心脏瓣膜病患者瓣膜替换术的护理

有报道，重症心脏瓣膜病的病死率为9％-14％，而对于各种原因导致的心脏瓣膜病变，瓣膜置换术可解除瓣膜狭窄或反流，改善血流动力学，长期改善心功能，但手术创伤，心肌缺血再灌注自由基的损伤，麻醉药物的影响，均可在短期内加重心功能的损害。对于心脏瓣膜病患者，注意围手术期各环节处理，即重视术前心功能改善，恰当选择手术时机，术中加强心肌的保护，合理纠正病变，术后严密监护，可提高手术成功率。我院2001年12月-2007年1月为608例心脏瓣膜病患者施行瓣膜替换手术，由于重视围手术期各个环节的处理和护理，采取各种综合措施，取得良好效果，现报道如下。     

心脏瓣膜病患者瓣膜替换术的护理

有报道[1,2],重症心脏瓣膜病的病死率为9%～14%,而对于各种原因导致的心脏瓣膜病变,瓣膜置换术可解除瓣膜狭窄或反流,改善血流动力学,长期改善心功能,但手术创伤,心肌缺血再灌注自由基的损伤,麻醉药物的影响,均可在短期内加重心功能的损害.对于心脏瓣膜病患者,注意围手术期各环节处理,即重视术前心功能改善,恰当选择手术时机,术中加强心肌的保护,合理纠正病变,术后严密监护,可提高手术成功率.我院2001年12月-2007年1月为608例心脏瓣膜病患者施行瓣膜替换手术,由于重视围手术期各个环节的处理和护理,采取各种综合措施,取得良好效果,现报道如下.     

心功能Ⅳ级瓣膜置换术患者的围手术期护理

心脏瓣膜病是威胁人类健康的主要心脏病种之一,其发病率及致死率均处于较高的水平;尤其是术前心功能Ⅳ级的心脏瓣膜病患者。术前心功能Ⅳ级心脏瓣膜病患者的手术效果及预后与很多因素有关,其中围手术期的护理工作是至关重要的环节。回顾2010年1月-2011年12月的20例术前心功能均为Ⅳ级的心脏瓣膜置换患者,对其术前心理护理、术后血流动力学监护、呼吸道管理、预防感染、抗凝治疗等多方面进行讨论和总结。现报道如下。     

重症心脏瓣膜病的围手术期处理

目的 总结重症心脏瓣膜病患者围手术期处理临床经验,提高治疗效果,降低死亡率.方法 回顾性分析1998年1月至2007年1月67例重症瓣膜病患者的围手术期处理措施、术中心肌保护方法及手术技术要点.结果 早期死亡8例,死亡率11.9%(8/67);死亡原因:左心室低心排血量综合征致多脏器功能衰竭5例,室性心律失常3例;并发症35例次,其中低心排血量综合征11例次,多脏器功能衰竭6例,心律失常9例,肺部感染3例,二次开胸止血2例,心包填塞2例,脑梗死、脑出血各1例.结论 加强重症心脏瓣膜病围手术期处理,选择恰当的手术时机,缩短手术时间,加强心肌保护,保留二尖瓣下结构,积极处理三尖瓣反流,可减少术后并发症、降低死亡率,提高远期疗效.     

1例重症瓣膜病合并类夙湿关节炎患者行心脏手术的围手术期护理

目的总结重症瓣膜病合并类风湿关节炎患者行心脏手术的围手术期护理经验,提高治疗效果。方法对我科收治的1例重症瓣膜病合并类风湿关节炎患者瓣膜置换的临床资料进行回顾性分析。结果此例患者虽然病情严重,但给予严格有效的围手术期护理和健康教育,使患者顺利度过了围手术期。结论术前改善心功能,严格术后护理以及有效的健康教育是患者顺利度过危险期并取得良好效果的有力措施。     

1例重症瓣膜病合并类风湿关节炎患者行心脏手术的围手术期护理

目的 总结重症瓣膜病合并类风湿关节炎患者行心脏手术的围手术期护理经验,提高治疗效果.方法 对我科收治的1例重症瓣膜病合并类风湿关节炎患者瓣膜置换的临床资料进行回顾性分析.结果 此例患者虽然病情严重,但给予严格有效的围手术期护理和健康教育,使患者顺利度过了围手术期.结论 术前改善心功能,严格术后护理以及有效的健康教育是患者顺利度过危险期并取得良好效果的有力措施.     

