Valvular heart disease--repair or replacement?

An estimated 3 million patients in India need treatment for valvular heart disease. Rheumatic heart disease continues to be the major aetiologic factor. The mitral valve is best conserved with valvotomy or repair. The aortic valve is difficult to repair and is best replaced by a biological substitute (autograft or homograft). The tricuspid valve can be repaired in all patients. Prosthetic valves offer good long term durability but introduce additional risks to the patients. Experience over the past three decades suggests that conservation of natural valve mechanism is currently the best option.     

风湿性心脏病手术3个瓣膜同时置换的临床经验

目的:探讨风湿性心脏病手术中3个瓣膜同时置换的经验。方法:对4例同时置换二尖瓣、主动脉瓣和三尖瓣的病人资料进行分析。结果:术中发现4例病人均有三尖瓣环扩大和瓣叶增厚导致关闭不全,2例病人伴有交界融合导致瓣膜狭窄。1例病人接受了二尖瓣位、主动脉瓣位以及三尖瓣位生物瓣置换。另3例病人接受了二尖瓣位和主动脉瓣位机械瓣置换,以及三尖瓣位生物瓣置换。1例病人死于术后低心排。其他病人平均随访30个月(12～49个月),术后心功能I级2例,Ⅱ级1例。结论:如果三尖瓣需要置换时应使用生物瓣。尽管左侧心脏瓣膜应用机械瓣,三尖瓣位应用生物瓣仍是较好的选择。     

Republished review: Mitral regurgitation in patients with aortic stenosis undergoing valve replacement

Mitral regurgitation is a frequent finding in patients with aortic stenosis scheduled for aortic valve replacement. Detection of mitral regurgitation in such patients has important implications, as it can independently affect functional status and prognosis. When mitral regurgitation is moderate to severe, a decision to operate on both valves should only be made following a careful clinical and echocardiographic assessment. Indeed, double-valve surgery increases perioperative and postoperative risks, and mitral regurgitation may improve spontaneously after isolated aortic valve replacement. Better understanding of the determinants of these changes appears particularly crucial in the light of recent advances in percutaneous aortic valve replacement.     

冠状动脉旁路移植术62例

目的 对冠状动脉旁路移植术（ＣＡＢＧ）进行临床研究,总结冠状动脉疾病术前 三、手术治疗、及术后处理的经验。方法 １９９８－１０／１９９９－０９行冠状旁路移植术６２例,其中包括３例风湿性心脏病患同时行二尖瓣替换术和２例夹层动脉瘤患同时行主动脉根部及主动脉瓣替换术。结果 随访１～１１ｍｏ,手术死亡４例。术后消化道大出血３例,其余患无严重并发症。结论 术前心功能严重受损的冠誊 知病患经药物调整后     

急诊心脏瓣膜置换术41例的临床分析

目的总结重症瓣膜患者行急诊外科治疗的经验。方法1998年7月~2007年7月,对41例重症瓣膜患者急诊行心脏瓣膜置换术,其中感染性心内膜炎24例,二尖瓣重度狭窄7例,主动脉瓣重度狭窄2例,二尖瓣腱索断裂5例,主动脉瓣重度关闭不全合并瓦氏窦瘤破裂2例,介入术后主动脉瓣关闭不全1例。结果全组无手术死亡,术后2例再发机械瓣膜感染,4例并发肾功能衰竭,2例并发低心排,3例脑梗死症状加重,最终均死亡,其余顺利康复,死亡率为26.8%。结论符合手术指征的危重瓣膜患者应该急诊行瓣膜置换术,术后应注意肺脏和肾脏的保护,并且合理使用抗生素。     

少儿心脏瓣膜畸形的瓣膜置换术

目的 分析与评价少儿先天性心脏瓣膜畸形机械瓣膜置换的适应证、瓣膜选择、抗凝及疗效。方法 2000.3～2001.12,9例先天性心脏瓣膜畸形的少儿施行机械瓣膜置换术。年龄9～17岁,平均11.4岁。房室管畸形3例,二尖瓣中—重度返流3例,主动脉瓣中—重度返流2例,三尖瓣下移畸形1例。6例二尖瓣置换,2例主动脉瓣置换,1例三尖瓣置换。置入瓣膜内径:二尖瓣23～25mm,平均24mm;主动脉瓣21mm;三尖瓣33mm。结果 无手术死亡。9例随访2～20月,平均13月,无死亡及与瓣膜相关的并发症。抗凝过度胃出血1例。结论 少儿心脏瓣膜畸形机械瓣膜置换早中期效果满意。置入双叶机械瓣膜的内径,二尖瓣>23mm,主动脉瓣>21mm,三尖瓣>29mm可保证长期血流动力学的需要而无需再换瓣。少儿机械瓣置换术后仍需抗凝。     

