高龄患者瓣膜置换术

目的总结高龄患者瓣膜置换术的临床特点,手术治疗方法及手术后效果及随访结果。方法回顾分析2006年10月—2009年11月我科外科手术治疗的18例70岁以上瓣膜置换手术患者临床资料,手术方法 ,术后结果及随访情况。结果术后有1例患者因严重肺感染死亡,17例患者均治愈出院,死亡率5.5%。术后随访3个月—2年患者生活质量明显改善,术后效果良好。结论高龄瓣膜置换术手术治疗安全、有效、远期效果良好。     

Prognostic Significance of LGE by CMR in Aortic Stenosis Patients Undergoing Valve Replacement

Background

Prior studies have shown that late gadolinium enhancement (LGE) by cardiac magnetic resonance (CMR) can detect focal fibrosis in aortic stenosis (AS), suggesting that it might predict higher mortality risk.

Objectives

This study was conducted to evaluate whether LGE-CMR can predict post-operative survival in patients with severe AS undergoing aortic valve replacement (AVR).

Methods

We prospectively evaluated survival (all-cause and cardiovascular disease related) according to LGE-CMR status in 154 consecutive AS patients (96 men; mean age: 74 ± 6 years) without a history of myocardial infarction undergoing surgical AVR and in 40 AS patients undergoing transcatheter aortic valve replacement (TAVR).

Results

LGE was present in 29% of patients undergoing surgical AVR and in 50% undergoing TAVR. During a median follow-up of 2.9 years, 21 patients undergoing surgical AVR and 20 undergoing TAVR died. In surgical AVR, the presence of LGE predicted higher post-operative mortality (odds ratio: 10.9; 95% confidence interval [CI]: 1.2 to 100.0; p = 0.02) and worse all-cause survival (73% vs. 88%; p = 0.02 by log-rank test) and cardiovascular disease related survival (85% vs. 95%; p = 0.03 by log-rank test) on 5-year Kaplan-Meier estimates of survival after surgical AVR. Multivariate Cox analysis identified the presence of LGE (hazard ratio: 2.8; 95% CI: 1.3 to 6.9; p = 0.025) and New York Heart Association functional class III/IV (hazard ratio: 3.2; 95% CI: 1.1 to 8.1; p < 0.01) as the sole independent predictors of all-cause mortality after surgical AVR. The presence of LGE also predicted higher all-cause mortality (p = 0.05) and cardiovascular disease related mortality (p = 0.03) in the subgroup of patients without angiographic coronary artery disease (n = 110) and higher cardiovascular disease related mortality in 25 patients undergoing transfemoral TAVR.

Conclusions

The presence of LGE indicating focal fibrosis or unrecognized infarct by CMR is an independent predictor of mortality in patients with AS undergoing AVR and could provide additional information in the pre-operative evaluation of risk in these patients.     

心脏瓣膜病变手术患者的营养评价

目的 :探讨心脏瓣膜病变手术患者的营养情况 ,提高此类患者的手术治疗效果。　　方法 :对心脏瓣膜病变组包括单瓣膜病变和联合瓣膜病变患者 186例 ,均行瓣膜置换术。观察手术前 ,手术后 1、6、12个月体重 ,血浆营养参数 ,总淋巴细胞计数 ,预后营养指数 (PNI) ,以及手术并发症的发生率。同时对正常组 99名进行上述营养参数观察。　　结果 :心脏瓣膜病变组体重、血浆营养参数、总淋巴细胞计数、PNI均较正常组有明显降低 (P<0 .0 1) ,手术后较手术前增高 ,除术后 1个月无明显改善 (P>0 .0 5 )外 ,其余均有明显差异 (P<0 .0 1) ;PNI高的患者手术并发症多 ,术后恢复慢 ,住院时间长。　　结论 :心脏瓣膜病变患者存在着不同程度的营养不良 ,心功能不全是导致营养不良的主要因素 ,营养是手术患者顺利恢复的保证。这一结论提示我们要充分重视心脏瓣膜病变患者的营养 ,预防手术后并发症     