心脏瓣膜病心肌细胞线粒体改变与临床因素的相关分析

目的 :对心脏瓣膜病患者心肌细胞线粒体改变与临床因素相关性进行研究 ,探讨哪些临床因素对评估重症心脏瓣膜病心功能有较大意义 ,为临床围手术期评估心功能作参考。方法 :4 0例心脏瓣膜病患者 ,按重症标准分为重症组 (16例 )和对照组 (2 4例 ) ,测定记录各临床因素 ,术中取病变的组织 ,对心肌细胞的线粒体改变作分析。结果 :重症组和对照组两组心肌线粒体改变均为 2级以上 ,对照组线粒体改变为 2～ 4级 ,中位数为 3级。重症组线粒体改变为 3～ 4级 ,中位数为 3 5级。重症组线粒体改变较对照组严重。线粒体改变与术前左心室短轴缩短率、心胸比例、心功能分级的相关系数分别为0 36 7、 0 4 0 1、 0 32 8,均为P <0 0 5 ,相关性良好 ,与其它临床因素无明显相关 (P >0 0 5 )。结论 :心脏瓣膜病患者心肌细胞线粒体结构均存在不同程度的损害 ,与病变的严重程度、术前左心室短轴缩短率、心胸比例、心功能分级关系密切。     

重症心脏瓣膜病心肌保护的临床研究

为探讨不同心肌保护方法对重症心脏瓣膜病患者心脏直视术中的心肌保护效果。将40例重症瓣膜病患者随机分为实验组和对照组。实验组(n=20)采用中浅低温氧合血停搏液先行主动脉根部顺灌或冠状动脉直接灌注停跳心脏+冠状静脉窦持续逆灌+开放前温血灌注心肌保护;对照组(n=20)采用冷血停搏液间断灌注心肌保护。观察两组围手术期心肌酶、心肌超微结构及临床血液动力学变化。结果显示,术后各时点实验组CK、CK-MB、cTnI水平均显著低于对照组,实验组心肌超微结构改变轻微,术后自动复跳率高,正性肌力药物用量少。因此,含血停搏液多种灌注方法结合可为重症心脏瓣膜病患者术中提供更好的心肌保护。     

重症心脏瓣膜病心肌保护的临床研究

为探讨不同心肌保护方法对重症心脏瓣膜病患者心脏直视术中的心肌保护效果。将40例重症瓣膜病患者随机分为实验组和对照组。实验组（n=20）采用中浅低温氧合血停搏液先行主动脉根部顺灌或冠状动脉直接灌注停跳心脏＋冠状静脉窦持续逆灌＋开放前温血灌注心肌保护；对照组（n=20）采用冷血停搏液间断灌注心肌保护。观察两组围手术期心肌酶、心肌超微结构及临床血液动力学变化。结果显示，术后各时点实验组CK、CK—MB、eTnI水平均显著低于对照组，实验组心肌超微结构改变轻微，术后自动复跳率高，正性肌力药物用量少。因此，含血停搏液多种灌注方法结合可为重症心脏瓣膜病患者术中提供更好的心肌保护。     

重症肝炎肝移植围术期应用抑肽酶对血管活性药物和输血输液需求的影响

目的探讨重症肝炎患者肝移植围术期应用抑肽酶对血管活性药物和输血输液需求的影响。方法重症肝炎40例随机分为抑肽酶组:微泵持续输入抑肽酶(4×106)U/h;对照组:输等容量生理盐水。观察两组患者肝移植围术期血流动力学、血液丢失量、输血和输液总量、血管活性药物用量、术后引流量、红细胞压积等临床情况。结果两组患者同一时间点的血流动力学和红细胞压积无显著性差异;抑肽酶组手术各期出血量和总出血量明显低于对照组(P<0.05),红细胞、血浆、血小板和液体输入量明显少于对照组(P<0.05);抑肽酶组无肝期和新肝期多巴胺、新肝期肾上腺素用量均少于对照组(P<0.05);两组去甲肾上腺素用量无显著性差异。结论重症肝炎肝移植围术期应用抑肽酶,可显著减少围术期失血、减少血液和液体的输注量,一定程度减少血管活性药物的需求。     

改良超滤在体外循环重症瓣膜置换手术中的临床应用

目的评价改良超滤在重症心脏瓣膜病患者瓣膜置换术中的临床效果。方法选取拟行瓣膜置换术的重症心脏瓣膜病患者84例,随机分为常规超滤组(CUF组)43例和改良超滤组(MUF组)41例。分别在围术期的不同时间点采集动脉血样监测电解质和血气;监测心排量(CO)、心排指数(CI)、左室每搏做功指数(LVSWI)及平均动脉压(MAP);计算氧合指数并记录相应时间点的气道压。结果 2组患者超滤后CO、CI、LVSWI均显著提高;与CUF组比较,MUF组改善更为明显;术后8～24 h,MUF组氧合指数好于CUF组;MUF组术后24 h尿量、胸腔引流量、呼吸机支持时少于CUF组,2组间气道压和ICU停留时间无显著差异。结论改良超滤用于重症心脏瓣膜病瓣膜置换术患者,可改善术后心肺功能,且效果优于常规超滤。     