球囊瓣膜成形术后二尖瓣瓣膜病变复发的外科治疗

目的总结球囊瓣膜成形术后二尖瓣瓣膜病变复发的外科治疗经验。方法回顾性分析我院1998年1月至2006年1月外科治疗的51例球囊瓣膜成形术后二尖瓣瓣膜病变复发患者的临床资料,并行二尖瓣置换术,就其病理改变、手术适应证及手术方法进行讨论。结果术中二尖瓣局部病理改变如下:交界硬化融合型3例,后瓣钙化卷缩型8例,交界钙化融合型34例,瓣膜与瓣下结构钙化型6例。术后早期死亡2例,死亡原因分别为低心排出量综合征和多脏器功能衰竭。46例患者术后获得6个月～7年的随访,随访率为90．2%,术后6个月随访时心功能均有不同程度改善。结论球囊瓣膜成形术后二尖瓣瓣膜病变复发以二尖瓣狭窄为主,外科治疗应以瓣膜置换术为宜,合并主动脉瓣及三尖瓣病变应同期积极手术纠正。     

冠心病合并二尖瓣返流的二尖瓣成形术104例临床分析

目的:回顾分析同期行二尖瓣成形和冠状动脉搭桥术的临床经验。方法:104例病人中男性60例,女性44例。冠状动脉单支病变6例,左主干病变7例,双支病变40例,三支病变58例。合并室壁瘤7例,室间隔穿孔4例,主动脉瓣病变7例。均在全麻体外循环下行冠状动脉旁路手术同时行二尖瓣成形手术,同期行主动脉瓣置换术5例,三尖瓣成形手术26例,室壁瘤切除3例,室间隔穿孔修补4例,冲洗射频迷宫消除房颤术1例。冠状动脉搭桥平均(3.33±1.5)支(1-6支)。结果:死亡1例(0.96%),术后随访二尖瓣返流0-Ⅰ级78例(75%),Ⅱ级23例(22.1%),Ⅲ级3例(2.9%)。结论:冠状动脉搭桥术同期二尖瓣成形手术效果良好,近期效果满意。     

老年退行性瓣膜病的临床特点及对策

随着生活质量的提高和生活方式的改变,老年退行性瓣膜病发病率逐年增高,其发病机制尚不十分清楚。病变主要累及左心瓣膜,引起钙化性主动脉瓣狭窄最为常见,二尖瓣脱垂致关闭不全次之。其病情发展缓慢,一旦出现症状生存期则明显缩短。药物治疗对轻者可以改善症状,重危患者往往难以奏效。对于主动脉瓣狭窄和二尖瓣关闭不全而言,人工瓣膜置换术仍然是目前公认有效的治疗方法,选择和把握手术时机十分重要。经皮球囊主动脉瓣成形术作为一种姑息性治疗手段可以改善高龄高危患者的临床症状。经皮导管主动脉瓣置入术及经皮二尖瓣成形技术将成为近几年临床上治疗老年退行性瓣膜病的研究方向,并被越来越多地应用于临床。     

风湿性心脏病三个瓣膜病变的手术治疗

１９８５年１月～１９９３年１２月行风湿性心脏病人工瓣膜替换术３３４例，其中对主动脉瓣、二尖瓣、三尖瓣三个瓣膜联合病变均行手术处理者１８例，占同期手术的５４％。１８例中有１７例行主动脉瓣及二尖瓣替换术；１例行主动脉瓣成形术及二尖瓣替换术，所用瓣膜均为机械瓣。三尖瓣手术中１２例行ＤｅＶｅｇａ瓣环成形术，另６例行三尖瓣交界切开及成形术。手术效果良好。术后１个月复查胸部Ｘ片见心胸比例较术前明显缩小（Ｐ＜０．０１）。认为二尖瓣、主动脉瓣。三尖瓣联合瓣膜病的术式以二尖瓣。主动脉瓣替换术及三尖瓣成形术较好。     

