感染性主动脉瓣心内膜炎的外科治疗

目的：报告感染性主动脉瓣心内膜炎的外科治疗经验。方法：７６例感染性主动脉瓣心内膜炎患者，男５８例，女１８例，平均年龄３７．８±１１．３（１２～６０）岁。其中动脉血培养阳性４１例，阴性３５例。２７例（急性活动期）因急性心力衰竭或严重败血症等并发症而急症手术，４９例（慢性静止期）在抗生素治疗６周后择期手术。本组７６例患者行主动脉瓣替换术７４例；应用带瓣管道行主动脉根部、主动脉瓣替换和冠状动脉移植术２例。同期处理动脉导管未闭３例、佛氏窦瘤破裂＋心室间隔缺损６例、心室间隔缺损３例、二尖瓣关闭不全１１例和三尖瓣关闭不全５例。结果：７６例患者术后早期死亡５例（６．６％）：急性活动期２例，慢性静止期３例。术后平均随访４．１５年（１０个月～１０年），晚期死亡４例，其中２例死于人工瓣膜性心内膜炎。结论：感染性主动脉瓣心内膜炎手术时机的掌握对治疗效果至关重要，急症手术并不增加手术死亡率。     

18例心脏瓣膜病急诊手术

对１８例危重心脏瓣膜病患者进行急诊手术治疗，其中行二尖瓣闭式分离术４例，二尖瓣替换术３例，再次二尖瓣替换术６例，主动脉瓣替换术３例，主动脉瓣加二尖瓣替换术２例。术后早期死亡４例（占２２．２％），其余均痊愈出院。本文对手术时机、手术要点及术后处理的特殊性做了讨论。     

施行双瓣膜替换术5例临床体会

施行双瓣膜替换术５例临床体会栖霞市人民医院（２６５３００）娄德剑，林雪维，衣涛源，于佳生，孙绍军我院对５例风湿性心脏病二尖瓣及主动脉瓣双瓣膜病变患者，应用侧倾蝶瓣行主动脉瓣及二尖瓣双瓣膜替换术。其中男３例，女２例；年龄３４～４８岁。术前ＮＹＨＡ心功能...     

心脏瓣膜替换术80例体会

作者１９８９年１０月－１９９３年６月行人工心脏瓣膜替换术８０例（共９３个瓣）的治疗体会。男３５例，女４５例，年龄６～５９岁。包括二尖瓣替换５２例，主动脉瓣替换１５例，二尖瓣、主动脉瓣双瓣替换１３例。住院死亡７例，死亡率为８．７５％。文章对术后早期并发症的预防和术后抗凝问题进行了简要讨论。     

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。     

二尖瓣狭窄闭式扩张术后的瓣膜替换术

目的：介绍二尖瓣闭式扩张术后的瓣膜替换术经验。方法：我院自１９７７年１１月至１９９３年１２月期间共行二尖瓣闭式扩张术后瓣膜替换术２２９例（男１４８例，女８１例）。瓣膜替换时平均年龄４３．９５±６．６０岁。其中急诊手术５例，择期手术２２４例，两次手术间隔为１２．９６±６．７９年。均在低温体外循环下手术，其中二尖瓣替换术２０８例（９０．８３％）；二尖瓣及主动脉瓣双瓣替换术２１例（９．１７％）。结果：总手术死亡率７．４２％，１９８７年前死亡率为２３．６８％，而近３年死亡率仅０．８８％（１／１１３）。结论：掌握好手术时机；注重心肌保护；避免广泛游离心包粘连；采用右房、房间隔切口显露二尖瓣，连续缝合法替换二尖瓣，使手术时间缩短；以及正确的术后处理等，均是降低死亡率的重要因素。     

