自体心包补片修补主动脉瓣环辅助主动脉瓣置换

背景：在主动脉置换过程中常遇到瓣环钙化、瓣周囊肿等特殊情况,这时一般应用特殊技术辅助主动脉瓣置换。 目的：观察自体心包补片修补主动脉瓣环辅助主动脉瓣置换治疗钙化性主动脉瓣狭窄并瓣环钙化的临床可行性。 方法：回顾性分析2009年1月至 2012年1月郑州大学第一附属医院42例钙化性主动脉瓣狭窄并瓣环钙化患者的临床资料,并通过统计学软件处理自体心包补片修补主动脉瓣环技术辅助主动脉瓣置换前后的主动脉瓣有效瓣口面积指数、最大跨瓣压差、血流峰值速度、左室射血分数等数据,分析自体心包补片修补主动脉瓣环技术辅助主动脉瓣置换的应用效果。 结果与结论：无置换中死亡病例,置换中主动脉阻断时间为52-88(63.0±18.1) min,体外循环时间为78-122(102.6±25.1) min,置换后1例患者出现急性肾功能衰竭,经床旁血透治疗后治愈。余患者无严重置换并发症。置换后住院天数为7-20(13.6±5.5) d。置换后多普勒超声心动图示：瓣膜功能良好,均未发现主动脉瓣周漏。置换后6个月的主动脉瓣有效瓣口面积指数、最大跨瓣压差、血流峰值速度、左室射血分数均有显著改善,与置换前比较差异均有显著性意义(P < 0.05)。证实对置换适应证合适的特殊换瓣患者,自体心包补片修补主动脉瓣环辅助主动脉瓣置换可取得满意的外科治疗效果,且操作安全简单,是一项可行的技术。     

小主动脉瓣环188例患者人工机械瓣换瓣术后疗效观察

目的回顾性分析188例成年人小主动脉瓣环(瓣环直径≤21 mm)人工机械瓣膜置换术后患者的疗效及心功能的变化,探讨3种机械瓣替换术后是否存在植入瓣膜与患者不匹配(PPM)现象。方法选择南京中医药大学附属医院心胸外科188例植入小主动脉瓣环(直径16~21 mm)成年患者(占所有主动脉瓣置换患者的45.83%),其中男性96例,女性92例;年龄17~72岁,平均年龄51.12岁。主动脉瓣二叶畸形10例,单纯主动脉瓣狭窄27例,单纯主动脉瓣关闭不全46例,二尖瓣联合主动脉瓣病变96例,感染性心内膜炎9例;其中20例置换17 mm SJ Regent机械瓣,45例置换19 mm SJ Regent机械瓣,30例置换21 mm SJ Regent机械瓣,31例置换Carbio-S 19 mm机械瓣,20例置换Carbio-S21 mm机械瓣,10例置换16 mm over-line Sorin机械瓣,16例置换18 mm over-line Sorin机械瓣,16例置换20 mm overline Sorin机械瓣。采用彩色多普勒超声心动图分别于术前、术后1周、术后3个月和1年,检测患者的左心室舒张末期内径、收缩末期内径、室间隔及左心室后壁厚度、左心室射血分数(LVEF)、左心室短轴缩短率(LVFS)和主动脉瓣跨瓣压差的变化,观察左心室质量指数变化情况,并进行各组比较分析。结果全组患者无手术死亡,围术期死亡2例,术后1年内不明原因猝死3例,其余183例患者均随访1年以上。参考各瓣膜厂家提供的有效瓣口面积指数(EOAI),该研究组无重度PPM,所有患者EOAI均大于0.65 cm~2/m~2,EOAI在0.65~0.85 cm~2/m~2(中度PPM)患者占35.14%,EOAI0.85 cm~2/m~2占64.86%,EOAI与主动脉瓣跨瓣压差之间无明显相关性;术后所有患者心功能均较术前提高2~3级。术后3个月至1年内平均LVEF和LVFS均在正常范围。术后各组患者3个月至1年左心室平均内径均恢复至正常范围。术后1周平均左心室质量指数为90.35 g/m~2,较术前(101.48 g/m~2)下降显著(P0.05),随访3个月到1年无显著变化;所有患者术后1周~1年内主动脉瓣跨瓣平均压差2.92 k Pa(21.92 mm Hg),各组患者术后1周随访至术后1年,主动脉瓣跨瓣压差均无显著变化。5组患者(16 mm over-line Sorin机械瓣组、20 mm over-line Sorin机械瓣组、17 mm SJ Regent机械瓣组、Carbio-S 19 mm机械瓣组、Carbio-S 21 mm机械瓣组)术后1年内主动脉瓣跨瓣压差与其他3组相比明显增大,组间差异有统计学意义(P0.05);其中16 mm over-line Sorin机械瓣组跨瓣压差最大。所有患者均未发现有PPM现象发生。结论采用中国市场上来自不同厂家的各种直径的主动脉瓣机械瓣膜置换术后未见明显PPM现象,左心室质量指数及主动脉跨瓣压差术后均在比较理想的范围;不同厂家的各种型号的人工主动脉机械瓣可以满足绝大多数成年小主动脉瓣环患者主动脉瓣置换的需求,大部分患者无须行主动脉瓣环扩大术或采用其他术式。     