彩色多普勒血流显像诊断风心病40例临床分析

作者用彩色多普勒血流显象诊断风湿性心脏病40例,男女各20例,年龄23岁～80岁。其中诊为单纯性二尖瓣狭窄11例;二尖瓣双病变8例:主动脉瓣及二尖瓣联合瓣膜病变19例;单纯主动脉瓣病变2例。二尖瓣病损率为95％,主动脉瓣病损率为50％。     

One year echocardiographic study of rheumatic heart disease at Enugu, Nigeria

BACKGROUND: Rheumatic heart disease is one of the commonest causes of heart disease in Nigeria. Previous studies on rheumatic heart disease in Nigeria were either clinical or retrospective echocardiographic studies. This study was aimed at determining the burden of chronic rheumatic mitral valve disease, pattern of valvular involvement, severity and associated valvular lesions, using echocardiography. PATIENTS AND METHODS: Between May, 2004 and April 2005, patients with symptomatic rheumatic heart disease, seen in the cardiac clinics of University of Nigeria Teaching Hospital, Enugu, were recruited for the study. The patients were investigated non-invasively with M-mode, Two-dimensional, Pulsed wave, Continuous wave and colour flow Doppler echocardiographic techniques in order to assess the mitral and other intracardiac valves for evidence of rheumatic heart disease. RESULTS: There were a total of 55 patients, 39 (70.9%) females and 16 (29.1%) males with a mean age of 29.34 +/- 11.57 years. Mitral valve disease was found in 54 (98.2%) and isolated aortic valve disease in 1 (1.8%) of cases. Mitral regurgitation occurred in 64.8%, mixed mitral valve disease in 25.9% and pure mitral stenosis in 9.3%. Mitral valve disease was associated with aortic valve disease in 33.3%, with tricuspid valve disease in 24.1% and with functional pulmonary incompetence in 9.3% of cases. CONCLUSION: Rheumatic heart disease in Nigeria is essentially a disease of the mitral valve as seen elsewhere in the world. Echocardiography should be done routinely for patients with rheumatic heart disease to facilitate accurate diagnosis and definitive treatment.     

Congenital quadricuspid aortic valve: analysis of 11 surgical cases

Background  Congenital quadricuspid aortic valve is rarely seen during aortic valve replacement (AVR). The diagnosis and treatment of the disease were reported in 11 cases.

Methods  Eleven patients (nine men and two women, mean age 33.4 years) with quadricuspid aortic valve were retrospectively evaluated. Medical records, echocardiograms and surgical treatment were reviewed.

Results  In accordance with the Hurwitz and Roberts classification, the patients were classified as type A (n=2), type B (n=7), type F (n=1) and type G (n=1). Three patients were associated with other heart diseases, including infective endocarditis and mitral prolaps, left superior vena cava, aortic aneurysm. All had aortic regurgitation (AR) except two with aortic stenosis (AS), detected by color-flow Doppler echocardiography. The congenital quadricuspid aortic valve deformity in seven patients was diagnosed by echocardiography. All patients underwent successful aortic valve replacement.

Conclusion  Quadricuspid aortic valve is a rare cause of aortic insufficiency, while echocardiography plays an important role in diagnosing the disease. Aortic valve replacement is the major therapy for the disease.

     

Clinical Evaluation Versus Echocardiography in the Assessment of Rheumatic Heart Disease

Background

Rheumatic heart disease (RHD) is still a common form of heart disease among children and young adults, especially in developing countries like India. Between 1940 and 1983, the prevalence rate of RHD varied from 1.8 to 11 per 1000 (national average 6 per 1000), while between 1984 and 1995 the rate varied from 1 to 5.4 per 1000 [1]. The study was carried out to assess the accuracy of a medical student''s clinical evaluation of valvular heart disease and compare it with that of an echocardiographic evaluation and to determine the sensitivity, specificity and predictive values of clinical examination as compared to echocardiography for the various lesions in RHD patients.