经胸骨下段正中小切口行心脏瓣膜手术

目的：探讨经胸骨下段正中小切口行各种心脏瓣膜手术的适应证和手术方法。 方法：３０例患者平均年龄４２．２±１０．１（１７～５８）岁。皮切口自第３胸肋关节水平至剑突根部,平均长度１１（９～１３）ｃｍ,自下而上纵行劈开胸骨至第２肋间处向右侧横断。手术于常规体外循环下进行,包括二尖瓣置换１９例,主动脉瓣置换３例,主动脉瓣及二尖瓣双瓣置换６例,二尖瓣Ｃａｒｐｅｎｔｉｅｒ环成形２例。７例同时行三尖瓣ＤｅＶｅｇａ环缩术。４例同时行左心房血栓清除。 结果：无手术死亡及并发症。平均主动脉阻断、体外循环和手术时间分别为５４．５±２４．９分、７９．２±２８．７分和１６０．９±４４．３分,术后呼吸机辅助１０．７±４．２小时,住院时间 １４．４±４．９天。术后胸液量２８２±１２５（５０～６３０）ｍｌ,有１６例患者（５３．３％）未输血。 结论：经胸骨下段正中小切口行心脏瓣膜手术安全可靠,美观,创伤小,出血少,保留了胸廓的连续性,早期结果满意。     

右心瓣膜感染性心内膜炎的外科治疗

目的：总结右心系统瓣膜心内膜炎的特点和手术处理经验。方法：回顾性分析右心系统瓣膜感染性心内膜炎１７例,其侵犯三尖瓣６例、肺动脉瓣４例,同时侵犯三尖瓣＋肺动脉瓣３例,肺动脉瓣＋主动脉瓣３例,主动脉瓣、二尖瓣、三尖瓣与肺动脉瓣同时受累１例。合并心脏畸形１４例,室间隔缺损修补术后、主动脉窦瘤破裂修补术后、起博器安置术后各１例。施行三尖瓣瓣膜游离缘或瓣膜赘生物切除直接缝合５例、三尖瓣瓣膜赘生物切除用自体心包片修补２例、部分瓣叶和瓣下结构切除缝合瓣叶并行人工腱索成形术１例,施行三尖瓣置换术２例;单纯行肺动脉瓣瓣叶赘生物切除４例,部分肺动脉瓣切除用自体心包片瓣叶成形术６例,切除肺动脉瓣用自体心包瓣置换１例。结果：术后早期死亡２例,病死率为１２％,术后早期并发急性肾功能不全３例,肝功能不全１例。术后随访５个月～１８年,平均随     

心脏直视手术中经食管超声心动图描记术的临床研究

目的：探讨术中经食管超声心动图描记术（ＩＴＥＥ）的临床应用价值。方法：回顾性研究总结１０６例接受ＩＴＥＥ检查的患者。结果：６６．０％的患者行瓣膜手术，其中包括二尖瓣成形术、二尖瓣替换术、主动脉瓣替换术、三尖瓣成形术及主动脉瓣、二尖瓣双瓣替换术；１２．３％的患者行左心室流出道疏通术；１１．３％的患者行带瓣主动脉替换术；１０．４％的患者行先天性心脏病矫治术，其中２例患者行经皮穿刺心房间隔缺损钮扣装置封堵术。结论：ＩＴＥＥ能即时评价人工瓣膜位于体内的功能状态，检出瓣周漏；准确地判断左心室流出道疏通的效果；ＩＴＥＥ检查在经皮穿刺缺损封堵术中也有较大的应用潜力。     

主动脉瓣及二尖瓣双瓣膜替换手术（附28例报告）

本文叙述了主动脉瓣及二尖瓣双瓣膜替换术。２８例病人均为风湿性心脏病。其中２例合并先天性心脏畸型。全组病例均置入人工机械瓣膜，其中８例同时行三尖瓣成形术。术后早期死亡１例，晚期死亡３例。本文对广义的心肌保护，主动脉瓣病变的判定，二尖瓣全周连续缝合，保留二尖瓣装置，三尖瓣的处理，主动脉瓣替换的一些方法，自体输血以及晚期死亡原因及预防等问题做了讨论。     

Obstruction of mechanical heart valve prostheses: clinical aspects and surgical management

