after conservative valvular surgery (Group A) or valvular replacement surgery (Group B). Group A: comprised 141 patients with a previous history of closed heart mitral commissurotomy (114 cases), open heart mitral commissurotomy (20 cases), mitral valvuloplasty (5 cases) or aortic commissurotomy (2 cases) reoperated after an average period of 153 +/- 44 months. At reoperation, prosthetic valve replacement of the previously operated valve was systematic and another valvular procedure was also performed in 66 cases. Hospital mortality was 7.8 p. 100. Mortality was high in patients reoperated in functional Class IV of the NYHA classification, after closed heart mitral commissurotomy performed over 10 years before hand. The global mortality rate was 17 p. 100 (average postoperative follow-up of 70 +/- 44 months). The actuarial 5 year survival rate was 85 +/- 6 p. 100 and the 10 year survival was 70 +/- 13 p. 100; NYHA Class IV cardiac failure was a significant poor prognostic factor (p less than 0.05). The prognosis of reoperation after commissurotomy depended mainly on the interval between the relapse of symptoms and reoperation. Group B: comprised 53 patients with valvular prostheses reoperated after an average period of 58 +/- 41 months. The indications of reoperation were prosthetic valve dysfunction (31 cases), perivalvular leak (5 cases), prosthetic valve thrombosis (6 cases), infective endocarditis (7 cases), haemolysis (1 case) and associated valvular disease (10 cases). Reoperation concerned mechanical prostheses in 26 cases and bioprostheses in 24 cases. It consisted in valvular replacement (51 cases) or reinsertion (2 cases). Eight patients underwent second reoperation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Intraoperative assessment of mitral valve and peri-operative results of surgical treatment of mitral valve disease in patients who previously underwent closed surgical and percutaneous transluminal mitral commissurotomy

BACKGROUND. Surgical open or closed mitral commisurotomy and percutaneous transluminal mitral commissurotomy (PTMC) are the well-established therapies in patients with mitral valve stenosis. However, due to various factors the long-term effects may not be optimal in some patients, so they should undergo surgical mitral valve replacement. AIM. The intra-operative assessment of the morphology of mitral valve and the evaluation of the peri-operative results of surgical treatment in patients with mitral valve disease who previously underwent closed surgical commissurotomy followed by PTMC. METHODS. Twenty one patients (20 males, mean age 49 years) who underwent surgery due to mitral valve disease after closed mitral commissurotomy and PTMC, are presented. The time from closed mitral commissurotomy to PTMC was 3-42 years, and the time from PTMC to mitral valve replacement - 9 days to almost 9 years. RESULTS. One patient died on the second day after the operation because of left ventricular failure. The outcome of the remaining patients was good. Advanced changes of the mitral valve and subvalvular apparatus were present in the majority of patients. CONCLUSIONS. The results of the implantation of mitral valve prosthesis in patients who previously underwent closed surgical mitral commissurotomy and PTMC are good. In some patients with a history of closed surgical mitral commissurotomy, PTMC delays surgical replacement of the mitral valve. Advanced changes in the mitral valve leaflets and subvalvular apparatus are the causes of PTMC failure.     

Intraoperative contrast echocardiography to evaluate mitral valve operations

Intraoperative two-dimensional contrast echocardiography was performed on 29 patients undergoing open heart surgery to determine the presence of mitral regurgitation before and immediately after the operative procedure: 14 patients had predominant mitral stenosis, 9 had severe mitral regurgitation and 6 had no mitral valve disease (control subjects). Two-dimensional echocardiography was performed by applying a 5 MHz transducer directly on the heart during injection of saline solution through an apical ventricular sump or transseptal needle, generating contrast microbubbles, with imaging in two planes. Baseline studies were performed after thoracotomy and pericardiotomy before cardiopulmonary bypass, and a second study was done after the operative procedure, with the patient off cardiopulmonary bypass with hemodynamic stabilization before chest closure. No control subject had contrast evidence of mitral regurgitation before or after cardiopulmonary bypass. Two of three patients with mitral valvuloplasty and two of five with commissurotomy required a second operative procedure before chest closure because of persistent mitral regurgitation detected by intraoperative two-dimensional contrast echocardiography. Thirteen of the 15 patients with valve replacement had no mitral regurgitation after cardiopulmonary bypass. Intraoperative two-dimensional echocardiographic findings correlated with data from postoperative clinical examinations and two-dimensional echocardiography-Doppler studies. It is concluded that two-dimensional echocardiography with contrast is an important intraoperative tool for assessing the presence and relative severity of mitral regurgitation after mitral commissurotomy, valvuloplasty or valve replacement. This technique may allow surgeons to be more aggressive in combining reparative operative procedures (that is, commissurotomy and valvuloplasty) in an attempt to retain native valves.     