Incidence and outcomes of infective endocarditis after transcatheter aortic valve implantation versus surgical aortic valve replacement

ObjectivesTranscatheter aortic valve implantation (TAVI) is an alternative to surgical aortic valve replacement (AVR) in aortic stenosis (AS). Infective endocarditis (IE) in patients with prosthetic heart valves is associated with significant morbidity and mortality. Data on the incidence, risk factors, and outcomes of IE after TAVI are conflicting. We evaluated these issues in patients with percutaneous TAVI vs. isolated surgical AVR (SAVR) at a nationwide level.MethodsBased on the administrative hospital discharge database, the study collected information for all patients with aortic stenosis treated with AVR in France between 2010 and 2018.ResultsA total of 47 553 patients undergoing TAVI and 60 253 patients undergoing isolated SAVR were identified. During a mean follow-up of 2.0 years (median (25th to 75th percentile) 1.2 (0.1–3.4) years), the incidence rates of IE were 1.89 (95% confidence interval (CI) 1.78–2.00) and 1.40 (95% CI 1.34–1.46) events per 100 person-years in unmatched TAVI and SAVR patients, respectively. In 32 582 propensity-matched patients (16 291 with TAVI and 16 291 with SAVR), risk of IE was not different in patients treated with TAVI vs. SAVR (incidence rates of IE 1.86 (95% CI 1.70–2.04) %/year vs 1.71 (95% CI 1.58–1.85) %/year respectively, relative risk (RR) 1.09, 95% CI 0.96–1.23). In these matched patients, total mortality was higher in TAVI patients with IE (43.0% 95% CI 37.3–49.3) than in SAVR patients with IE (32.8% 95% CI 28.6–37.3; RR 1.32, 95% CI 1.08–1.60).DiscussionIn a nationwide cohort of patients with AS, treatment with TAVI was associated with a risk of IE similar to that following SAVR. Mortality was higher for patients with IE following TAVI than for those with IE following SAVR.     

儿童心脏瓣膜置换手术技巧及效果

目的总结14例儿童心脏瓣膜置换术的经验,探讨儿童瓣膜置换的手术指征、瓣膜选择、手术技术和术后抗凝治疗等问题。方法全组14例中10例为先天性心脏瓣膜病变,3例风湿性病变,1例先天性室间隔缺损致心内膜炎、主动脉瓣膜菌栓。在中低温体外循环下手术,二尖瓣置换7例,主动脉瓣置换6例,二尖瓣置换 主动脉瓣置换1例。均采用机械瓣。若合并其它先天性心脏畸形或三尖瓣关闭不全,同期矫治。术后常规应用华法林抗凝。结果本组手术死亡1例,12例心功能恢复至I级,1例心功能II级。发生1例感染性心内膜炎,治愈。均坚持采用华法林抗凝,无血栓栓塞及抗凝相关并发症发生,瓣膜功能良好。结论儿童心脏瓣膜置换术采用机械瓣效果较好;应用低强度的华法林进行抗凝治疗安全可靠。     

A case in which biventricular assist device support was required after aortic valve replacement with a bioprosthetic valve