One hundred patients (32 male) aged 5 months to 82 years (median 32 years) underwent 106 surgical procedures for 112 mechanical prosthetic valves obstructed by a thrombus (n = 61) or pannus (n = 7), or both (n = 44), between January 1, 1980 and December 31, 1989. The position of the obstructed prosthesis was aortic in 51 patients (48%), mitral in 49 (46%) and both aortic and mitral in 6 (6%). The types of obstructed prosthetic valves were Bj?rk-Shiley (n = 51), St. Jude (n = 41) and Medtronic-Hall (n = 20). The time interval between valve replacement and obstruction ranged from 6 weeks to 13 years (median 4 years). Of 63% of patients in whom coagulation variables were available at the time of obstruction, 70% were receiving inadequate anticoagulant therapy. In 63% of the procedures the patient was in New York Heart Association functional class IV. Two patients underwent preoperative thrombolysis with incomplete results. Operative procedures included valve replacement (n = 81), valve declotting and excision of pannus (n = 23) and aortic valve replacement and mitral valve declotting (n = 2). The early mortality rate was 12.3% (13 patients), and there was no difference between surgery for mitral prostheses (12.2%) versus aortic prostheses (13.7%). The perioperative mortality rate was 17.5% (11 of 63 patients) in patients in functional class IV and 4.7% (2 of 43 patients) in those in functional classes I to III (p less than 0.05). For valve replacement, the mortality rate was 12% (10 of 81 patients) and for declotting of the prosthesis 13% (3 of 23 patients).(ABSTRACT TRUNCATED AT 250 WORDS)     

Cardiac surgery in octogenarians; peri-operative outcome and long-term results.

AIMS: Because the elderly are increasingly referred for operation, we reviewed the results of cardiac surgery in patients of 80 years or older. METHODS AND RESULTS: Records of 182 consecutive octogenarians who had had cardiac operations between 1992 and 1998 were reviewed. Follow-up was 100% complete. Seventy patients had coronary grafting (CABG), 70 aortic valve replacement, 30 aortic valve replacement+CABG, and 12 mitral valve repair/replacement. Rates of hospital death, stroke, and prolonged stay (>14 days) were as follows: CABG: 7 (10%), 2 (2.8%) and 41 (58%); aortic valve replacement: 6 (8.5%), 2 (2.8%) and 32 (45.7%); aortic valve replacement+CABG: 8 (26.5%), 1 (3.8%) and 14 (46.6%); mitral valve repair/replacement: 3 (25%), 1 (8.3%) and 5 (41.6%). Multivariate predictors (P<0.05) of hospital death were New York Heart Association functional class, urgent procedure, prolonged cardiopulmonary bypass time, and, after aortic valve replacement, previous percutaneous aortic valvuloplasty. Ascending aortic atheromatous disease was predictive of stroke, while pre-operative myocardial infarction was predictive of prolonged hospital stay. Actuarial 5-year survival was as follows: CABG, 65.8+/-8.8%; aortic valve replacement, 63.6+/-7.1%; aortic valve replacement+CABG, 62.4+/-6.8%; mitral valve repair/replacement, 57.1+/-5.6%; and total, 63.0+/-5.6%. Multivariate predictors of late death were pre-operative myocardial infarction, and urgent procedure. Ninety percent of long-term survivors were in New York Heart Association class I or II, and 87% believed having a heart operation after age 80 years was a good choice. CONCLUSION: Cardiac operations are successful in most octogenarians with increased hospital mortality, and longer hospital stay. Long-term survival and quality of life are good.     

Early clinical results with the Xenomedica porcine bioprosthesis

All patients undergoing heart valve replacement with a glutaraldehyde-preserved Xenomedica xenograft from June 1983 through November 1983, were reviewed. This analysis included 75 patients: 37 having undergone aortic valve replacement, 23 mitral valve replacement, and 15 mitral and aortic valve replacement. Of 70 patients discharged from the hospital, there were 5 late deaths, which represents an incidence of 1.06% per patient-year. Twenty-six patients were recatheterized between 3 and 6 months postoperatively. The mean mitral valve orifice area was 1.57 +/- 0.37 cm2. The average mitral valve gradient was 9.8 +/- 2.9 mmHg. No differences in hemodynamic behavior were found between standard and composite mitral prostheses. The average aortic valve peak systolic gradient was 11 +/- 6 mmHg. Fourteen out of the 34 mitral (41%) and 5 out of 52 aortic (9.6%) prostheses have some degree of incompetence. We have discontinued the use of this cardiac bioprosthesis due to the frequent appearance of incompetence in mitral valves, and high transvalvular gradients in mitral prostheses.     