Predictors and Prognostic Impact of Nutritional Changes After Transcatheter Aortic Valve Replacement

BackgroundLittle is known about changes in nutritional status as an index of frailty on clinical outcomes after transcatheter aortic valve replacement (TAVR). This study aimed to assess the clinical impact of serum albumin changes after TAVR.MethodsChanges in serum albumin levels from baseline to 1 year after TAVR were evaluated in 1524 patients who were classified as having hypoalbuminemia (<3.5 g/dl) and normoalbuminemia (≥3.5 g/dl) at each timepoint. The patients were categorized into 4 groups: NN (baseline normoalbuminemia, 1-year normoalbuminemia: n = 1119), HN (baseline hypoalbuminemia, 1-year normoalbuminemia: n = 202), NH (baseline normoalbuminemia, 1-year hypoalbuminemia: n = 121), and HH (baseline hypoalbuminemia, 1-year hypoalbuminemia: n = 82). We also defined late hypoalbuminemia as hypoalbuminemia identified at the 1-year assessment. Clinical outcomes were compared among 4 groups. Multivariable analysis was driven to assess the variables associated with late hypoalbuminemia and long-term mortality.ResultsThe cumulative 3-year mortality was significantly different among the 4 groups (NN: 11.4%, HN: 10.7%, NH: 25.4%, HH: 44.4%, p < 0.001). Multivariable Cox regression analysis revealed that the NH group had a higher mortality risk (hazard ratio [HR]; 2.80 and 3.53, 95% confidence interval [CI]; 1.71–4.57 and 2.06–6.06, p < 0.001 and p < 0.001, respectively), whereas the HN group had a similar risk (HR; 1.16, 95% CI; 0.66–2.06, p = 0.61) compared with the NN group. Baseline hypoalbuminemia, low body mass index, liver disease, peripheral artery disease, and hospital readmission within 1 year were predictors of late hypoalbuminemia (all p < 0.05).ConclusionSerial albumin assessment may identify poor prognostic subsets in patients with persistent and late acquired malnutrition after TAVR.     

Transcatheter Aortic Valve Replacement in Patients With Multivalvular Heart Disease

As transcatheter aortic valve replacement becomes a more dominant treatment option across all risk profiles, the frequency of encountering patients with multivalvular disease will increase. Furthermore, percutaneous interventions to treat other valvular lesions are also evolving. Understanding the clinical implications and treatment options for a second valvular lesion is becoming increasingly important to guide heart team decisions, and this paper aims to review the evidence around these situations. Diagnosis of multivalvular disease can be challenging because of changes in physiology. There are little randomized data to guide therapy in multivalvular disease. Multidisciplinary heart team decisions can be invaluable in integrating the plethora of clinical, hemodynamic, and imaging data on which an optimal management strategy can be planned. Prospective studies to assess the role of structural valve interventions in the transcatheter aortic valve replacement era would greatly help improve outcomes for structural heart patients.     

Mitral Valve Replacement in Patients After Aortic Valve Replacement

Abstract Background: Mitral valve replacement in patients who previously had undergone aortic valve replacement is a technical challenge. The rigid aortic prosthesis limits visualization of the anterior mitral annulus and placement of sutures. Methods: Reoperative mitral valve replacement was performed in five patients after aortic valve replacement. Two patients underwent resternotomy to allow verification of normal aortic prosthetic valve function. Anterolateral right thoracotomy was used for reentry in the remaining three patients. Exposure of the anterior mitral annulus was accomplished by initial traction on the intact anterior leaflet, with resection of this leaflet only after placement of sutures. Results: All patients survived the surgical procedure and are well 2 to 30 months after operation. In one patient it was impossible to open one cusp of the mitral prosthesis, nor was it possible to rotate the valve. The valve was reimplanted, but sutures were tied only after testing for full free cusp motion. Conclusions: When appropriate, right thoracotomy incision offers excellent exposure of the mitral valve with minimal dissection. Placement of sutures along the anterior portion of the annulus is facilitated by traction downwards on the anterior leaflet. Full range of motion of the prosthetic cusps should be verified before tying the sutures.     

