心脏机械瓣膜置换术后抗凝的相关问题

各种类型的人造心脏瓣膜已在成千上万的患者身上置换,取得了令人满意的效果.但机械瓣膜置换术后的血栓栓塞及出血也是其严重的并发症,故需长期抗凝.该文综述了近期国内外对于心脏机械瓣膜置换术后患者抗凝治疗的发展及现状,以及抗凝相关问题的处理.对于心脏机械瓣膜术后患者的抗凝强度以及方法,国内外也仍有争议,今后机械瓣膜抗凝强度的研究仍将是重点.     

心脏机械瓣膜置换术后抗凝的相关问题

各种类型的人造心脏瓣膜已在成千上万的患者身上置换，取得了令人满意的效果。但机械瓣膜置换术后的血栓栓塞及出血也是其严重的并发症，故需长期抗凝。该文综述了近期国内外对于心脏机械瓣膜置换术后患者抗凝治疗的发展及现状，以及抗凝相关问题的处理。对于心脏机械瓣膜术后患者的抗凝强度以及方法，国内外也仍有争议，今后机械瓣膜抗凝强度的研究仍将是重点。     

人造瓣膜感染性心内膜炎

人造瓣膜感染性心内膜炎是发生于心脏人造瓣膜置换术后的一种严重并发症,本文就其诊断标准、分期、病理改变、病原学、临床表现、辅助检查、处理、影响预后的因素、与抗凝处理的关系等方面,对其作了详尽介绍。     

心脏机械瓣膜置换术后患者出院的抗凝指导

目的探讨出院抗凝指导对机械瓣膜置换术后患者的重要性。方法对102例患者进行出院抗凝指导,使其掌握心脏机械瓣膜置换术后服用抗凝药物的方法及抗凝的意义,同时监测凝血功能的重要性和必要性,减少因服药不当导致的并发症,延长机械瓣膜的使用寿命。结果通过出院时的抗凝指导,102例机械瓣膜置换术后患者掌握了用药等方面的注意事项,提高了患者抗凝监测的依从性,减少了瓣膜置换术后并发症的发生。结论及时系统地对患者进行出院的抗凝指导,能够减少术后并发症的发生,对延长瓣膜的使用时间、提高患者生命质量至关重要。     

中国人群瓣膜置换术后患者华法林个体化治疗最新研究进展

<正>心脏瓣膜置换术是治疗严重瓣膜疾病的有效手段[1-3],我国每年有近10万名患者接受治疗。我国以风湿性瓣膜疾病为主,人工机械瓣膜的使用率高达70%。由于机械瓣膜表面材料与血液相互作用及血流动力学改变,换瓣术后必需终生抗凝治疗。华法林作为机械瓣膜置换术后临床一线口服抗凝药物,但其治疗窗窄、个体差异大以及出血或血栓等并发症,合理用药已成亟待解决的临床问题。影响华法林疗     

华法令在瓣膜置换术后的应用

瓣膜置换术是治疗瓣膜病的有效手段，随着手术技术及体外循环、术后监护水平的提高，其手术死亡率越来越低。但是此类患者的长期预后并不乐观，其主要原因是术后抗凝引起的并发症。因此，制定严格的抗凝计划对改善患者的长期预后有着重要意义。本文综述国内外近年来的相关文献，希冀对瓣膜术后抗凝治疗规范有所裨益。     

机械瓣膜替换术后初期抗凝方法的探讨

人造机械瓣膜替换有病变的天然心脏瓣膜后,影响其远期生存率的关键问题是出血和血栓栓塞等并发症[1,2].近年临床研究发现,低强度的抗凝治疗降低抗凝出血发生率的同时,并不增加血栓栓塞发生率[3～5].因此,国内外在人造心脏瓣膜替换术后,有逐步采用低度抗凝慢度的趋势[5～7],并获得了初步效果,但适应我国人群抗凝强度的理想标准尚未达成到共识,因此,探讨适宜的最佳抗凝水准至关重要.     