The natural history of aortic valve disease after mitral valve surgery

OBJECTIVES

The present study evaluates the long-term course of aortic valve disease and the need for aortic valve surgery in patients with rheumatic mitral valve disease who underwent mitral valve surgery.

BACKGROUND

Little is known about the natural history of aortic valve disease in patients undergoing mitral valve surgery for rheumatic mitral valve disease. In addition there is no firm policy regarding the appropriate treatment of mild aortic valve disease while replacing the mitral valve.

METHODS

One-hundred thirty-one patients (44 male, 87 female; mean age 61 ± 13 yr, range 35 to 89) were followed after mitral valve surgery for a mean period of 13 ± 7 years. All patients had rheumatic heart disease. Aortic valve function was assessed preoperatively by cardiac catheterization and during follow-up by transthoracic echocardiography.

RESULTS

At the time of mitral valve surgery, 59 patients (45%) had mild aortic valve disease: 7 (5%) aortic stenosis (AS), 58 (44%) aortic regurgitation (AR). At the end of follow-up, 96 patients (73%) had aortic valve disease: 33 AS (mild or moderate except in two cases) and 90 AR (mild or moderate except in one case). Among patients without aortic valve disease at the time of the mitral valve surgery, only three patients developed significant aortic valve disease after 25 years of follow-up procedures. Disease progression was noted in three of the seven patients with AS (2 to severe) and in six of the fifty eight with AR (1 to severe). Fifty two (90%) with mild AR remained stable after a mean follow-up period of 16 years. In only three patients (2%) the aortic valve disease progressed significantly after 9, 17 and 22 years. In only six patients of the entire cohort (5%), aortic valve replacement was needed after a mean period of 21 years (range 15 to 33). In four of them the primary indication for the second surgery was dysfunction of the prosthetic mitral valve.

CONCLUSIONS

Our findings indicate that, among patients with rheumatic heart disease, a considerable number of patients have mild aortic valve disease at the time of mitral valve surgery. Yet most do not progress to severe disease, and aortic valve replacement is rarely needed after a long follow-up period. Thus, prophylactic valve replacement is not indicated in these cases.     

Clinical and echocardiographic evaluation of the St. Jude cardiac valve prosthesis: follow-up of 126 patients

One hundred twenty-six patients with a St. Jude valve prosthesis were followed up clinically and studied by combined M-mode echocardiography and phonocardiography. Fifty patients underwent aortic valve replacement, 58 underwent mitral valve replacement and 18 underwent a combination of the two. The early postoperative mortality rate was 8% for aortic, 6.9% for mitral and 6% for combined valve replacement. Follow-up ranged from 2 to 46 months (mean +/- SD 28 +/- 9). The late postoperative mortality rate was 5%; in patients who survived, improvement in New York Heart Association functional class occurred in 97%. Major thromboembolic events occurred in two patients and anticoagulation-related complications occurred in three patients. Valve-related complications occurred in 14 patients and included bacterial endocarditis (6 patients), paravalvular leak (5 patients), severe hemolysis (1 patient), thrombosis of valve (1 patient) and possible mechanical valve failure (1 patient). In 7 of these 14 patients, repeat surgery was required and 5 patients survived. Abnormal echocardiographic findings in these seven patients included a shortened aortic closure (A2) to mitral valve opening interval, increased left atrial and left ventricular size and initial diastolic rounding of the St. Jude valve motion in the patient with the thrombosed valve. It is concluded that the St. Jude valve prosthesis is associated with favorable functional results and a low complication rate for a mean follow-up period of 28 months. Combined M-mode echocardiography and phonocardiography may be useful in assessing patients with suspected complications related to the St. Jude cardiac valve.     