Method

50 children between the ages of 5-16 years, attending the out patient department or admitted in a large teaching hospital, satisfying the criteria of RHD, were included in the study. Each patient underwent detailed clinical evaluation and relevant investigations including echocardiography.

Results

Mitral valve was involved most often both by echocardiography and clinically. Isolated aortic valve involvement was rare. The most common lesion was mitral regurgitation (MR) both by auscultation and by echo. Mixed lesions were seen more often than pure lesions. Mitral stenosis (MS) had the highest sensitivity while tricuspid regurgitation (TR) had the highest specificity. MR had the highest positive predictive value and MS the highest negative predictive value. Sensitivity and specificity of aortic regurgitation (AR) was very low when compared to earlier studies. There was a statistically significant difference between echo diagnosis and clinical diagnosis (p < 0.05).

Conclusion

It is recommended that echocardiography be done routinely for the diagnosis of cardiac lesions in patients of RHD as clinical examination alone can miss various lesions, especially when the lesions are mild or when multiple lesions are present.Key Words: Aortic valve, Children, Mitral valve, Rheumatic heart disease, Tricuspid valve     

风湿性心脏病合并冠状动脉粥样硬化性心脏病的同期手术治疗

目的总结风湿性心脏病（风心病）合并蔻状动脉粥样硬化性心脏病（冠心病）患者同期手术治疗的临床经验。方法我科从2007年1月～2012年3月,对14例风心病合并冠心病患者进行同期瓣膜置换和冠脉搭桥手术治疗,并对其临床资料进行回顾性分析。结果全组手术均顺利完成,使用人工心脏瓣膜15枚,二尖瓣成形环1枚;共搭桥20根,平均1．43根;手术时间（224．5±38．6）min,体外循环时间（105．2±27．4）rain,主动脉阻断时间（78．4±15．6）min。术后死亡1例,其余均痊愈出院;术后平均住院时间（13．1±3．4）d。随访13例,平均随访（39．2±11．3）月,全部存活,心功能改善,生活质量提高。结论对风心病合并冠心病患者进行同期瓣膜置换和冠脉搭桥手术治疗,安全性高,疗效满意。     

Hypertension in aortic valve disease and its response to valve replacement.

We have investigated the prevalence of hypertension and the response of blood pressure to operation in 87 patients with lone aortic valve disease who underwent aortic valve replacement. In patients with aortic stenosis alone 26% were hypertensive pre-operatively (age and sex adjusted blood pressure greater than 160 systolic and or greater than 95 mmHg diastolic) and 24% were hypertensive post-operatively. In those with aortic regurgitation alone, hypertension was present in 65% before and 57% after valve replacement using the same criterion. For combined stenosis and regurgitation, the prevalence was 54% and 62%, respectively. The post-operative increase in systolic pressure in patients with aortic stenosis occurred mainly in those with a history of left ventricular failure. In those with aortic regurgitation or combined stenosis with regurgitation, diastolic pressure rose after valve replacement resulting in a prevalence of diastolic hypertension of 44% and 35%, respectively. Blood pressure changes were not predicted by the type of valve inserted nor its size. Our data show that despite severe symptomatic aortic valve disease, systolic hypertension was common in aortic stenosis and diastolic hypertension was found in aortic regurgitation. This underlines the importance of blood pressure monitoring in patients following aortic valve replacement.     

Epidemiology of rheumatic and congenital heart diseases in school children.

A stratified random sample of 10,263 school-going children in the age group of 6-16 years from government and private schools were screened for the prevalence of rheumatic fever, rheumatic heart diseases and congenital heart diseases. Fourteen children were found to have rheumatic heart disease with valvular lesions either single or in combination eg, pure mitral stenosis (6 cases), mitral regurgitation (4 cases), combined mitral stenosis and mitral regurgitation (3 cases) and aortic and mitral regurgitation (one case). Eight children had congenital heart diseases in the form of ventricular septal defect (3 cases), atrial septal defect (2 cases), patent ductus arteriosus (2 cases) and congenital bicuspid aortic valve (one case) while none had active rheumatic fever.     

