大左室、低射血分值心脏瓣膜病的外科治疗

目的 :总结大左室、低射血分值心脏瓣膜病的外科治疗经验。方法 :72例大左室、低射血分值的心脏瓣膜患者行外科手术治疗 ,术前注意改善心肺功能 ,术中采用温血停搏液灌注 ,保留二尖瓣后瓣及瓣下结构 ,术后强心利尿扩血管治疗 ,积极防治术后并发症。结果 :本组术后早期发生心、肺、肝、肾等重要器官并发症 17例 ,围术期及术后早期住院期间死亡 7例 ,治愈出院 65例。结论 :大左室、低射血分值的心脏瓣膜患者行外科手术治疗危险性大 ,术后并发症多 ;选择合适手术时机 ,加强肺功能锻炼和围术期处理是提高大左室、低射血分值患者瓣膜置换术疗效的重要措施     

危重心脏瓣膜病的外科治疗

目的 探讨危重心脏瓣膜病手术治疗和围术期处理。方法 1991年10月—2003年12月危重心脏瓣膜病患者46例接受手术治疗,其中男21例,女25例;年龄28～65岁。术前心功能Ⅲ级22例,Ⅳ级24例。二尖瓣置换术15例,主动脉瓣置换术6例,二尖瓣加主动脉瓣置换术25例;同时行三尖瓣成形术38例,左房血栓清除术8例。结果 早期主要并发症为室性心律失常、低心排血量综合征、呼吸衰竭和多器官功能衰竭。早期死亡1例。结论 危重心脏瓣膜病的外科治疗应注重围术期处理,适当选择手术时机,合理纠正病变,加强术后并发症的防治。     

46例危重心脏瓣膜病的手术治疗及并发症分析

目的探讨危重心脏瓣膜病手术治疗和围手术期处理的经验。方法46例危重心脏瓣膜病患者接受二尖瓣置换术（MVR）27例,二尖瓣并主动脉瓣置换术13例,主动脉瓣置换术（AVR）6例;同时行三尖瓣环缩术12例,左房折叠术11例。结果早期主要并发症为室性心律失常、低心排血量综合征、呼吸衰竭和多器官功能衰竭。早期死亡7例,其中室性心律失常2例、术后脑出血1例、多器官功能衰竭（MSOF）4例。结论危重心脏瓣膜病的外科治疗应注意围手术期处理,适当选择手术时机,合理纠正病变,加强术后并发症防治。     

重症心脏瓣膜病的外科治疗(附75例报告)

对75例重症心脏瓣膜病患者施行瓣膜置换术。均采用机械瓣。患者术前心功能Ⅲ级28例，Ⅳ级47例。共行二尖瓣置换术29例．主动脉瓣置换术9例，二尖瓣＋主动脉瓣置换术37例。同时施行三尖瓣成形术62例，左房血栓清除术17例，左房成形术12例，冠状动脉搭桥术4例。术后早期死亡5例。认为良好的术前准备、恰当的手术时机和手术方式．积极防治并发症可提高重症心脏瓣膜病的疗效。     

老年心脏瓣膜病患者的外科治疗

目的总结180例65岁以上老年心脏瓣膜病患者的手术风险及手术并发症。方法 2008年2月—2013年6月,180例65岁以上患者接受心脏瓣膜手术,行主动脉瓣置换术65例,二尖瓣置换术30例,二尖瓣成形术25例,双瓣置换术25例,主动脉瓣置换+二尖瓣成形术28例,主动脉瓣置换+升主动脉成形术4例,Bentall手术3例。同期行冠状动脉旁路移植术26例,三尖瓣成形术33例,房颤消融术34例,左心房取血栓术5例,室缺修补术1例。使用生物瓣153例(85%),机械瓣27例(15%)。结果全组患者住院死亡9例,其余171例患者治愈出院。结论随着外科手术技术的日益成熟,术前详细评估手术风险,术中加强心肌及肾功能的保护,可以明显提高手术成功率,改善患者的预后,提高患者生活质量。     

瓣膜置换术围手术期电风暴两例

例1,男性,49岁,先天性二尖瓣畸形,二尖瓣后叶脱垂,巨大左室,心房颤动,行二尖瓣置换术加Atricure双极射频治疗心房颤动,开放升主动脉后心脏自动复跳,辅助循环过程中出现电风暴,给予抗心律失常药物,反复电除颤7次后电风暴终止。例2,女性,57岁,心脏瓣膜病,二尖瓣重度狭窄伴中度返流,主动脉瓣中度返流,行双瓣置换术,术后心力衰竭症状明显改善,术后第15天突发电风暴,反复发作心室颤动、尖端扭转性室性心动过速。给予静脉补钾,抗心律失常药物,反复电除颤5次,并安装心脏临时起搏器,电风暴终止。两例患者出院后随访状况良好。     