Mid-term results after heart valve replacement with the CarboMedics bileaflet prosthesis: experience with 785 implants.

BACKGROUND: The aim of the study was to evaluate our clinical experience with the CarboMedics Heart Valve Prosthesis. METHODS: Between October 1991 and December 1997, six hundred seventy-two consecutive patients (361 men, 54%; 311 women, 46%; mean age 57 +/- 12 year, range 6-73 years) underwent mechanical valve implantation at the Division of Cardiac Surgery of the University of Verona. Preoperatively, 69% of the patients were in NYHA FC III or IV. Eighty-one patients (12%) had undergone a previous cardiac operation and 14.5% had an ejection fraction less than 35%. We performed an aortic valve replacement in 309 patients (78 valved-conduits for replacement of the entire aortic root), a mitral valve replacement in 250, and a double valve in 113. 52 patients (8%) underwent associated myocardial revascularization. RESULTS: Early mortality was 2.8% (5/309 aortic, 1.6%; 11/250 mitral, 4.4%; 3/113 double, 2.6%). Late mortality was 4.4%. Actuarial survival at 5 years was 89.3% (aortic, 91.1%, mitral 86.4%, double 90.5%). Thromboembolism occurred in 26 patients (3.9%) and major hemorrhagic events in 20 (3%). Nine patients (1.3%) required a reoperation, in 3 cases (0.4%) after endocarditis (Staphylococcus epidermidis). No structural deterioration occurred in our series. CONCLUSION: Our study appears to confirm the safety and reliability of the CarboMedics mechanical valve prosthesis, even in old age groups. This bileaflet prosthesis demonstrates no structural deterioration, a low incidence of complications, and good hemodynamic performance.     

Ventricular septal defect with congenital mitral valve disease: long-term results of corrective surgery

BACKGROUND: A retrospective analysis of the mortality, morbidity and long-term follow-up of patients undergoing corrective surgery for ventricular septal defect and congenital mitral valve disease is presented. METHODS AND RESULTS: Between January 1991 and December 2000, 69 consecutive patients aged 2 months to 45 years (median 18 months) underwent repair of ventricular septal defect and associated mitral valve disease. In 52 patients (75%), the ventricular septal defects were located in the perimembranous and subarterial area. Forty-six patients had congenital mitral incompetence and 23 had congenital mitral stenosis. The ventricular septal defect was repaired through the right atrium in all. Sixty-five patients underwent reconstruction of the mitral valve and 4 underwent primary mitral valve replacement. Another 4 patients underwent mitral valve replacement after a failed repair. Associated procedures included: patent ductus arteriosus ligation (n=12), aortic valve replacement (n=6), coarctation repair (n=13), interrupted aortic arch repair (n=1), atrial septal defect closure (n=17) and Takeuchi repair (n=1). There were 6 early deaths (8.6%). Three deaths were due to pulmonary arterial hypertensive crisis and one due to residual mitral stenosis. One death was due to intractable congestive heart failure. Another patient died due to persistent low cardiac output. Follow-up ranged from 6 months to 120 months (mean 64.4+/-33.6 months). Reoperation was required in 22 patients, mainly for recurrent/residual mitral valve dysfunction or hemodynamically significant left ventricular outflow tract obstruction. There were 4 late deaths, 2 due to residual mitral stenosis and the other 2 as a result of a thrombosed prosthetic valve. At 10 years, the actuarial survival rate was 850+/-5.0%, and freedom from reoperation was 45%+/-10.0%. CONCLUSIONS: Reconstruction of the mitral valve along with closure of VSD is possible in most cases. However, careful follow-up is recommended to detect changes in the mitral valve status over a course of time.     

