主动脉瓣置换术后SAM现象机制及相关因素的探讨

目的探讨主动脉瓣置换术后SAM现象的发生机制并对其相关因素进行分析,旨在进一步认识此现象.方法 48例严重主动脉瓣狭窄病人,男26例,女22例;年龄20～58岁.行主动脉瓣置换术后1周内复查超声心动图,以是否出现SAM现象分成两组,对左室舒张末期内径、收缩末期内径、左室流出道内径、室间隔和左室后壁厚度、左室流出道射流速度及压力阶差进行对比.结果无手术死亡.9例左室流出道流速显著增加(大于2.5 m/s),其中6例出现了SAM现象.除左室后壁对比差异无显著性外,其余指标对比差异均具显著性(P＜0.05或0.01).结论主动脉瓣置换术后出现SAM现象与左室流出道流速和压力阶差增大有直接关系,而小左室舒张末期内径、收缩末期内径、流出道内径及增厚的室间隔是SAM现象的主要病理解剖基础.     

心脏二尖瓣置换术后左心室破裂四例

1981年5月～1999年5月我院共行心脏二尖瓣置换术和同期主动脉瓣置换术703例,发生左心室破裂4例,占0.57%,现报告如下。1　临床资料与方法本组共4例,男2例,女2例。年龄28～48岁。术前均诊断为风湿性心脏病,二尖瓣狭窄伴关闭不全;有轻度三尖瓣关闭不全2例,轻度主动脉瓣关闭不全1例     

右心房房间隔和左心房顶联合切口置换二尖瓣技术

1997年 10月至 1999年 12月 ,我们采用经右心房房间隔和左心房顶联合切口 ,对 2 3例再次二尖瓣手术或左、右心房均较小的病人进行二尖瓣置换术 ,效果满意 ,现报道如下。临床资料　 2 3例中男 12例 ,女 11例 ;年龄 2 6～ 6 5岁。原发疾病为风湿性心脏瓣膜病 2 1例、退行性瓣膜病变和冠心病所致二尖瓣关闭不全各 1例。本次手术包括二尖瓣闭式扩张术后 9例、二尖瓣置换术后 4例、二尖瓣和主动脉瓣双瓣置换术后和心室间隔缺损修补术后二尖瓣狭窄各 1例 ;单纯二尖瓣狭窄 6例、二尖瓣狭窄并主动脉瓣狭窄和冠心病合并二尖瓣腱索断裂各 1例。心功能…     

心内直视术后并发晚期心脏压塞病人的护理

体外循环心内直视术后并发心脏压塞是一种严重并发症，多见于术后（24-48h）出血造成急性心脏压塞，但也有少数病例发生在术后1周至数周之内，为晚期心脏压塞[1]，临床上较易忽视。我院1993年11月至1997年6月施行体外循环心内直视手术504例，术后并发晚期心脏压塞10例，护理如下。116床资料10例中男6例，女4例。年龄9-54岁。先天性心脏病（法洛氏四联症）行法洛氏四联症纠正术3例，风湿性心脏病二尖瓣狭窄行二尖瓣置换术4例，二尖瓣狭窄伴主动脉瓣关闭不全行二尖瓣与主动脉瓣同时置换术3例。10例术前心功能均为m-IV级，体外循环总转流时间7…     

4例真菌性心内膜炎

1996年 1月以来 ,我们治疗真菌性心内膜炎 4例 ,现总结诊疗体会如下。临床资料　 4例中男 3例 ,女 1例。年龄分别为 5、6 0、47和 5 1岁。术前诊断分别为室间隔缺损修补术后合并感染性心内膜炎、主动脉瓣置换术后合并感染性心内膜炎、二尖瓣狭窄合并感染性心内膜炎及二尖瓣狭窄伴左房血栓。 3例男病人均有高热、白细胞增高 ,术前彩色多普勒超声提示有赘生物生长 ,其中 2例血培养有真菌生长。 1例女病人无中毒症状 ,术前彩色多普勒超声提示有左房血栓。分别行更换补片再次室间隔缺损修补术、再次主动脉瓣置换术、二尖瓣置换术及二尖瓣置换加…     

