心脏瓣膜置换术后再次手术治疗(附50例报告)

目的探讨心脏瓣膜手术后机械瓣膜急性功能障碍、人工瓣膜心内膜炎、人工瓣膜瓣周漏及生物瓣衰败再次手术指征、手术时机及手术治疗要点。方法选风湿性心脏病瓣膜替换术后49例,扩张性心肌病左室减容术同时行二、三尖瓣替换术后1例。人工瓣膜急性失功9例中,术后菌落样赘生物和心内膜炎2例,左室腔内残留腱索卡住碟片2例,破裂的左心室后壁卡住后瓣叶1例,碟片边缘缺损1例,碟瓣瓣钩断裂1例,陈旧及机化血栓形成2例,均急症行再次换瓣手术,其中4例急症手术行股动脉插管灌注。术后瓣周漏2例,限期手术,采用带垫片直接褥式缝合修补。生物瓣衰败39例中,二尖瓣位19只猪瓣及18只牛心包瓣多为不同程度的瓣叶增厚、钙化,同时合并不同程度瓣叶撕裂、穿孔,择期行再次瓣膜替换术及附加手术。结果术后早期死亡2例,出现并发症4例,晚期死亡1例。47例心功能恢复至Ⅰ～Ⅱ级。结论换瓣术后病人多是处于心功能已损害至严重程度或急症时期,手术死亡率高,掌握好再次换瓣手术指征、时机及方法,可大大降低死亡率。     

心脏瓣膜置换术后患者再次换瓣效果观察

目的观察心脏瓣膜置换术后再次换瓣的效果。方法本组59例患者,其中风湿性心脏病瓣膜替换术后58例,扩张性心肌病左室减容术同时行二、三尖瓣替换术后1例。因机械瓣膜急性功能障碍、人工瓣膜心内膜炎、人工瓣膜瓣周漏及生物瓣衰败出现瓣膜功能缺失者急症行再次换瓣手术,其中5例急症手术时行股动脉插管灌注。换瓣术后瓣周漏6例,4例行再次瓣膜置换术,2例限期直接采用带垫片褥式缝合修补术。生物瓣衰败43例中,23枚猪瓣及25枚牛心包瓣多为不同程度的瓣叶增厚、钙化,同时合并不同程度瓣叶撕裂、穿孔,择期行再次瓣膜替换术及附加手术。结果术后早期死亡2例,出现并发症4例,晚期死亡2例,失访5例。50例心功能恢复至Ⅰ~Ⅱ级。结论 心脏瓣膜置换术后出现严重瓣膜功能缺失者行再次换瓣效果较好。     

58例人造主动脉瓣的再次手术

巴黎Broussais医院于1963年～1973年共作了1092例人造主动脉瓣替换术(12001260型Starr-Edwards球瓣783例,2300型Starr-Edwards金属球瓣60例;Smeloff-Cutter球瓣249例),死亡165例,死亡率为15％。927例生存者随访了6月至9年,78例作了再次手术,其中20例由于人造瓣膜型号特殊或记录不全而难于分析,本文分析其余58例再次手术的经验。两次手术间的时距为3月～8 1/2年。术后早期再手术的指征为感染、瓣周渗漏及溶血;     

先天性二尖瓣关闭不全的再次手术

目的:回顾性分析先天性二尖瓣关闭不全再次手术的问题。方法:自2002年至2009年间共438例先天性二尖瓣关闭不全(不包括完全性或部分性房室通道)患儿行二尖瓣成形手术,所有患儿中有15例(3.4%)行再次二尖瓣手术,其中再次行二尖瓣成形术12例(组1),二尖瓣置换术3例(组2)。再次手术的原因包括:严重溶血和残余或复发二尖瓣关闭不全。术中根据瓣膜病变情况选择合适的成形方法,包括二尖瓣瓣环环缩、腱索转移、双孔成形和瓣膜置换手术。对所有患者均行临床评估和超声心动图检查评估二尖瓣功能。结果:全组患儿无死亡病例,所有15例随访患儿亦无死亡。组2患儿年龄、体质量和心胸比均大于组1。组1患儿中术中见原缝线撕裂2例,瓣环扩大4例,瓣叶局部裂3例,组1患儿术后超声心动图见二尖瓣关闭不全较术前明显减轻(P0.01)。组2中3例患儿均行二尖瓣双叶机械瓣置换。结论:二尖瓣成形术仍是先天性二尖瓣关闭不全再次手术的首选术式,对术前心功能差且瓣膜条件不理想的患儿行瓣膜置换手术是理智的选择。     