经导管主动脉瓣膜置换术在重症主动脉瓣膜病中的临床应用

目的 评估经导管主动脉瓣置换术治疗重症主动脉瓣膜疾病患者的临床应用效果.方法 回顾性分析2018年7月至2020年6月期间广州市第一人民医院心脏大血管外科进行经导管主动脉瓣置换术(TAVR)的14例患者,其中男性7例、女性7例,平均手术年龄(69.5±7.5)岁,美国胸外科医师协会STS平均评分(14.1±6.2)％,...     

The Relationship Between Heart-Failure Hospitalization and Mortality in Patients Receiving Transcatheter Aortic Valve Replacement

Background

Patients who have had transcatheter aortic valve replacement (TAVR) are at risk of hospitalization during the first year postprocedure. Few studies have examined the incidence of heart- failure hospitalizations (HFH) post-TAVR and the impact this has on subsequent hospitalizations and mortality. Our aim was to determine the incidence, predictors, and mortality associated with HFH post-TAVR.

The Importance of Assessing Nutritional Status in Elderly Patients with Heart Failure

Heart failure (HF) is a syndrome characterized by high morbidity and mortality, despite advances in medical and device therapy that have significantly improved survival. The outcome of HF in elderly patients results from a combination of biological, functional, psychological, and environmental factors, one of which is nutritional status. Malnutrition, as well as HF, is frequently present with aging. Early detection might lead to earlier intervention. It is our goal to review the importance of nutritional status in elderly patients with HF, as well as tools for assessing it. We also propose a simple decision algorithm for the nutritional assessment of elderly patients with HF.     

射频消融迷宫术加瓣膜置换术治疗并发房颤的风湿性心脏瓣膜病

介绍心内直视下以射频消融代替切割冷冻施行迷宫术加瓣膜置换术治疗并发房颤的风湿性心脏瓣膜病经验。８例在体外循环心内直视下按照迷宫线路施行射频消融,同时完成瓣膜置换。６例术后即转为窦性心律;２例术后结性及窦性心律交替出现,出院时转为窦性心律。以射频消融代替切割冷冻施行迷宫术治疗房颤安全简便有效     

心脏瓣膜置换术患者围术期乌司他丁对基质金属蛋白酶9的影响

目的观察乌司他丁对心脏瓣膜置换术患者围术期基质金属蛋白酶9的影响,以了解乌司他丁对体外循环所致的肺损伤是否具有保护作用。方法40例择期心脏瓣膜置换术患者,随机分为2组(每组20例)。乌司他丁组按12ku/kg体重计算乌司他丁用量,分别在麻醉诱导和心肺转流开始时按6ku/kg静注乌司他丁共两次,对照组用等量生理盐水替代,用法同乌司他丁组。分别于麻醉诱导前,心脏直视手术体外循环10min,30min,心脏直视手术体外循环后1h,3h,6h抽取桡动脉血,用ELISA法测定血浆基质金属蛋白酶9的浓度。同时测定诱导前,心脏直视手术体外循环后1h,3h,6h等时间点的肺死腔率和血浆肺泡动脉血氧分压差。结果两组患者年龄、体重、性别比、体表面积、血红蛋白、红细胞压积、术前心肺功能,病种,总转流时间、主动脉阻断时间,手术类别和手术时间的变化均无统计学意义。心脏直视手术体外循环10min至循环后6h两组基质金属蛋白酶9均较麻醉诱导前明显升高(P<0.05),均在心脏直视手术体外循环达高峰。循环后1h至6h至两组肺死腔率,肺泡动脉血氧分压差均较诱导前明显升高(P<0.05),肺死腔率在体外循环后1h达高峰,肺泡动脉血氧分压差在体外循环后3h达高峰。乌司他丁组体外循环30min至体外循环后6h时基质金属蛋白酶9和循环后1h至6h肺死腔率,肺泡动脉血氧分压差均明显低于对照组(P<0.05)。结论乌司他丁能明显减轻心脏瓣膜置换术患者围术期基质金属蛋白酶9的过度释放,减轻术后早期肺死腔率和肺泡动脉血氧分压差,对改善肺氧合保护肺功能有一定的作用。     