高密度标测导管指导下心房扑动和室性期前收缩的射频消融2例

正1病例资料病例1为外科术后心房扑动患者,男性,52岁,因风湿性心脏瓣膜病于1993年行二尖瓣机械瓣置换术,主动脉瓣和三尖瓣成形术。入院前40 d,患者突发心悸症状,自觉心律不齐,查心电图提示为心房扑动,口服美托洛尔和胺碘酮治疗心悸症状稍有好转,但心电图仍显示为心房扑动。经胸超声心动图提示左房增大(内径47 mm),左室(内径43 mm)及射血分数(60.7%)正常,机械瓣瓣膜功能未见异常,主动脉     

二尖瓣及主动脉瓣联合瓣膜置换术112例分析

目的探讨二尖瓣及主动脉瓣联合瓣膜置换术治疗严重联合瓣膜病的临床价值。方法对112例行二尖瓣及主动脉瓣置换术的患者进行回顾性总结和分析,其中风湿性心脏病111例,退行性瓣膜病1例。术前心功能（NYHA）Ⅲ级76例,Ⅳ级12例,再次瓣膜置换8例。均采用胸部正中切口,全部切除二尖瓣90例,保留前瓣2例,保留后瓣10例,保留全瓣10例;术中同时行三尖瓣成形术68例。共置换人工心脏瓣膜224枚。结果手术病死率1．78％,术后早期并发症发生率25．89％。结论二尖瓣及主动脉瓣联合瓣膜置换术是治疗严重联合瓣膜病的最好方法。     

危重心脏瓣膜病的手术治疗

目的总结危重心脏瓣膜病的手术治疗经验。方法对187例危重心脏瓣膜病患者先行强心利尿治疗控制心衰后,行二尖瓣置换术（MVR）44例,主动脉瓣置换术（AVR）27例,主动脉瓣联合二尖瓣置换术（DVR）111例,三尖瓣置换术（TVR）1例,同时行三尖瓣成形术（TVP）129例,冠状动脉旁路移植术（CABG）17例,房间隔缺损修补术（ASD）＋二尖瓣置换术4例;术后调整心脏前后负荷,适当延长呼吸机使用时间,加强呼吸道管理,维持水电解质平衡,加强抗凝。结果本组死亡17例,其中术中心脏复跳困难2例,低心排7例,肾功能衰竭2例,术后突发心律失常5例,机械瓣失功能1例。139例术后随访1~60个月,心功能Ⅰ级112例,Ⅱ级17例,Ⅲ级8例,Ⅳ级2例;仍存在心绞痛1例,心脏瓣周漏2例。结论恰当的围手术期处理、合理的术式选择是手术治疗重症心脏瓣膜疾病的关键。     

老年心脏瓣膜置换术27例临床观察

目的观察老年（≥65岁）心脏瓣膜置换术的疗效。方法老年心脏瓣膜病患者27例,行二尖瓣置换术16例,二尖瓣及主动脉瓣置换术3例,主动脉瓣置换术8例。结果 24例患者术后恢复顺利出院,随访3~27个月,其中心功能改善至Ⅰ级者15例,Ⅱ级者8例;发生严重并发症7例,经治疗后均恢复。本组死亡3例。结论老年心脏瓣膜置换术临床疗效较好。     

心脏瓣膜病巨大左心室病人的瓣膜置换

目的：探讨瓣膜病巨大左心室病人的临床特点，及影响手术疗效的主要因素，提高瓣膜置换术后的疗效。方法：共47例瓣膜病巨大左心室病人行瓣膜置换术，其中主动脉与二尖瓣双瓣置换35例，二尖瓣置换5例，主动脉置换7例，同时行三尖瓣成形42例，左房折叠4例。结果：术后早期并发症14例(349／6)，死亡2例(4．259／6)，影响瓣膜置换手术早期疗效的主要因素是严重左室扩大，严重左室收缩功能下降，射血分数(EF)＜0．40，左室短轴缩短率(FS)＜0．25和严重低心输出量综合征，和围术期室颤。结论：掌握合适手术时机，注意心肌保护措施，最大限度地保留心内结构是巨大左心室病人瓣膜置换手术成功的重要因素。     