人造瓣膜换置后的再手术:影响早期及远期生存率的因素

1960年12月至1977年7月,作者等施行了1445例瓣膜换置术,术后有83例成人病例接受了89次再手术。本文对这89次再手术进行回顾性研究。再次手术的基本指证是:与人造瓣膜有关的全身性疾病(感染、栓塞、溶血)以及与人造瓣膜有关的关闭不全(瓣周渗漏,球瓣的球变形,同种瓣膜的退缩)和狭窄(血栓形成,血管翁,同种瓣的阻塞)。再手术后至少随访6个月。结果:总的再手     

房室间隔缺损矫治术后左侧房室瓣反流的外科治疗

目的：探讨房室间隔缺损矫治术后左侧房室瓣反流的病理改变、再手术方法的选择，总结围手术期治疗经验，提高再手术治疗效果。 方法：回顾分析上海交通大学医学院附属新华医院1995年1月至2016年12月收治的72例房室间隔缺损（AVSD）矫治术后左侧房室瓣反流患者的临床资料，其中男47例，女25例，年龄2～62岁，平均17.5岁。术前心功能分级（NYHA）Ⅱ级23例、Ⅲ级43例、Ⅳ级6例。曾行部分性AVSD矫治术38例、完全性AVSD矫治术23例、过渡性AVSD矫治术11例。再次手术行瓣膜修复术43例；瓣膜置换术25例；4例先行瓣膜修复术，停体外后经食道超声提示房室瓣仍有中度以上反流，随即改行机械瓣置换。 结果：术后早期死亡1例，因术后顽固性低心排、出现多器官功能衰竭死亡。2例患者机械瓣置换术后出现Ⅲ度房室传导阻滞，1例术后10天恢复窦性心律，另1例安装永久起搏器。1例4岁患者行机械瓣置换术后不能撤离体外循环，行左心辅助56小时后顺利恢复，痊愈出院。术后随访62例，失访9例均为瓣膜修复者，术后随访6个月至18年，平均11.6年。34例瓣膜修复患者中，左侧房室瓣均无梗阻，23例左侧房室瓣为轻微或轻度反流，5例中度反流，6例分别于再次手术后7d、10d、3年、6年、7年、10年后再因重度左侧房室瓣反流而行瓣膜置换术。28例瓣膜置换者，2例因机械瓣功能不全分别于术后3年、7年再次置换机械瓣。术后远期死亡5例，瓣膜修复2例、置换3例。生存患者术后心功能均明显改善。 结论：对房室间隔缺损矫治术后再发生的左侧房室瓣反流，选择恰当的手术方式进行及时的手术治疗，能取得满意的近期和远期疗效。     

右心瓣膜替换术

本文报告28例右心瓣膜替换术,其中三尖瓣替换(TVR)24例,肺动脉瓣替换(PVR)4例。手术死亡6例,均为TVR病例,死亡率21.4%,死亡与术前心功能差有关。远期随诊2～72个月,除了TVR用机械瓣的患者2例中1例瓣失灵再次手术,1例抗凝过量出血外,余无并发症发生。作者认为,右心瓣膜若需手术,则尽量施行成形术;如病变严重必须换瓣,则首选包括同种瓣在内的生物瓣。     