心脏机械瓣膜置换术后患者早期华法林抗凝的并发症及其影响因素

目的探讨心脏机械瓣膜置换术后患者早期华法林抗凝相关并发症的发生率及其影响因素。方法以门诊复诊和电话随访的方式对180例心脏瓣膜置换术后早期应用华法林抗凝治疗的患者进行调查,记录患者抗凝认知、治疗依从性、社会支持情况及抗凝并发症发生情况。结果 180例患者中发生出血50例(27.78%),栓塞6例(3.34%),抗凝认知得分和社会支持得分是患者发生抗凝相关并发症的显著预测因子。结论华法林抗凝相关并发症发生率较高,医务人员应加强对患者及其照护者抗凝知识的指导,同时强调社会支持对患者术后抗凝治疗效果的重要性,降低华法林相关并发症的发生率。     

机械瓣膜替换术后初抗凝方法的探讨

人适机械瓣膜替换有病变的天然心脏瓣膜后，影响其远期生存率的关键问题是出血和血栓栓塞等并发症。近年临床研究发现，低强度的抗凝治疗降低抗凝出血发生率的同时，并不增加血栓栓塞发生率。因此，国内外在人造心脏瓣膜替换术后，有逐步采用低度抗凝强度的趋势，并获得了初步效果，但适应我国人群抗凝强度的理想标准尚未达成到共识，因     

人工机械瓣膜功能障碍诊断及治疗进展

瓣膜置换术是治疗瓣膜疾病的主要手段,而人造瓣膜功能障碍为心脏瓣膜置换术中较为严重的并发症之一,按瓣膜种类可分为机械瓣功能障碍和生物瓣功能障碍,按临床特点可分为急性和慢性功能障碍,按发病机制可分为内源性因素和外源性因素障碍,临床上机械瓣膜功能障碍起病急,可能带来严重后果,需要尽旱诊断和处理,现对人工机械瓣膜功能障碍的常见原因、临床表现、诊断和治疗做一综述。     

Thrombolytic therapy in prosthetic valve thrombosis during early pregnancy

Regardless of the improvements in the design of prosthetic heart valves and the use of anticoagulation, systemic embolism and valve thrombosis remains the most dreaded complications of mechanical heart valve replacement. A course of thrombolytic therapy may be considered as a first-line therapy for prosthetic heart valve thrombosis. The safety of thrombolysis in early pregnancy is not known. We describe a primigravida with mitral valve replacement status presenting with acute prosthetic valve thrombosis and treated successfully with intravenous streptokinase.     

Mechanical Prosthetic Valve Thrombosis: Case Report and Review of the Literature

Mechanical prosthetic valve thrombosis is a life-threatening complication necessitating immediate intervention. The presenting signs and symptoms of this illness are somewhat variable, but physical examination and transesophageal echocardiography enable rapid diagnosis. To avoid catastrophic complications, valve replacement or debridement, or thrombolysis in the correct setting, must be performed without delay. It is not entirely clear which therapy is superior. For any given patient, the risks of thrombolytic therapy, including bleeding, systemic embolism, and failure to restore valvular function, must be weighed against the risks of surgical intervention. Once the decision is made to operate, the choice of valve replacement versus debridement is one best made intraoperatively, upon visual inspection of the valve apparatus. Despite aggressive therapy, morbidity and mortality from prosthetic valve thrombosis and its treatment are not trivial. Fortunately, with current prosthetic devices and aggressive prophylactic anticoagulation, the incidence of prosthetic valve thrombosis remains low. Antiplatelet therapy may offer additional benefit to patients being prophylaxed with warfarin. This report details the case of a woman with aortic and mitral prosthetic valves who presented with heart failure and evidence of severe aortic prosthetic dysfunction after a period of suboptimal anticoagulation. She successfully underwent debridement of the mitral prosthesis and replacement of the aortic valve. The relevant literature is reviewed.     

Fulminant thrombosis of mechanical mitral valve prosthesis

In patients with prosthetic heart valves non-cardiac surgery may require temporary discontinuation of oral anticoagulation. Although the risk of valve related thromboembolic complications may generally be only slightly increased during the short perioperative period, in the presence of certain risk factors, replacement of oral anticoagulation with heparin is recommended. In the presented patient, unusually fulminant and finally fatal thrombosis of a mechanical mitral valve prosthesis developed within only 48 hours after non-cardiac surgery despite heparin treatment. The thrombosis was triggered by clinical conditions favouring a hypercoagulable state. This report dramatically shows that despite improvements in prosthetic heart valve design and in the management of anticoagulation, thrombosis remains one of the most dangerous complications after valve replacement with a mechanical prosthesis.