合并大左室瓣膜置换术的外科治疗体会

目的总结合并大左室瓣膜病的治疗经验。方法1998年4月～2004月年对28例合并大左室瓣膜病人行瓣膜置换术。其中二尖瓣置换术13例,主动脉瓣置换术13例,主动脉瓣和二尖瓣双瓣置换术1例,Bentall手术1例;同期处理并存畸形及病变7例。结果治愈出院25例,术后早期死亡3例。合并症22例,其中心律失常20例、低心排出量综合征2例。结论充分的术前准备,恰当的手术处理,术后积极防治恶性心律失常和低心排出量综合征是提高手术效果的关键。     

Advances in percutaneous treatment for adult valvular heart disease

Valvular heart disease occurs in 2–3% of the general population with an increase in prevalence with advancing age. The aetiology of valvular heart disease has evolved in recent decades with degenerative aortic and mitral valve disease supplanting rheumatic heart disease as a primary cause. The common valve lesions to be discussed in this article are aortic stenosis and mitral regurgitation. The traditional approach to calcific aortic stenosis when either symptoms or left ventricular impairment develops is surgical aortic valve replacement and it remains a treatment with excellent outcomes. In recent years there has been interest in less invasive approaches, including percutaneous and transapical aortic valve implantation. With refinements in technology these approaches are becoming a potential treatment option, primarily for high-risk patients who may otherwise be unsuitable for traditional open surgical treatment. Catheter-based approaches for mitral valve disease are also evolving. Mitral regurgitation may often be the result of mitral annular dilatation seen in patients with an enlarged left ventricle or left atrium. Percutaneous implantation of a constricting device in the coronary sinus, which lies in close proximity to the mitral annulus, results in a change to the geometry of the mitral valve and reduced regurgitation. Another technique in patients with degenerative mitral regurgitation is the endovascular edge-to-edge repair in which coaptation of the mitral valve leaflets can be improved with a percutaneously deployed clip. Small patient series indicate that these new techniques are promising. As such, advances in percutaneous interventional and surgical approaches have the potential to further improve outcomes for selected patients with valvular heart disease.     

Assessment of trans‐aortic pressure gradient using a coronary pressure wire in patients with mechanical aortic and mitral valve prostheses

Accurate evaluation of trans‐aortic valvular pressure gradients is challenging in cases where dual mechanical aortic and mitral valve prostheses are present. Non‐invasive Doppler echocardiographic imaging has its limitations due to multiple geometric assumptions. Invasive measurement of trans‐valvular gradients with cardiac catheterization can provide further information in patients with two mechanical valves, where simultaneous pressure measurements in the left ventricle and ascending aorta must be obtained. Obtaining access to the left ventricle via the mitral valve after a trans‐septal puncture is not feasible in the case of a concomitant mechanical mitral valve, whereas left ventricular apical puncture technique is associated with high procedural risks. Retrograde crossing of a bileaflet mechanical aortic prosthesis with standard catheters is associated with the risk of catheter entrapment and acute valvular regurgitation. In these cases, the assessment of trans‐valvular gradients using a 0.014? diameter coronary pressure wire technique has been described in a few case reports. We present the case of a 76‐year‐old female with rheumatic valvular heart disease who underwent mechanical aortic and mitral valve replacement in the past. She presented with decompensated heart failure and echocardiographic findings suggestive of elevated pressure gradient across the mechanical aortic valve prosthesis. The use of a high‐fidelity 0.014? diameter coronary pressure guidewire resulted in the detection of a normal trans‐valvular pressure gradient across the mechanical aortic valve. This avoided a high‐risk third redo valve surgery in our patient. © 2017 Wiley Periodicals, Inc.     

Radionuclide ventriculography in aortic and mitral valve insufficiency. Pre- and post-operative studies of valve replacement surgery