单纯三尖瓣替换手术五例体会

单纯性三尖瓣替换手术远比二尖瓣和主动脉瓣的替换手术少,且在术时和术后处理上具有一定的特殊性.1975年以来,我们为5例本病患者施行三尖瓣替换手术,现予报道,并浅谈体会.1 临床资料本组5例中,男3例,女2例;年龄17～48岁,平均37.5岁.Ebstein畸形2例,矫正性大动脉转位合并严重三尖瓣关闭不全2例,三尖瓣严重关闭不全合并右室双腔心和右室流出道狭窄1例.2例Ebstein畸形病人在进行Hardy手术悬吊下移的隔瓣和后瓣并折叠房化心室后,因仍有三尖瓣严重关闭不全,被迫在右房室环位分别移栽31mm外径的国产碟瓣,结果1例手术后第6天突发人造瓣膜功能障碍而猝死;1例术后合并短暂的低心排和肾功能衰竭,经抢救,手术后第31天痊愈出院,随访1年6个月,心功能为Ⅱ级.2例矫正性大动脉转位合并解剖三尖瓣严重关闭不全者,术中均见三尖瓣叶增厚挛缩,严重关闭不全,手术切除病变的前瓣和后瓣,保留隔瓣,分别替换以27mm外径和31mm外径碟瓣.术后1例恢复顺利,1例出现短暂的低心排和肺功能不良,经治疗均痊愈,     

近期人造心脏生物瓣膜在瓣膜外科的应用

我们近年来在瓣膜替换术中应用人工生物瓣的例数有逐年增多的趋势。目的　评价人造心脏生物瓣膜在瓣膜外科中的应用趋势。对象　我院自1998年 1月～ 1999年 12月共有 9例患者行生物瓣替换手术。风湿性心脏病 5例 ,退行性变 2例 ,冠心病 2例。方法　全组 9例二尖瓣替换均采用MedtronicHankockⅡ型生物瓣 ,5例 2 7号 ,4例2 9号。结果　本组手术无死亡。术后均口服华法令抗凝治疗。术后B型超声心动图提示瓣膜功能良好。随诊近 1年结果令人满意。结论　由于生物瓣应用于老年人有良好的耐久性 ,同时可以避免因抗凝治疗出现的各种并发症。因此 ,随着生物瓣的防衰坏处理的不断进展、再手术技术的不断提高、对生活质量的日益重视和经济的发展 ,人造心脏生物瓣膜将会得到重新的评价和更广泛的应用     

单纯二尖瓣换置术的早期和晚期并发症(8种不同人造瓣膜的比较)

自1960年Starr-Edwards球瓣问世以来,为了改善二尖瓣换置术的临床疗效,发展了许多新型瓣膜。Smeloff-Cutter首先对球瓣作了改进,以后又出现了多种低柱身碟形瓣膜,希望能改善血流情况,但这些人造瓣膜的机械变形却较球瓣为多,为了减少人造二尖瓣的栓塞并发症,曾用织物包裹球瓣的框架。本文总结作者应用8种人造二尖瓣的经验。自1966年至1971年,应用8种人造瓣膜为153例病人施行单纯二尖瓣换置术,其中7例曾再次手术换置不同的瓣膜。大多数瓣膜病变为风湿性。13例兼有三尖瓣关闭不     

Transprosthetic catheterization of a Bj?rk-Shiley aortic prosthesis with fatal outcome

Retrograde transprosthetic catheterization of a Bj?rk-Shiley aortic prosthesis (type ABP) using a Sones catheter resulted in sticking of the tilting disc. Every attempt to withdraw the catheter failed and the patient died before he could be transferred for emergency reoperation. We advise against transprosthetic catheterization of tilting or bileaflet prostheses, which has been reported to be easily to perform without apparent risk. If left ventricular catheterization is mandatory after aortic valve replacement, the transseptal approach should be used. This is the only procedure which permits accurate evaluation of the functioning of the prosthesis or a concomitant mitral valve disease.     