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。     

脂蛋白磷脂酶A2与慢性心力衰竭患者预后的关系

【】目的 评估脂蛋白磷脂酶A2(Lipoprotein-associated phospholipase A2,Lp-PLA2)与慢性心衰死亡率之间的关系。方法 选取慢性心衰患者150例,正常对照组150例,检测Lp-PLA2浓度,比较心衰组与对照组血浆Lp-PLA2的水平差异。再将心衰组根据Lp-PLA2水平分为高水平组和低水平组,比较2组间基本资料的差异,最后,评估Lp-PLA2与心衰患者死亡率的关系。结果 心衰组Lp-PLA2水平明显高于对照组,高Lp-PLA2组患者有更高的死亡风险,COX回归分析显示Log Lp-PLA2每增加1个单位,心衰患者的死亡风险增加3.688倍。结论 血浆Lp-PLA2水平与心衰患者死亡率之间密切相关,为预测心衰患者死亡的独立危险因子。     

INR Self-Management Following Mechanical Heart Valve Replacement

INR self-management can reduce severe thromboembolic and hemorrhagic complications following mechanical heart valve replacement. Beginning anticoagulation therapy immediately in the postoperative period further reduces anticoagulant-induced complications. Data were collected from the first 600 surviving patients (from a total study sample of 1200 patients) who completed follow-up of at least 2 years. Patients were randomly divided into a self-management group and a control group. INR self-management reduced severe hemorrhagic and thromboembolic complications (P=0.018). Nearly 80% of INR values recorded by patients themselves, regardless of educational level, were within the target therapeutic range of INR 2.5–4.5, compared with 62% of INR values monitored by family practitioners. Only 8.3% of patients trained in self-management immediately after surgery were unable to continue with INR self-management. The results differed slightly between patient groups with different levels of education. We conclude that all patients for whom anticoagulation is indicated are candidates for INR self-management regardless of education level.     

低白蛋白对老年慢性心力衰竭患者长期预后的影响

目的通过倾向性评分分层分析法探讨低白蛋白对老年慢性心力衰竭患者长期预后的影响。方法连续入选1271例老年慢性心力衰竭患者,按血清白蛋白水平分为两组:白蛋白正常组(血清白蛋白≥35 g/L)、低白蛋白组(血清白蛋白35 g/L)。以全因死亡为主要终点,采用倾向性评分分层分析法,通过多因素COX回归分别评价分层前后低白蛋白对长期预后的影响。结果分层之前,与白蛋白正常组相比,低白蛋白组年龄更大,心功能纽约分级、直接胆红素、碱性磷酸酶、肌酐、脑钠肽更高,高血压更少,血红蛋白、间接胆红素、胆固醇、血钠、入院射血分数更低,入院心率更快。所有患者平均随访23.9个月,随访期间,整体死亡165人,病死率为13.0%;低白蛋白组死亡76人,病死率为46.1%;白蛋白正常组死亡260人,病死率为23.5%。单因素COX回归分析显示,低白蛋白是老年慢性心衰患者长期死亡风险增加的强独立预测因子(HR为2.540,95%CI为1.966~3.282,P0.001);即使校正了倾向性评分值后,低白蛋白患者的长期死亡风险仍比白蛋白正常者显著增加了56.1%(HR为1.561,95%CI为1.186~2.054,P=0.001)。采用倾向性评分分层分析法后,合并的HR为1.724,95%CI为1.311~2.268,提示低白蛋白患者的长期死亡风险要比白蛋白正常者高0.724倍。结论对于老年慢性心力衰竭患者,低白蛋白预示着死亡风险的增加,纠正低白蛋白有可能改善心衰患者的预后。