Radionuclide ventriculography (RNV) is now a well-established procedure for the noninvasive evaluation of cardiac hemodynamics, including the detection and quantification of valvular regurgitation. 46 patients undergoing aortic or mitral valve replacement were examined by RNV pre- and postoperatively. The specificity of RNV in the diagnosis of aortic or mitral incompetence was high. All cases of moderate to severe aortic regurgitation were identified. This, however, was not true for mitral incompetence. A significant overlap between the left atrium and the left ventricle in the LAO view is held responsible for this decrease in sensitivity. The quantification of aortic regurgitation and the assessment of left ventricular function by RNV appears to hold promise in the preoperative workup. This diagnostic approach yields important additional information, which may be essential in the appropriate timing of surgical intervention. Aortic valve replacement for incompetence as well as for stenosis was accompanied by a significant improvement in global left ventricular ejection fraction. No postoperative change in ejection fraction was found in cases of mitral incompetence, while a slight increase was observed following operative therapy for mitral stenosis. The radioisotope findings were correlated to the results obtained by cardiac catheterization and noninvasive techniques such as echocardiography. The place of RNV in the pre- and postoperative management of valvular heart disease is delineated in this paper. It is of special value in the evaluation of aortic incompetence and may be an important diagnostic adjunct in the approach to the patient with mitral valve disease or aortic stenosis.     

Echocardiographic studies of left ventricular wall motion and dimensions after valvular heart surgery

Echocardiograms obtained from 50 patients after valvular heart surgery (in 33 cases within 2 months of the procedure) were examined to study patterns of interventricular septal motion and left ventricular dimensional changes. Preoperative echograms were available in 28 cases. Before and after mitral commissurotomy septal motion and left ventricular diameters as well as the percent systolic shortening of the echocardiographic transverse axis were within normal limits. Before operation, aortic and mitral regurgitation were associated with increases in end-diastolic and end-systolic diameters, septal motion and percent systolic shortening of the left ventricular diameter. Septal dyssynergy, defined as paradoxical motion or marked hypokinesia, was seen within 2 months of operation in 91 percent of patients after aortic valve replacement and in 42 percent after mitral valve replacement. Of subjects studied more than 2 months postoperatively, none with mitral valve replacement and only 33 percent with aortic valve replacement manifested septal dyssynergy. After valve replacement for aortic or mitral regurgitation there were significant decreases in end-diastolic diameter, septal excursion and total and percent left ventricular systolic shortening. Two subjects not having valve replacement also demonstrated paradoxical septal motion postoperatively. The cause of septal dyssynergy after valvular surgery was not apparent although the use of cardiopulmonary bypass was an essential condition.We conclude that echocardiography can be utilized to follow up changes in left ventricular wall motion and dimensions after surgery for valvular heart disease, and that it may be of value in assessing the early and late postoperative results.     

老年人退行性心脏瓣膜病166例超声心动图分析

目的探讨老年人退行性心脏瓣膜病的超声心动图特点。方法采用美国HP5500及飞凡彩色多普勒超声诊断仪，观察166例老年退行性心脏瓣膜病患者的心脏结构及心功能变化。结果单纯主动脉瓣膜钙化者93例（56．0％），单纯二尖瓣钙化18例（10．8％），主动脉瓣和二尖瓣联合钙化为55例（33．1％）；左房扩大116例（69．9％），左心室舒张功能减退142例（85．5％）；136例导致心脏瓣膜功能障碍，其中主动脉瓣返流70例，占42．2％，主动脉瓣狭窄23例，占13．9％，二尖瓣返流20例，占12．0％，二尖瓣狭窄8例，占4．8％，主动脉瓣返流＋主动脉瓣狭窄10例，占6．0％，二尖瓣返流＋二尖瓣狭窄5例，占3．0％。瓣膜功能障碍检出率最高为主动脉关闭不全（42．2％），其次为主动脉瓣狭窄（13．9％），发病率最低为二尖瓣狭窄伴关闭不全（3．0％）。结论老年人退行性心脏瓣膜病缺乏特异的临床表现，随着年龄的增加，联合瓣膜钙化比例增加，瓣膜功能障碍中主动脉瓣关闭不全比例最高，左房扩大的比例也增加。     

同种主动脉瓣在心脏外科的应用

目的总结同种主动脉瓣在心脏外科的应用,探讨其优越性。方法1995年1月至2000年12月,应用同种带瓣主动脉手术治疗先天性及后天性瓣膜疾病18例。其中完全性大动脉转位并右室双出口1例,行Rastelli手术;主动脉瓣狭窄及（或）关闭不全17例,先天性8例,风湿性9例,1例行Ross手术,余皆行主动脉瓣置换手术。结果早期死亡1例：Rastelli手术患者术后因严重低心排死亡;其余均顺利康复。随诊2～10年,1例主动脉瓣置换术后1年因同种瓣严重瓣损毁行二次手术置换机械瓣,术后18d死于多器官系统功能衰竭;其余患者术后生存状态均良好。结论同种主动脉瓣用于心脏瓣膜的置换及心室流出道的重建,可获得很好的临床效果。