复发性心脏瓣膜病再次外科治疗效果及其相关因素

目的:回顾性分析对二尖瓣闭式扩张术、瓣膜成形术、瓣周漏、人工机械瓣功能障碍、生物瓣衰坏等原因引起的复发性瓣膜病变进行再次手术的效果和相关因素。方法: 复发性瓣膜病患者331（男143,女188）例,年龄12～73(46±12)岁,两次手术间隔时间2月～25(17±8)年。其中二尖瓣闭式扩张术后再狭窄143例,二尖瓣或主动脉瓣成形术后瓣膜病变复发53例,生物瓣衰坏32例,瓣周漏26例,换瓣术后其它瓣膜病21例,人工瓣膜替换或瓣膜成形术后心内膜炎17例, Ebstein畸形矫治术后三尖瓣关闭不全15例,人工瓣膜机械功能故障9例,室间隔缺损修补术并行瓣膜成形术后心内膜炎7例,完全或部分性心内膜垫缺损和矫正性大动脉转位术后二尖瓣或三尖瓣关闭不全6 例,二尖瓣球囊扩张术2例。再次手术方式为二尖瓣替换术,主动脉瓣替换术,二尖瓣和主动脉瓣替换术,三尖瓣替换术,瓣周漏修补术及三尖瓣成形术等。结果: 全组共死亡27例,占8.2％,早期主要死亡原因为低心排出量综合征、室性心律失常、多脏器功能衰竭、左心室破裂、感染性心内膜炎、肾功能衰竭。随访259例,随访期6月～21（10±7）年,心功能恢复至Ⅰ～Ⅱ级189例。复发性心脏瓣膜病再次手术的危险因素包括术前心功能差、重要脏器功能不全、急诊手术、主动脉阻断时间和体外循环时间长等。结论: 针对再手术相关的危险因素进行积极防治,适时而妥善的外科手术和围手术期处理仍可获良好效果。     

Clinical and necropsy observations early after simultaneous replacement of the mitral and aortic valves

Clinical and necropsy findings are described in 54 patients, aged 25 to 83 years (mean 53), who died within 60 days of simultaneous replacements of both mitral and aortic valves. The patients were separated into 4 groups on the basis of the presence of stenosis (with or without associated regurgitation) or pure regurgitation of each valve: 30 patients (56%) had combined mitral and aortic valve stenosis; 12 patients (22%) had mitral stenosis and pure aortic regurgitation; 8 patients (15%) had pure regurgitation of both valves; and 4 patients (7%) had pure aortic regurgitation and mitral stenosis. Necropsy examination in the 54 patients disclosed a high frequency (48%) of anatomic evidence of interference to poppet or disc movement in either the mitral or aortic valve position or both. Anatomic evidence of interference to movement of a poppet or disc in the aortic valve position was twice as common as anatomic evidence of interference to poppet or disc movement in the mitral position. Interference to poppet movement is attributable to the prosthesis's being too large for the ascending aorta or left ventricular cavity in which it resided. The ascending aorta is infrequently enlarged in patients with combined mitral and aortic valve dysfunction irrespective of whether the aortic valve is stenotic or purely regurgitant. Likewise, the left ventricular cavity is usually not dilated in patients with combined mitral and aortic valve stenosis, the most common indication for replacement of both left-sided cardiac valves. Of the 54 patients, 12 (22%) had 1 mechanical and 1 bioprosthesis inserted. It is recommended that both substitute valves should be mechanical prostheses or both should be bioprostheses.     

Auscultatory and echophonocardiographic characteristics of the normally functioning Medtronic-Hall aortic valve prosthesis

We recorded auscultatory and echophonocardiographic findingsin 30 patients who had a normally functioningMedtronic-Hall(M-H) tilting disc valve prosthesis in the aortic position.The opening and closing sounds were invariably audible. Echophonocardiographyshowed that a typical opening sound consisted of 2 or 3 sharpclicks which were related to the onset and termination of thedisc opening excursion. The closing sound comprised at least2 separate clicks which coincided with the onset and completionof the valve closure. An early systolic ejection type murmurwas heard in 25 patients and a faint early diastolic murmurin 2. The disc motion could be recorded echocardiographicallyin 27 patients. The opening amplitude of the disc varied from3 to 11 mm. The intervals from the Q wave and the first heartsound to the onset of valve opening measured 116±20 ms(mean± standard deviation) and 54 ±14 ms, respectively.The opening and closing velocities of the disc were also easilymeasurable but showed a wide patient-to-patient variation. In5 patients, the examination was repeated after 8 to 12 months.The reproducibility was excellent for the auscultatory findingsand fair for the echophonocardiographic time intervals and discopening amplitude, but poor for the disc velocities. Familiaritywith these normal findings should help clinicians to determinewhether an aortic M-H valve functions normally or not.     