心瓣膜置换术后电机械分离五例

电机械分离是指心脏有电活动而无有效的收缩。心瓣膜置换术后电机械分离少见。1994年至2003年,我们收治心瓣膜置换术后电机械分离患者5例,现报告如下。1临床资料与方法本组共5例,男3例,女2例;年龄59.0±7.4岁;体重58.0±9.2kg。二尖瓣狭窄伴关闭不全3例,主动脉瓣关闭不全1例,主动脉瓣关闭不全伴二尖瓣狭窄关闭不全1例。术前心胸比率0.58±0.03。分别行二尖瓣置换术、主动脉瓣置换术或主动脉瓣、二尖瓣置换术。体外循环时间68.5±19.5min,升主动脉阻断时间32.4±33.7min。5例电机械分离患者均发生在术后住ICU期间,其临床特点为早期心电监测…     

心脏瓣膜病合并动脉导管未闭手术的体外循环特点

心脏瓣膜病合并动脉导管未闭 (ＰＤＡ)较少见。 1992年至 2 0 0 0年 ,我们在临床工作中遇到 7例 ,其中 2例术前诊断明确 ,5例术前漏诊动脉导管未闭 ,均在体外循环中因心内回血多等被发现。大量的心内回血严重地影响了外科手术操作及体外循环管理 ,术后还易出现肺部及脑部并发症。现就其一些特殊征象的处理总结如下。临床资料　本组 7例中男 3例 ,女 4例 ;年龄 17～ 5 6岁 ;体重 40～ 6 0ｋｇ。术前 2例诊断为先天性和风湿性联合瓣膜病 ,拟行二尖瓣及主动脉瓣置换术 ;2例诊断为风湿性心脏病二尖瓣狭窄及关闭不全、主动脉瓣狭窄及关闭不全及先…     

三尖瓣置换术及近远期疗效

1994年 1月～ 2 0 0 1年 4月 ,我们对 19例风湿性心瓣膜病患者施行了三尖瓣置换术 (TVR) ,占同期心瓣膜置换术的3.4 1% ,并就 TVR的近远期疗效进行了观察。1　临床资料与方法本组共 19例 ,男 4例 ,女 15例 ;平均年龄 4 2 .3± 10 .2岁。风湿性二尖瓣狭窄 10例 ,风湿性二尖瓣、主动脉瓣双瓣膜病变 9例。术前均有肝肿大 ,12例出现心源性恶病质。胸部 X线片示 :心胸比率 0 .6 9± 0 .12 ;超声心动图示 :三尖瓣重度反流 ,合并二尖瓣和 /或主动脉瓣病变 ;心电图示 :心房颤动 18例。术前心功能 级 5例 , 级 14例。行 TVR+二尖瓣置换术 (MVR…     

二尖瓣置换术后左心室后壁破裂3例

198 9年 1月至 1999年 12月 ,我们共为 840例病人施行了二尖瓣置换术。术中、术后共发生左心室后壁破裂 3例 ,现道告如下。资料与方法　例 1　女 ,42例。风湿性心脏病 ,重度主动脉瓣狭窄并关闭不全 ,中度二尖瓣狭窄并关闭不全 ,重度三尖瓣关闭不全 ,心功能ＩＶ级。 1989年 8月行二尖瓣及主动脉瓣置换术。术中见主动脉瓣严重纤维化、钙化 ,二尖瓣纤维化 ,瓣下结构挛缩。二尖瓣置换 2 7号、主动脉瓣置换 2 1号单叶机械瓣。心脏复跳后发现左心室后壁近左房室瓣环处有 1ｃｍ裂口 ,可见人工瓣环 ,遂立即建立体外循环 ,取 1 5ｃｍ× 1 0ｃｍ涤纶片…     