Cardiac valve replacement in patients over 75 years of age

Elderly patients with symptomatic cardiac valvular malfunction have a grave prognosis if managed medically but can be offered a reasonable chance for long-term survival and a good chance for improvement by replacement of the malfunctioning valve. A series of patients 75 years of age and older who underwent aortic valve replacement (31 patients) mitral valve replacement (9 patients), or combined valve replacement (on patient) has been reviewed. The overall operative mortality for aortic valve replacement was 23% (17% over the past 5 years) and the 5-year actuarial survival was 54 +/- 11%. The operative mortality for mitral replacement was 11% and the 5-year actuarial survival was 55 +/- 21%. The average hospital stay for survivors was 19 days after aortic valve replacement. Four patients have had embolic events since valve replacement, 3 after aortic and one after mitral valve replacement. The addition of coronary artery bypass surgery to the valve replacement procedure is becoming more frequent and may have contributed to improved operative survival. A literature review of reported clinical experience shows that the advancement of cardiac surgery has permitted a redefining of the group thought as "elderly", and that this group has an improved operative survival with the improvements in cardiac valve surgery.     

Influence of surgery on the natural history of rheumatic mitral and aortic valve disease

The rate of survival, the evolution of functional cardiac status and the incidence of major complications during a 5 year period were studied in 410 patients with rheumatic mitral or aortic valve disease, of whom 200 were treated medically and 210 by surgery. The 5 year survival rates in patients with various types of rheumatic mitral valve disease were similar (45 percent for those with mitral stenosis and 46 percent for those with mitral insufficiency or mixed mitral insufficiency and stenosis). The survival rate in patients with aortic valve disease was somewhat more favorable (64 percent).Mitral valvulotomy had the most positive influence on mortality. The 85 percent 5 year survival rate of patients who underwent this procedure was significantly higher than that of patients with medically treated mitral stenosis. In patients submitted to mitral and aortic valve replacement, the survival rate was also improved in comparison with data in the corresponding medically treated groups, but to a lesser degree (70 percent for aortic valve replacement and 60 percent for mitral valve replacement). In all surgically treated groups, initial operative mortality was the primary determinant of the rate of survival at the end of 5 years.Survivors of all surgical groups had appreciable improvement in cardiac functional classification and a remarkable reduction in the incidence of heart failure and atrial fibrillation. The incidence of infectious endocarditis was significantly reduced after mitral valvulotomy, as compared with the incidence in patients with medically treated mitral stenosis. Mitral and aortic valve replacement did not reduce the incidence of infectious endocarditis. The incidence of thromboembolic phenomena was favorably influenced by mitral valvulotomy and aortic valve replacement, but not by mitral valve replacement.     

The risk of reoperative heart valve procedures in Octogenarian patients

BACKGROUND AND AIM OF THE STUDY: The authors' experience is reported of cardiac reoperations for valvular heart disease in octogenarian patients. METHODS: The records of 22 consecutive patients (10 men, 12 women) aged > or =80 years (mean age 82.4+/-2.3 years) who underwent cardiac reoperation for aortic and/or mitral valvular heart disease at the authors' institution between 1991 and 2001 were retrospectively reviewed. RESULTS: Indications for reoperation were structural dysfunction of a previously implanted bioprosthetic valve in 11 patients (50%), new valvular heart disease in six (27%), progression of rheumatic valvular heart disease in four (18%), and prosthetic valve infective endocarditis in one patient (5%). Fourteen patients (64%) underwent isolated aortic valve replacement (AVR), two (9%) had AVR plus coronary artery bypass grafting (CABG), one patient (5%) had aortic root replacement plus CABG, three patients (14%) had isolated mitral valve replacement (MVR), one patient (5%) had MVR plus ascending aorta replacement, and one (5%) had AVR plus MVR. Postoperative complications occurred in 18 patients (82%). The hospital mortality rate was 32%. Actuarial survival estimates at one year, and at three and five years were 62.6%, 56.3% and 40.2%, respectively. CONCLUSION: Cardiac reoperations for valvular heart disease in octogenarians carry a high postoperative morbidity and mortality. These findings must be taken into account in the management of associated mild or moderate valvular heart disease, and in the choice of heart valve prosthesis at the initial operation in younger patients.