Postoperative disc entrapment following cardiac valve replacement--a report of ten cases

The sudden jamming of a prosthetic valve disc is one cause for postoperative hemodynamic deterioration. This complication occurred in 10 instances (2% of disc valves implanted), resulting in 4 fatalities. In 6 patients the disc entrapment was a complication following mitral valve replacement, and in 4 others the malfunction followed aortic valve surgery. The entrapment of the disc occurred on the second postoperative day in 3 patients. Two of these were due to an unresected chordal strand becoming wedged between the disc and valve rim of a Bj?rk-Shiley mitral prosthesis and resulted in death. In the third patient, the aortic valve disc became attached to the Bj?rk-Shiley composite aortic graft following the repair of an aortic dissection. A firm blood clot had formed between the graft and the oversewn aortic wall. This patient recovered after cardiopulmonary resuscitation and subsequent reoperation. The remaining cases developed while the patients were still either on the operating table or in the recovery room. The mechanisms of the disc entrapments are presented and the significance of an early correct diagnosis and urgent surgical correction is underlined.     

心脏瓣膜替换术122例分析

本院自１９８４年３月至１９９２年１２月，应用侧倾碟瓣、牛心包生物瓣和Ｓｔ．Ｊｕｄｅ瓣施行心脏瓣膜替换１２２例。除１例外，病因均为风湿性病变。二尖瓣替换９６例，双瓣膜替换１７例，主动脉瓣替换９例。心功能（ＮＹＨＡ）Ⅲ级者７８例，Ⅳ级者２１例。术后１个月内死亡１５例（１２．３％）。死亡原因主要为心室颤动，细菌性、霉菌性心内膜炎，低心输出量综合征等。８３例随访６～９６个月，晚期死亡５例。余均症状改善，多数已恢复工作。本文还就换瓣手术指征，心室颤动的原因，重症患者机械呼吸的应用，术后心内膜炎等问题进行讨论。     

Thrombosis on Bjork-Shiley aortic valve prosthesis. Clinical, arteriographic, echocardiographic and therapeutic observations in seven cases

Seven patients with massive thrombosis on a Bjork-Shiley aortic valve prosthesis are described. This complication was documented in 5 percent of our patients with a Bjork-Shiley valve and occurred 3 to 19 months (mean 13 months) after insertion of the prosthesis. Only one patient had adequate anticoagulant therapy at the time of diagnosis. All patients had acute or subacute clinical deterioration. Anginal chest pain was the presenting symptom in four patients, and acute left ventricular failure in three. In all patients, the closing click of the Bjork-Shiley prosthesis was not heard, and new aortic systolic or diastolic murmurs were audible. Cardiac catheterization and aortic root cinearteriography were performed in five patients. Severe prosthetic regurgitation was found In four patients and mild regurgitation in one. Abnormal disc motion—fixation of the disc in the open position, abnormal limited opening of the disc or imperfect closure—was demonstrated in all arteriographic studies. Echocardiograms revealed an immobile disc in two patients.Five patients were surgically treated by thrombectomy and debridement of the prosthetic valve; the original prostheses were left in situ. Four of these patients are alive and one died. Two patients who did not undergo surgical treatment died. Thrombosis on the Bjork-Shiley aortic valve has a high fatality rate. Suspicion of this complication should be followed by emergency catheterization and surgery. In critically ill patients, surgery may be required even without angiography. The occurrence of this serious complication, mostly in patients with a normal coagulatory state, indicates the need for permanent anticoagulation in patients with a Bjork-Shiley aortic valve prosthesis.     