We report the case of a 45-year-old man with severe aortic regurgitation. The patient underwent aortic valve replacement with a bioprosthetic valve, but was unable to be weaned from cardiopulmonary bypass (CPB). Intraoperative coronary angiography revealed stenosis of the right coronary orifice, so an intra-aortic balloon pump was inserted and coronary artery bypass grafting to the right coronary artery was conducted; however, weaning from CPB again failed. Left ventricular assist using a Gyro centrifugal pump was performed between the left atrium and left femoral artery, along with right ventricular assist using a Nikkiso centrifugal pump between the right atrium and pulmonary artery. Flow rates averaged from 2.0 to 2.8l/min for the left-side ventricular assist device (VAD) and 2.1–3.8l/min for the right-side VAD. The bypass rate reached approximately 70% at maximum. No thromboembolic events were documented during VAD support. The patient underwent explantation of VADs on postoperative day 4. No thrombus was identified on the bioprosthetic aortic valve by transesophageal echocardiography. The left-side pump displayed no thrombus, while the right-side pump had a small thrombus at the shaft. The patient was discharged from the hospital and was alive as of 2 year postoperatively. To the best of our knowledge, no clinical study has yet compared the antithrombotic properties of two centrifugal pumps in one patient where mechanical support was performed for the same duration and flow rate.     

A European update on transcatheter aortic valve implantation (TAVI) in the COVID era

Minimally invasive approaches for aortic valve replacement are now at the forefront of pathological aortic valve treatment. New trials show comparability of these devices to existing therapies, not only in high-risk surgical cohorts but also in low-risk and intermediate-risk cohorts. This review provides vital clinical and anatomical background to aortic valvular disease treatment guidelines, while also providing an update on transcatheter aortic valve implantation (TAVI) devices in Europe, their interventional trials and associated complications.     

经心尖主动脉瓣置换术治疗高危单纯无钙化主动脉瓣关闭不全的手术配合

目的探讨国产J-Valve?支架瓣膜行经心尖主动脉瓣置换(TAVR)术治疗高危单纯无钙化主动脉瓣关闭不全的手术配合方法。 方法收集2017年3月至2018年3月在首都医科大学附属北京安贞医院高危单纯无钙化主动脉瓣关闭不全患者资料,共15例。所有患者均使用国产J-Valve?系统为患者行TAVR术。经过细致的术前评估(包括术前访视、熟悉仪器设备、介入耗材设备等)、术中流畅的手术配合[包括严格遵循无菌原则、术中患者体温保护、X线防护、激活全血凝固时间(ACT)的监测以及支架瓣膜的装配等]和术中安全管理(包括防止输送器移位和动脉置管的护理等)。观测患者术中是否使用心肺转流、发生心室快速起搏、中转行常规体外循环下TAVR术,是否有冠状动脉阻塞、植入瓣膜是否有移位,有无瓣膜内狭窄及瓣周漏等情况发生,观测术后即刻平均主动脉瓣跨瓣压差;患者在ICU是否顺利脱离呼吸机拔除气管插管,术中平均出血量、患者在ICU时间和呼吸机辅助通气时间、射血分数以及是否存在瓣周漏等;了解患者心功能分级、活动耐量以及是否存在胸闷、心绞痛等症状。 结果本研究中所有患者均成功完成TAVR术,未使用心肺转流、未发生心室快速起搏,无中转行常规体外循环下TAVR术,未发生冠状动脉阻塞或植入瓣膜移位,未见瓣膜内狭窄及瓣周漏等情况。术后即刻平均主动脉跨瓣压差为[5.8(4.9,12.9)] mmHg(1 mmHg＝0.133 kPa)。所有患者在ICU均顺利脱离呼吸机拔除气管插管,术中平均出血量为[200.0 (100.0, 500.0)]mL,患者在ICU时间为(1.2±0.4) d,呼吸机辅助通气时间为[19.0 (8.5, 23.5)] h,平均射血分数为(56.2±15.6)%,仅有2例患者存在微量瓣周漏。末次随访中,10例患者心功能Ⅰ级,4例为Ⅱ级,1例为Ⅲ级;患者的活动耐量都较术前明显改善;患者术后胸闷、心绞痛等症状较术前明显改善。 结论手术室护士正确掌握TAVR术的手术配合方法,术前做好患者的心理护理以及各项术前准备,手术过程中与外科医师密切配合,是患者手术成功的保证。     

Clinical predictors of prosthesis-patient mismatch after aortic valve replacement for aortic stenosis

OBJECTIVE:

We sought to ascertain predictors of Patient Prosthesis Mismatch, an independent predictor of mortality, in patients with aortic stenosis using bioprosthetic valves.