心脏瓣膜病并巨大左房室心脏瓣膜替换的经验

目的:探讨心脏瓣膜病并巨大左房室心脏瓣膜替换的外科手术指征、方法及围手术期处理。方法:1980年1月至2004年1月,对心脏瓣膜病并巨大左房室施行瓣膜置换156例,其中男性52例,女性104例,年龄14~69岁;术前心功能Ⅲ级52例,Ⅳ级104例。心胸比率0·70~0·94。超声心动图检查示左心室舒张末径60~94mm,左心房径62~118mm。射血分数(EF)0·26~0·65。二尖瓣置换98例,主动脉瓣置换10例,二尖瓣+主动脉瓣置换48例。同时施行三尖瓣成形42例,左心房血栓清除20例,左心房成形20例。结果:早期死亡12例(7·7%),低心排出量综合征、心室颤动、呼吸衰竭及多脏器功能衰竭为最常见原因。结论:注重手术前准备,适当选择手术时机,加强术中心肌保护及术后并发症的防治,可进一步提高外科疗效。     

Long-term results of open radical mitral commissurotomy: ten year follow-up study of 202 patients

Two hundred two patients undergoing open radical mitral commissurotomy for mitral stenosis between 1967 and 1978 were evaluated. Follow-up data were obtained in 98 percent of patients (follow-up range 1 to 122 months, mean 42). One hundred forty-four patients (71 percent) underwent only commissurotomy; 58 patients required associated cardiac procedures. One hundred twenty-eight patients (63 percent) had a history of rheumatic fever and 15 (7 percent) had undergone prior closed mitral commissurotomy. Preoperative emboli were recorded in 25 percent.Cardiopulmonary bypass and left atriotomy were utilized to perform a radical valvulotomy, not only eliminating the mitral valve gradient, but also opening the valve as much as possible without producing insufficiency. The left atrial appendage was routinely checked for thrombus and usually closed with sutures. Induced aortic regurgitation by retrograde insertion of a perforated catheter was utilized to detect mitral insufficiency after commissurotomy. Mitral anulopiasty was performed when necessary.The operative mortality rate was 1.7 percent and the long-term mortality rate 2.5 percent. Preoperatively, 155 patients (77 percent) were in New York Heart Association functional class III or IV. At follow-up examination, 90 percent (178) were in functional class I or II. Postoperative emboli were rare (3 percent), but occurred more often after preoperative embolism or failure to obliterate the left atrial appendage. Multifactorial analysis showed that the presence of a residual mitral gradient or regurgitation indicated a poor prognosis. The 5 year complication-free survival rate in this group was significantly less than that in patients without residual valve dysfunction (75 versus 87 percent, p < 0.05).Open radical mitral commissurotomy appears to be a safe method for relieving valve obstruction. It allows removal of thrombus and oversewing of the left atrial appendage, which may reduce the possibility of significant postoperative embolic events. Reduction in turbulent blood flow by creating a widely patent and competent mitral valve diminishes progressive valve fibrosis and generally obviates the need for future valve replacement.     

18例心脏瓣膜病急诊手术

对１８例危重心脏瓣膜病患者进行急诊手术治疗，其中行二尖瓣闭式分离术４例，二尖瓣替换术３例，再次二尖瓣替换术６例，主动脉瓣替换术３例，主动脉瓣加二尖瓣替换术２例。术后早期死亡４例（占２２．２％），其余均痊愈出院。本文对手术时机、手术要点及术后处理的特殊性做了讨论。     

Early risks of open heart surgery for mitral valve disease.

During 1972 and 1973, a total of 235 patients had open heart surgery for mitral valve disease unassociated with significant aortic or rheumatic tricuspid valve disease. Thirty-one underwent closed heart mitral commissurotomy, without mortality. Of the 204 patients undergoing open operation, 125 had sequential measurement of cardiac output and mixed venous oxygen pressure. The hospital mortality rate was 6.4 percent in the larger group of 204 patients and in the 125 with cardiac output measurements. The rate was greater in those with class IV disability (New York Heart Association criteria) preoperatively than in those with class III or II disability. The mean +/- standard deviation of the average cardiac index early postoperatively was 2.05 +/- 0.579 liters-min--1-m--2. Cardiac index was lower in the patients who died early postoperatively than in those who did not. The probability of hospital death was a significant function of cardiac index. The predicted probability of death was 10 percent with an average cardiac index of 1.42 liters-min--1-m--2 and increased sharply with lower indexes. Cardiac index was lower early postoperatively than preoperatively, and was lower in patients in class IV than in those in class III. There was no significant difference in cardiac index between patients with mitral valve replacement and those in repair. A history of closed commissurotomy, age, duration of cardiopulmonary bypass, duration of cardiac ischemia and method of myocardial preservation did not significantly influence cardiac index or hospital mortality rate. There was no significant relation between mixed venous oxygen pressure and hospital death. Further improvement in results of mitral valve surgery requires adequate preservation of left ventricular performance before, during and after operation.