小年龄患儿的二尖瓣置换手术

目的 总结5岁以下二尖瓣病变患儿行二尖瓣置换手术的治疗经验.方法 2008年1月至2011年12月,共12例5岁以下的二尖瓣病变患儿进行二尖瓣置换手术.其中男9例,女3例;年龄4～58个月,平均(26.2±18.1)个月;体质量5.6 ～13.0 kg,平均(9.6±3.8) kg.患儿有中度以上二尖瓣反流或(和)明显的二尖瓣狭窄,均伴有明显的心功能衰竭.3例为二尖瓣成形术后再行二尖瓣置换术.均置入机械瓣膜,9例采用17 ～ 23号主动脉瓣反向置入,3例采用25～27号二尖瓣正向置入.结果 手术死亡1例(8.3％).术后心律失常2例,轻度溶血2例,经治疗均恢复正常.11例生存患儿心功能改善明显,未出现出血和血栓形成等异常情况.结论 严重二尖瓣病变对小年龄儿童的心功能影响极大,尽早手术干预是惟一的选择,二尖瓣置换术是二尖瓣成形手术效果不佳患儿的最后选择.采用型号相对较小的主动脉瓣倒置置入二尖瓣环内,基本解决了机械瓣瓣膜-患者不匹配的问题,但置入小型号机械瓣的患儿再次行二尖瓣置换术的可能较大;小年龄儿童有良好的抗凝依从性,但需加强监测抗凝指标,以防发生出血和栓塞.     

主动脉瓣及二尖瓣直视成形手术

对２３例主动脉瓣及二尖瓣病变者行直视成形手术。引起瓣膜病变的原因：先天性病变５例，风湿性病变１８例。术前心功能，Ⅱ级者４例，Ⅲ级者１４例，Ⅳ级者５例。术后对２０例患者进行随访３～２４个月，心脏功能明显改善。     

二尖瓣置换术后远期功能性三尖瓣关闭不全的外科治疗

目的：报告二尖瓣置换（ＭＶＲ）术后远期三尖瓣关闭不全（ＴＲ）外科治疗的结果及作用,方法：３７例ＭＶＲ术后中重度ＩＲ病人,其中人工二尖瓣为生物瓣者１３,机械瓣２４例,有１１例行内科保守治疗,２６例行外科手术治疗,手术类型,ＭＶＲ加三尖瓣置换２例,ＭＶＲ加三法瓣成形１１例,三尖瓣置换３例,三尖瓣成型１０例,三尖瓣成形术包括改良Ｋay形成形１２例,改良ＤeVega成形术７例,加成形环的三尖瓣成形术２例,结果：１１例内科治疗者,７个月－７．５年后７６例死亡,病死率为５４．５％,26例手术治疗者,术后早期病死２例,病死率为７．７％,随访个月－１０．５年,晚期死亡例,仍中度ＴＲ２例,结论：ＭＶＲ术后远期ＴＲ的产生与不可逆的左心损害或（和）严重肺动脉高压有关,对重度ＴＲ伴有临床症状、左心功能基本正常者,行三尖瓣成形或三尖瓣置换术可取得良好的效果。     

Long-term experience with the Sorin Bicarbon and Edwards Mira mechanical valve prostheses in the mitral position

OBJECTIVE: Sorin Bicarbon (SB) and Edwards Mira (EM) valves have an identical mechanical design but different sewing cuffs. The purpose of this retrospective study was to analyze the long-term clinical and echocardiographic outcomes after mitral valve replacement with these two valves in a combined population of patients. METHODS: We retrospectively reviewed records of 73 patients who underwent mitral valve replacement using SB (n = 19) or EM (n = 54) valves. Preoperatively, 49 patients (68.1%) were in New York Heart Association (NYHA) functional class III or IV. Concomitant procedures were performed in 52 patients (71.2%). Early and late postoperative echocardiography was performed in 69 and 57 patients, respectively. RESULTS: Operative mortality was 4.1%, and early morbidity was 9.6%. Overall patient survival at 9 years was 85.1% +/- 4.8%. Actuarial freedom from valve-related death was 95.4% +/- 2.6% at 9 years. As shown by Doppler echocardiography, the early and late mean transprosthetic pressure gradients were 3.4 +/- 1.4 mmHg and 3.8 +/- 2.1 mmHg, respectively. At the end of follow-up, 98.4% of survivors were in NYHA class I or II. CONCLUSION: The Sorin Bicarbon and, Edwards Mira mechanical valves in the mitral position provide satisfactory long-term clinical and echocardiographic performance.     