二尖瓣病变并肺动脉高压围术期低氧血症分析

目的总结二尖瓣病变并肺动脉高压患者围术期低氧血症的治疗方法。方法选择二尖瓣病变并肺动脉高压围术期发生低氧血症、低心排血量患者76例,给予呼吸机辅助呼吸、硝酸甘油0.5~1.0μg/（kg.min）持续泵入、米力农0.3~0.7μg/（kg.min）泵入。结果死亡3例,均因严重低氧血症、心衰,经治疗低氧血症等无改善,于术后7~10 d因继发多器官功能衰竭死亡;其余患者经治疗后好转出院,心功能Ⅱ、Ⅲ级。随访5月~5年,心功能Ⅰ级17例、Ⅱ级58例,术后3年死亡1例,该患者因置入生物瓣合并高血压死于脑出血。结论二尖瓣病变并肺动脉高压患者围术期易发生低氧血症,严重的低氧血症可通过扩张肺动脉降低肺动脉压并配合心功能支持药物及呼吸机治疗矫正。硝酸甘油、米力农等有效剂量泵入是降低肺动脉压改善低氧血症的有效方法。     

心脏瓣膜和冠状动脉联合病变老年患者同期外科治疗围术期的呼吸道护理

目的探讨接受同期外科治疗心脏瓣膜和冠状动脉联合病变老年患者合理有效的围手术期呼吸道护理方法。方法对27例同期行心脏瓣膜置换或成形术和冠状动脉旁路移植术的老年患者围手术期呼吸道护理进行回顾性分析。结果术后并发肺不张2例,肺部感染1例,呼吸道并发症发生率为11.1%;死亡1例,其余均痊愈出院。结论合理有效的围术期呼吸道护理工作,是保证心脏瓣膜和冠状动脉联合病变老年患者同期外科治疗疗效,减少呼吸道并发症的重要措施。     

血清降钙素原对风湿性心脏病围术期感染的诊断价值

目的 探讨风湿性心脏病瓣膜置换术围术期血清降钙素原(PCT)检测对围术期感染的鉴别诊断价值.方法 以56例风湿性心脏病瓣膜置换术围术期患者为研究对象,分别测定其围术期血常规及血清PCT浓度,观察患者术后早期感染并发症发生情况以及与围术期血清PCT浓度变化的关系.结果 术后发生肺部感染1例,发生手术切口愈合不良6例(切口感染组),余49例患者未诊断术后感染.所有患者均好转出院,无一例严重并发症发生.所有患者术前血清PCT值均＜0.05 mg/L,术后均升高.切口感染组与非感染组患者血清PCT于术后第1天明显升高并达到峰值(1.13±1.09)mg/L,随后逐渐下降,并于术后第3天回复到正常参考范围.两组患者PCT降至0.25 mg/L以下的平均时间为(3.7±2.5)d,术后1例肺部感染患者于术后第5天检测到血清PCT又出现异常升高,第9天后才恢复到正常参考范围.术后PCT降至0.25 mg/L以下,停用抗生素.结论 PCT是风湿性心脏病术后继发感染较好的诊断和观察指标,对指导抗生素的应用有很高的临床价值.     

Inhaled nitric oxide improves hemodynamics in patients with acute pulmonary hypertension after high-risk cardiac surgery

Severe pulmonary hypertension and right-sided circulatory failure (RSCF) represent an increasing cause of morbidity and mortality in patients undergoing high-risk cardiac surgery. Increased pulmonary vascular resistance in the setting of cardiopulmonary bypass (CPB) may further lead to decrease blood flow across the pulmonary vascular bed; thereby decreasing left ventricular filling and cardiac output. Current management techniques for RSCF include both nonspecific vasodilator and inotropic agents (often limited by systemic hypotension) and the placement of right ventricular assist devices (associated with increased perioperative morbidity). Inhaled nitric oxide (NOi) represents a novel, specific pulmonary vasodilator that has been proven efficacious in these clinical settings. We evaluated 34 patients in 38 operations who underwent cardiac surgery at Columbia Presbyterian Medical Center, and who received NOi (20 ppm) through a modified ventilatory circuit for hemodynamically significant elevations in pulmonary vascular resistance. Nine patients underwent cardiac transplantation, three patients bilateral lung transplantation, 16 patients left ventricular assist device placement and 10 patients routine cardiac surgery. Patients receiving NOi exhibited substantial reductions in mean pulmonary artery pressure (mPAP) (34.6 +/- 2.0 to 26.0 +/- 1.7 mmHg, p < 0.0001), with improvements in systemic hemodynamics, mean arterial pressure (68 +/- 3.1 to 75.9 +/- 2.0 mmHg, p = 0.006). In five cases, patients could not be weaned from CPB until NOi was administered. Patients were maintained on NOi from 6 to 240 h postoperatively (median duration 36 h). Inhaled NO induces substantial reductions in mPAP and increases in both cardiac index and systemic blood pressure in patients displaying elevated pulmonary hemodynamics after high-risk cardiac surgery. NO is, therefore, a useful adjunct in these patients in whom acute pulmonary hypertension threatens right ventricular function and hemodynamic stability.     