METHOD:

We analyzed 2,107 sequential surgeries. Patient Prosthesis Mismatch was calculated using the effective orifice area of the prosthesis divided by the patient''s body surface area. We defined nonsignificant, moderate, and severe Patient Prosthesis Mismatch as effective orifice area indexes of >0.85 cm²/m, 0.85-0.66 cm²/m², and ≤0.65 cm²/m², respectively.

RESULTS:

A total of 311 bioprosthetic patients were identified. The incidence of nonsignificant, moderate, and severe Patient Prosthesis Mismatch was 41%, 42, and 16%, respectively. Severe Patient Prosthesis Mismatch was significantly more prevalent in females (82%). In severe Patient Prosthesis Mismatch, the perfusion and the cross-clamp times were considerably lower when compared with nonsignificant Patient Prosthesis Mismatch and moderate Patient Prosthesis Mismatch. Patients with severe Patient Prosthesis Mismatch had a significantly higher likelihood of spending time in the intensive care unit and a significantly longer length of stay in the hospital. Body surface area was not different in severe Patient Prosthesis Mismatch when compared with nonsignificant Patient Prosthesis Mismatch. In-hospital mortality in patients with nonsignificant, moderate, and severe Patient Prosthesis Mismatch was 2.3%, 6.1%, and 8%, respectively. Minimally invasive surgery was significantly associated with moderate Patient Prosthesis Mismatch in 49% of the patients, but not with severe Patient Prosthesis Mismatch.

CONCLUSION:

Severe Patient Prosthesis Mismatch is more common in females, but not in those with minimal available body surface area. Though operative times were shorter in these patients, intensive care unit and hospital lengths of stay were longer. Surgeons and cardiologists should be cognizant of these clinical predictors and complications prior to valve surgery.     