Early stenosis and calcification of glutaraldehyde-preserved porcine xenografts in children

Thirty-four glutaraldehyde-preserved porcine aortic valves have been implanted in children at the Center of Thoracic and Cardiovascular Surgery in G?ttingen since 1972. Severe stenosis of the right ventricular outflow tract (RVOT) due to massive calcification of the bioprosthetic valve was detected 15 to 76 months after surgery in 2 of 3 children with hospital-made, and in one of 25 children with commercially available valved conduits. The results with Hancock xenograft valves in mitral position were even more alarming. Five out of 6 children, aged 5 to 15 years (mean 9 years) presented similar massive calcification patterns of the bioprosthesis, necessitating reoperation from 23 to 63 months (mean 38.8 months) after implantation. Focal calcium deposits were found mostly in the central layers of the cusps; severe stenosis and regurgitation were due to immobilization of the leaf-lets which were fixed in a semi-open position. The causes for early valve dysfunction and calcification of glutaraldehyde-fixed porcine aortic bioprostheses in children remain to be further investigated. Degenerative changes have been shown to commence early after implantation, resulting in collagen disruption as early as 2 years later (3, 7, 19). There is evidence that these lesions could be predisposing factors for calcification, leading to accelerated calcification rats in children and patients with a high-calcium-turnover. The use of bioprostheses in children and adolescents must therefore be questioned since they appear to carry a high prospect to early valve deterioration.     

Echo- and phonocardiographic studies in patients with Lillehei-Kaster aortic valve prostheses.

Simultaneous echo- and phonocardiographic studies were performed in 17 patients with normally functioning Lillehei-Kaster (LK) tilting disc prosthesis in the aortic position. The LK aortic valve prosthesis was well recorded by echocardiography with a disc excursion of 14 to 25 mm and very fast opening and closing velocities, too rapid for quantitative assessment. On phonocardiography the opening click of the prosthesis was only rarely observed (2 out of 17 cases), while the closing sound was consistently present in all patients, occurring within 5 msec of the point of complete closure of aortic disc prosthesis by echocardiography. Systolic time intervals (STI) measured by combined echo-and phonocardiography were similar to the predicted values in 15 patients who had no evidence of residual cardiac dysfunction. In the remaining 2 patients, one or more components of the STI differed by more than 2 standard deviations from the predicted values, and in these there were associated findings to explain the discrepancies. This study illustrates the echo- and phonocardiographic features of the normally functioning LK aortic valve prosthesis. In addition, precise measurements of the isometric contraction and relaxation periods as well as standard systolic time intervals are possible with these techniques.     

The Ultracor tilting disc heart valve prosthesis in the aortic position: mid-term follow up

BACKGROUND AND AIM OF THE STUDY: The Ultracor valve is a recent introduction in the evolution of the tilting disc valve. This report summarizes a single surgeon's experience with the valve in the aortic position over a nine-year period. METHODS: Between 1990 and 1999, 94 patients received an Ultracor heart valve prosthesis in the aortic position. Forty-five patients (48%) had associated procedures, of which 32 (34%) were coronary artery grafts. Mean follow up was 2.6 years; total follow up was 229 patient-years. Follow up was 100% complete. RESULTS: The actuarial survival rate, including operative mortality rate, at five years was 82%. Actuarial freedom from valve-related death was 96% at five years. The linearized complication rate was 1.7%/year for late valve-related mortality, 1.7%/year for thromboembolism, 2.2%/year for anticoagulant-related hemorrhage (ACH), 1.3%/year for prosthetic valve endocarditis (PVE), and 1.7%/year for reoperation. The estimates of actuarial freedom from complications at five years were thromboembolism 89%, ACH 90%, PVE 96% and reoperation 96%. No structural failure or valve thrombosis was observed. CONCLUSION: Our experience over nine years showed the Ultracor heart valve prosthesis in the aortic position to be comparable with other currently evaluated mechanical heart valves in terms of durability and clinical results. Further study in this area should concentrate on the impact of valve type on left ventricular recovery post-implantation to provide additional information to the surgeon when selecting a valve from the plethora of choices available.