有支架与无支架生物瓣膜行主动脉瓣置换临床对比研究

目的　探讨无支架Medtronic生物瓣行主动脉瓣置换的临床效果。方法　将 6 8例同期施行主动脉瓣置换术病人分为 2组 ,38例行无支架Medtronic生物瓣置换 ,30例对照组行有支架生物瓣置换。术前及术后 2个月随访行超声心动图检查。结果　无支架组和有支架组病人术后各项检测指标差异有显著性意义。无支架组跨瓣压差 (18 0± 3 7)mmHg(1mmHg =0 133kPa)明显低于有支架组(33 7± 8 3)mmHg;左室射血分数 0 6 5± 0 0 5 ,明显高于有支架组 0 5 6± 0 0 8;左室收缩末内径和左室舒张末内径分别为 (3 8± 0 8)cm和 (4 5± 0 4 )cm ,明显低于有支架组 (4 2± 1 4 )cm和 (5 1± 0 9)cm ;无支架组瓣环内径 (2 2 1± 1 8)mm大于有支架组 (19 5± 1 7)mm。结论　无支架Medtronic生物瓣较有支架生物瓣具有较低的跨瓣压差和良好的血流动力学 ,能促进左室功能的恢复。     

Comparative Rest and Exercise Hemodynamics of Allograft and Prosthetic Valves in the Aortic Position

Background. Allograft aortic valve replacement has gained widespread acceptance. However, there is little information about in vivo allograft valve function at rest and during exercise.

Methods. Cardiac catheterization was performed to measure hemodynamic variables at rest and during supine bicycle exercise in 44 patients who had had aortic valve replacement using allograft valves or Bicer or St. Jude Medical prosthetic valves 19 to 27 mm in diameter. Sixteen patients received an allograft valve; 17, a Bicer valve; and 11, a St. Jude Medical valve. There were no significant differences between the three groups in age, body surface area, left ventricular end-systolic and end-diastolic volume indices, exercise cardiac index, exercise heart rate, or work load achieved. Left ventricular and ascending aortic pressures were measured simultaneously according to the transseptal method.

Results. The mean pressure gradient was generally higher for the Bicer and St. Jude Medical valves than for the allograft valves, both at rest and during exercise. Significant differences were obtained in patients with small-sized valves (21 and 23 mm); pressure gradients were higher in the prosthetic valve groups. In patients with large-sized prosthetic valves (25 mm), there were no significant differences between the three groups at rest and during exercise. However, there was no pressure gradient at all for allograft valves.

Conclusions. Exercise cardiac catheterization confirms that the allograft aortic valve is an ideal substitute from the hemodynamic aspect, particularly in patients with a small aortic root and in those who perform strenuous exercise.     

Selection of Prosthetic Valve and Evidence—Need for the Development of Japan’s Own Guidelines

Purpose: In 2014, the American Heart Association (AHA)/American College of Cardiology (ACC) guidelines were largely revised with regard to the selection of prosthetic valves. (1) A mechanical prosthesis is reasonable for aortic valve replacement (AVR) or mitral valve replacement (MVR) in patients less than 60 years of age, (2) A bioprosthesis is reasonable in patients more than 70 years of age, and (3) Either a bioprosthetic or mechanical valve is reasonable in patients between 60 and 70 years of age.Japan faces the unprecedented population aging, and moreover, the average life expectancy is longer among the Japanese than the Westerners. In Japan, whether this choice is appropriate seems questionable.Methods: This time, with the revision of the AHA/ACC guidelines, it might be necessary to take into consideration the average life expectancy of Japanese people and revise the Japanese guidelines accordingly.Results: We should consider whether 60–70 years should be set as a gray zone regarding the age criteria for choosing biological valves, or if the age should be set higher relative to that specified in the western guidelines, given the longer Japanese life expectancy.Conclusion: We believe that the development of unique, Japanese guidelines for the selection of prosthetic valves will allow us to provide appropriate selection and treatment for each patient.     