经胸及经食管超声对人工心脏机械瓣正常及病理性反流的对比研究

目的：评估经食管超声及彩色血流显像对人工机械瓣膜正常及病理性反流的诊断价值。方法：分析2004—05～2014—02期间经TTE及TEE检查的人工机械瓣资料完整的病例52例,男25例,女27例,平均年龄44．66-＋5．09岁,其中二尖瓣位置机械瓣置换数52个,主动脉瓣位置机械瓣置换数27个,双瓣置换的重叠病例18例。二尖瓣位机械瓣反流分级标准以反流口缩流宽度划分。主动脉瓣位机械瓣的偏心性反流分级标准以Jet宽／LVO宽度划分,瓣周漏分级以漏口彩色血流占瓣环周长比率划分。结果：（1）二尖瓣替换病人,1TrE显像诊断人工机械瓣二尖瓣正常及病理性反流的准确性为59．62％,低估率为28．85％,高估率为36．54％,漏检率为19．23％。（2）主动脉瓣替换病人,TTE诊断人工机械主动脉瓣正常及病理性反流的准确性为85．18％,低估率11．1％,高估率为14．81％。结论：TEE在评价人工机械瓣膜病理性反流方面尤其是对人工心脏机械瓣二尖瓣的评价优于经胸超声,起到了明确诊断的决定性作用。     

Risk factors for mortality after coronary artery bypass grafting in patients with low left ventricular ejection fraction

Background We managed to assess and confirm the risk factors for mortality after coronary artery bypass grafting （CABG） operations so as to map out the proper guidance of surgical strategy especially in patients with low left ventncular ejection fraction （LVEF） in domestic polyclinic like ours. Methods Five hundred and forty-eight consecutive patients underwent CABG from December 1999 through August 2005 were analyzed retrospectively. Eighty-nine cases had an LVEF of 40% or less. All together twenty-two candidate factors were evaluated for their association with perioperative death using univariate and multivariate stepwise Logistic analysis. Results When data from all the patients who had undergone CABG were taken into account, LVEF, left ventricular end diastolic diameter （LVEDD）, mitral regurgitation, aneurysm of the heart wall, mitral repair/replacement, resection of aneurysm, concomitant aortic valve replacement, and perioperative intra-aortic balloon counter-pulsation （IABP）, left ventricular assist device （LVAD） and cardiopulmonary bypass （CPB） all showed an association with perioperative death in univariate analysis, while an LVEF of 〉40%, on the other hand, appeared to be a protective factor. In multivariate analysis, moderate to severe mitral regurgitation, aneurysm of the heart wall, repair of septal perforation and aortic regurgitation were proved to be risk factors. When the analysis was restricted to patients with an LVEF of 40% or less, such variables as age, LVEDD, mitral regurgitation, mitral repair/replacement, IABP, and CPB were qualified as risk factors in a univariate analysis. Age, moderate mitral regurgitation, aneurysm of the heart wall, CPB, left main coronary artery disease and female were associated with pefioperative death in a multivariate logistic regression analysis. Conclusions Concerning the prognosis, patients who undergo CABG would have different risk factors when data from all the enrolled patients or data from patients with LVEF≤40% is compared. This is because low LVEF is itself an important risk factor. Regarding the low LVEF patients, the aggressive treatments including correction of mitral regurgitation and resection of aneurysm of the heart wall concomitant with CABG should be taken into account while planning the operative strategy to ensure the perioperative safety and prognosis.     

131例主动脉瓣及二尖瓣联合瓣膜置换治疗风湿性多瓣膜病变

目的探讨提高主动脉瓣及二尖瓣联合瓣膜置换治疗风湿性多瓣膜病变疗效的方法。方法1998年7月至2005年11月8年间,对131例风湿性多瓣膜病变患者施行外科治疗。男54例,女77例,年龄21~63岁,平均42.5±4.5岁。术前心功能Ⅲ~Ⅳ级者112例(占85.50%)。21例同期行Devega法三尖瓣成形。结果痊愈124例(占94.66%),死亡7例,(占5.34%),手术后存活病人心功能明显改善。结论对于严重风湿性多瓣膜病变的患者,加强围术期处理,改善病人的营养状况,选择适当的手术时机,改善心肌保护,提高手术技巧,积极纠治三尖瓣关闭不全,可提高主动脉瓣及二尖瓣联合瓣膜置换的疗效。