内皮素-1水平与单纯行主动脉瓣置换术患者术后新发房颤的相关性分析

目的探讨内皮素-1水平与单纯行主动脉瓣置换术患者术后新发房颤的关系。 方法回顾性分析2017年6月至2019年6月于首都医科大学附属北京安贞医院结构性心脏病外科中心单纯行主动脉瓣置换术的119例患者的临床资料,根据患者术后是否新发房颤分为术后房颤组(n＝28)和无术后房颤组(n＝91)。2组患者均于全身麻醉成功后取仰卧位,常规消毒铺巾,作胸部正中切口并劈开胸骨。切开心包并悬吊,肝素化后升主动脉、右心房二阶梯引流管插管建立体外循环,转机、降温,阻断循环,切开主动脉,探查主动脉瓣病变情况,剪除病变主动脉瓣,选择合适大小的人工主动脉瓣(机械瓣或生物瓣)进行置换,全周间断缝合。关闭主动脉切口。复温、排气,开放循环。并行稳定后停止体外循环,拔出动静脉管路。常规止血关胸,结束手术。统计患者术前各项资料中最可能影响术后房颤发生的因素[性别、年龄、体重指数、内皮素-1水平、基础疾病、美国纽约心脏病协会(NYHA)心功能分级、超声心动图指标]、术中资料(术中体外循环时间、主动脉阻断时间)及术后资料[术后机械通气时间、术后住院时间、行开胸止血术例数、使用何种类型人工瓣膜(机械瓣或生物瓣)]。数据比较采用t检验、非参数检验、χ²检验;通过受试者工作特征(ROC)曲线确定内皮素-1预测术后新发房颤的截断值;采用单因素和多因素Logistic回归分析与术后新发房颤相关的危险因素。 结果(1)术后房颤组患者的年龄为(53.0±12.1)岁,高于无术后房颤组[(47.1±13.6)岁],术前内皮素-1水平为0.43±0.19,高于无术后房颤组(0.27±0.14),NYHA分级≥3级患者比例为14.3%(4/28),高于无术后房颤组[4.4%(4/91)],左心房直径为(40.6±4.8) mm,大于无术后房颤组[(36.7±5.2 ) mm],主动脉瓣狭窄患者比例为39.3%(11/28),低于无术后房颤组[60.4%(55/91)],2组比较差异均有统计学意义(P<0.05);其他术前资料比较差异均无统计学意义(P>0.05)。(2)术后房颤组患者术中体外循环时间为(113.9±41.7) min,主动脉阻断时间为(75.3±24.1) min,无术后房颤组患者术中体外循环时间为(108.6±46.3) min,主动脉阻断时间为(72.5±31.4) min,2组比较差异均无统计学意义(t＝－0.547、－0.432,P＝0.59、0.67)。(3)术后房颤组患者术后机械通气时间、术后住院时间分别为(24.7±14.3) h、(9.1±3.6) d,均大于无术后房颤组[(19.6±9.5) h、(7.6±2.9) d];置换机械瓣患者比例为85.7%(24/28),低于无术后房颤组[96.7%(88/91)],置换生物瓣膜患者比例为14.3%(4/28),高于无术后房颤组[3.3%(3/91)],2组比较差异均有统计学意义(P<0.05);术后房颤组患者术后行开胸止血术的比例为3.6%(1/28),高于无术后房颤组[2.2%(2/91)],2组比较差异无统计学意义(P>0.05)。(4)采用ROC曲线对内皮素-1预测术后新发房颤的价值进行分析可得,曲线下面积为0.76,95%CI：0.66～0.85,截断值0.265 pmol/L,特异度0.75,敏感度0.63。根据截断值将患者分为内皮素-1>0.265组(n＝55)和内皮素-1<0.265组(n＝64),对2组患者术前、术中资料和术后资料进行比较,结果可得内皮素-1>0.265组患者左心房直径大于内皮素-1<0.265组患者,主动脉瓣狭窄患者比例低于内皮素-1<0.265组患者,术后新发房颤的发生率(38.2%)明显高于内皮素-1<0.265组(10.9%),差异均有统计学意义(P<0.05),其他各项比较差异均无统计学意义(P>0.05)。对收集到的患者资料进行单因素Logistic回归分析,发现年龄、NYHA分级≥3级、左心房直径、主动脉瓣狭窄、术后机械通气时间、置换生物瓣及内皮素-1>0.265 pmol/L均与术后新发房颤的发生相关;对以上指标进行多因素Logistic回归分析结果可得左心房直径、置换生物瓣和内皮素-1>0.265 pmol/L与患者术后新发房颤的发生呈独立相关。 结论在单纯行单纯主动脉瓣置换术的患者中,除左心房直径、置换生物瓣外,较高的内皮素-1水平也是患者发生术后新发房颤的独立危险因素。     

应用三维打印技术构建心脏瓣膜病术前主动脉根部模型的可行性研究

目的探讨应用三维(three dimensional,3D)打印技术构建心脏瓣膜病术前主动脉根部模型的可行性。方法前瞻性入选术前接受CT检查且拟行主动脉瓣置换术的患者8例,其中6例的主动脉疾病手术指征为主动脉瓣重度狭窄(2例合并主动脉瓣二叶式畸形),1例为人工生物瓣置入术后瓣膜失功能,1例为主动脉根部瘤合并主动脉瓣反流。CT扫描均使用前瞻性心电门控采集,将患者收缩期CT图像导入Mimics、3-matic、Magics、Freeform等医学三维图像建模及编辑软件,逐一进行疾病三维模型的构建,并打印出实物模型。结果 8例患者的主动脉疾病模型均成功构建,模型质量满意,有3例模型得到了手术验证。患者中位年龄为74岁(52～82岁),三维建模的中位耗时为4.5 h(3.0～5.5 h),3D打印的中位耗时为5 h(5～9 h),中位材料成本为3050元(2600～9700元)。结论应用3D打印技术构建心脏瓣膜病术前主动脉根部模型是可行的。