小左室病人行二尖瓣置换术机械瓣膜型号的选择

目的探讨小左室病人行二尖瓣置换术时选择大口径机械瓣膜的可行性。方法将左室舒张末径小于40mm进行单独二尖瓣置换手术者分为小口径M-1二尖瓣25号瓣膜组和大口径M-2二尖瓣25号组。每组病人手术后均测定各瓣膜跨瓣压差、流速和肺动脉压，应用SPSS行统计分析。结果大口径M-2二尖瓣组和小口径M-1二尖瓣25号瓣膜组相比，跨瓣压差小[（5．9±1．6）mmHg对（10．7±3．2）mmHg]，在体瓣口面积大[（2．9±0．2）cm^2对（2．6±0．2）cm^2）]，瓣膜匹配指数大[（1．92±0．23）cm^2／m^2对（1．73±0．18）cm^2／m^2]，差异有统计学意义。结论在注意心肌保护和围术期处理的条件下，左室舒张末径较小者行二尖瓣置换手术时也应置入较大口径的机械二尖瓣瓣膜，以取得良好围术期血流动力学结果和临床效果。     

Mitral Valve Replacement with Dura Mater Bioprostheses

Dura mater bioprostheses for cardiac valve replacement were first introduced in Brazil. They have been used since 1975 at the National Heart Hospital, London, as a mitral valve replacement instead of fascia lata valves or inverted aortic homograft valves. During this period 120 patients have had dura mater valves inserted in the mitral position; 29 also received an aortic valve replacement, 6 with dura mater, 20 with an aortic homograft, 2 with an aortic xeno-graft and 1 with a prosthetic valve. Perivalvular leaks occurred with seven of these mitral valves, and another seven presented with detached cusps. All but one of these 14 valves were replaced. Emboli have occurred in four of the patients, one of whom died after 35 months with thrombus on the aortic valve, but with an unaffected mitral valve. There were 15 early deaths, a hospital mortality of 12.5%. and 10 late deaths, a postoperative mortality of 9.5%. Actuarial analysis has shown a four-year postoperative survival of 78.970.     

无支架二尖瓣制备、保存和体外三尖瓣置换技术探讨

目的观察深低温保存猪二尖瓣超微结构,探索无支架二尖瓣制作方法和置换三尖瓣技术。方法采用猪二尖瓣制成无支架瓣膜,抗生素灭菌深低温保存,透射电子显微镜观察深低温保存１个月的猪二尖瓣组织结构。将离体猪心三尖瓣切除,将无支架猪二尖瓣前瓣环缝合于隔瓣环,二尖瓣后瓣环缝合于三尖瓣前后瓣环,两乳头肌缝合于右心室前壁,完成无支架二尖瓣置换三尖瓣,注水试验观察瓣膜启闭功能。结果透射电子显微镜观察到,深低温保存猪二尖瓣内皮细胞结构完整,胶原纤维结构致密,排列整齐,成纤维细胞胞膜完整,细胞核无固缩现象,线粒体无明显肿胀。无支架二尖瓣置换的离体猪心三尖瓣启闭功能良好。结论深低温保存的无支架猪二尖瓣结构完整,活性得到很好保持。瓣膜设计合理,用此瓣膜置换三尖瓣技术可行     

THIRTY YEARS EXPERIENCE WITH HEART VALVE SURGERY: ISOLATED MITRAL VALVE REPLACEMENT

Background : Thirty years have elapsed since the commencement of open-heart surgery in South Australia. A retrospective study was performed to evaluate mortality and complication rates and to identify factors associated with poor outcomes in all patients who underwent prosthetic mitral valve replacement during this period. Methods : Questionnaires and personal contact have been used to generate a combined database of pre-operative and postoperative information and long-term follow-up on 938 patients who underwent isolated prosthetic mitral valve replacement at the Cardio-Thoracic Surgical Unit of the Royal Adelaide Hospital between 1963 and 1993. Results : Complete survival follow-up data were obtained for 92% (865) of the patients. The Starr-Edwards valve was used in 95% (891) of the patients, a Bjork-Shiley prosthesis in 2.5% (23) of the patients, and only 24 (2.5%) other valves were inserted. The hospital mortality rate for the 30-year period was 4.7%. The mean age of the patients who underwent surgery was greater in each of the three successive decades. A long-term survival advantage was observed for patients with mitral stenosis, however, survival was significantly shorter for patients with higher New York Heart Association (NYHA) functional classifications and for patients in pre-operative atrial fibrillation. Pre-operative dyspnoea was significantly improved following mitral valve replacement. The rates of postoperative haemorrhagic and embolic complications were low by comparison with other published series. Conclusion : Mitral valve recipients do not regain a normalized life expectancy, but risk factors that determine long-term survival can be identified pre-operatively to aid appropriate patient selection.