风湿性瓣膜病变合并肺动脉高压87例观察

目的:总结87例风湿性瓣膜病变合并肺动脉高压患者行手术治疗的围术期处理经验。方法:87例风湿性瓣膜病变合并肺动脉高压患者行二尖瓣置换75例,二尖瓣置换 主动脉瓣置换12例。结果:此组患者手术过程顺利,术后并发低心输出量综合征5例,严重心律失常9例,早期死亡2例,病死率2.3%,其中低心排1例,1例因多脏器功能衰竭死亡。结论:风湿性瓣膜病变合并肺动脉高压患者病情较重,注意围术期各环节处理,即重视术前心功能改善,术中加强心肌保护,合理纠正病变,术后严密监护,可提高手术成功率。     

Redo cardiac surgery in a Jehovah's Witness, the importance of a multidisciplinary approach to blood conservation

Although Jehovah's Witnesses present a particular problem when undergoing surgery because of their refusal to accept stored blood, it is now quite common to undertake uncomplicated cardiac surgery in these patients. Complex or redo cardiac surgery however, is often associated with major blood loss, and is conventionally contraindicated in Jehovah's Witnesses. We describe the perioperative management of a Jehovah's Witness who underwent a resternotomy for mitral valve replacement and coronary artery bypass grafting having previously had an aortic valve replacement and mitral valve repair. The importance of a multidisciplinary approach to blood conservation is discussed.     

Spectrum of reoperations after repair of aortic coarctation: importance of an individualized approach because of coexistent cardiovascular disease

OBJECTIVE: To determine the indications for and spectrum of late reoperations in adults who had previously undergone coarctation repair. PATIENTS AND METHODS: We reviewed clinical, cardiac catheterization, and echocardiographic data and criteria for reoperation, surgical procedures, and outcome in 43 patients who underwent 54 reoperations between 1972 and 1996. RESULTS: Of the reoperations for recoarctation or associated cardiovascular disease (or both), 20% were performed in asymptomatic patients and 80% in symptomatic patients. Associated cardiovascular disease included bicuspid aortic valve in 36 patients (84%), aortic arch hypoplasia in 12 (28%), true or false aortic aneurysm in 6 (14%), mitral valve disease in 6 (14%), and subvalvular aortic stenosis in 5 (12%). Surgical procedures included 22 recoarctation repairs and 32 other cardiovascular interventions. Simultaneous repair of recoarctation and associated cardiovascular disease was performed as a single-stage repair in 5 reoperations through a median sternotomy using an extra-anatomic, ascending-to-descending aortic bypass, with no complications. One patient died (surgical mortality, 1.9%) of preexisting severe pulmonary vascular obstructive disease. CONCLUSIONS: After coarctation repair, associated cardiovascular diseases are the most common cause for reoperation. An individualized surgical approach is important and may range from valve replacement or recoarctation surgery to extra-anatomic bypass combined with other cardiovascular procedures, enabling simultaneous repair of recoarctation and associated lesions. Despite complex surgical techniques and multiple reoperations, morbidity and mortality were low in our series.     

Right upper lobe pulmonary edema after mitral valve replacement caused by paravalvular leakage recognized by bedside transesophageal echocardiography

OBJECTIVE: To describe an unusual case of right upper lobe pulmonary edema caused by acute paravalvular leakage that was identified by the use of bedside transesophageal echocardiography. DESIGN: Case report. SETTING: University-affiliated hospital. PATIENT: A 59-yr-old male patient underwent prosthetic mitral valve replacement (St. Jude valve) for severe mitral regurgitation and developed sudden onset of dyspnea and change in consciousness with blood pressure decreased to 70/30 mm Hg. Elevation of central venous pressure and images of transthoracic echocardiography led to the diagnosis of cardiac tamponade. CONCLUSION: Acute paravalvular leakage after mitral valvular replacement should be considered as one of the differential diagnoses for unilateral pulmonary edema. Physical findings of a holosystolic murmur and findings from bedside transesophageal echocardiography can confirm the diagnosis, avoiding delay in management.     

二尖瓣病变患者术前肺功能的改变

自1991年6月至1992年12月,测定了40例二尖瓣病变患者术前的肺功能。结果显示82.5％的病人肺功能有损害,其中轻度损害为50％,中度损害的为27.5％,重度损害为5％。结论:二尖瓣病变常常导致患者的肺功能下降。术前测定二尖瓣病变患者的肺功能,有助于心肺功能的判断,有助于指导病人围术期中的处理。