Keywords: complications; mitral valve; mechanical prosthesis; thrombosis     

Congestive heart failure in valvular heart disease in pregnancies with and without valvular prostheses and anticoagulant therapy

The course and complications of pregnancies in 46 patients with valvular disease and congestive heart failure with or without valve prostheses are described. In group I consisting of 33 women without valve replacement and without anticoagulant therapy one thromboembolic event was seen, emergency closed or open heart surgery was necessary five times. One still-birth happened after open heart surgery. In group II, of 13 patients with prosthetic valve replacement and anticoagulation therapy there was no thromboembolism, but 2 spontaneous abortions and 2 premature stillbirths; 2 fetuses died after delivery, 3 had congenital abnormalities. Pregnancies in patients with valvular disease and congestive heart failure can be sustained relatively safely for the mother, even if emergency heart surgery becomes necessary. Heart surgery and anticoagulation treatment carry a higher risk for the fetus. Uterine blood loss is not increased, if coumadine treatment is switched to heparin administration shortly before delivery.     

Prosthetic valve endocarditis: what is the evidence for anticoagulant therapy?

The use of anticoagulant therapy in prosthetic valve endocarditis is a controversial management issue. Some authorities believe that anticoagulation increases the potential risk of cerebral haemorrhage after a thromboembolism whereas others, however, affirm that cessation of anticoagulation itself increases the risk of thromboembolism and subsequent morbidity and mortality. We reviewed the association of anticoagulant therapy and cerebral complications in patients with prosthetic valve endocarditis. Our results suggest that anticoagulant therapy reduces the risk of thromboembolism and is not associated with increased risk of intracranial haemorrhage.     

Failure of low molecular-weight heparin in the prevention of prosthetic mitral valve thrombosis during pregnancy: case report and a review of options for anticoagulation

All mechanical heart valves are thrombogenic and may be associated with thromboembolic complications if anticoagulation is inadequate. This risk is increased in pregnancy due to a hypercoagulable state. The ideal anticoagulation regimen in pregnant patients with prosthetic heart valves is uncertain. Oral dicoumarol anticoagulants, subcutaneous low molecular-weight heparin, subcutaneous high-dose heparin and continuous high-dose intravenous heparin each have their own merits and demerits. A case is presented of a pregnant patient who had prosthetic valve thrombosis while receiving low molecular-weight heparin and who required re-do prosthetic mitral valve replacement. An analysis is also included of the options available for anticoagulating this difficult patient group.     

生物瓣应用于老年心脏瓣膜置换术的临床总结

目的 探讨老年心脏瓣膜病患者应用生物瓣置换的价值.方法 对36例老年患者施行生物瓣膜置换术,其中行二尖瓣置换18例,主动脉瓣置换10例,二尖瓣及主动脉瓣置换8例;同期行三尖瓣成形术12例,冠脉搭桥术6例.结果 本组围手术期死亡2例.出院后随访1～48个月,心功能恢复至Ⅰ级9例、Ⅱ级21例、Ⅲ级2例.结论 老年患者应用生物瓣具有良好的耐久性,并可避免因抗凝治疗出现的各种并发症,临床应用值得推广。     

Anticoagulation with low molecular-weight heparin in patients with prosthetic heart valve replacements

In six patients with prosthetic heart valve replacement anticoagulation was performed with low molecular weight heparin for 4-58 weeks. The treatment was indicated because of one or more severe cerebral or gastrointestinal bleeding complications during therapy with oral anticoagulants or conventional heparin. The dose of the low molecular weight heparin ranged individually from 2,500 to 12,000 units once a day subcutaneously and was adjusted on the basis of the general bleeding tendency of the patient and the specific anticoagulant effect on factor Xa. Under this treatment no heart valve thrombosis occurred. Two minor bleeding complications were observed in two patients. All patients suffered previously from severe bleeding complications with conventional anticoagulants. One additional patient, who had been treated one year earlier with the low molecular weight heparin, again experienced embolism during treatment with only 1 X 5,000 anti factor Xa units per day. We conclude that anticoagulation with low molecular weight heparin may be recommended for patients with prosthetic heart valve replacement and severe bleeding problems with conventional anticoagulants. In patients with recurrent embolism higher doses should be administered.     

老年心脏瓣膜病变的外科治疗体会

目的 总结老年心脏瓣膜病变的外科治疗经验.方法 回顾性分析160例老年心脏瓣膜病变外科治疗患者的临床资料.行二尖瓣置换（MVR）65例,主动脉瓣置换（AVR）45例,双瓣置换50例;同期行三尖瓣成形术108例,冠状动脉搭桥术19例,左房折叠术4例.结果 手术早期死亡6例,死亡率为3.9%.随访140例,随访时间6个月至8年,死亡2例,其余138例术后随诊复查人工瓣膜功能良好,左心室射血分数（LVEF）提高,心功能均提高1～2级,无瓣周漏、人工瓣膜心内膜炎及心脏血栓形成,没有因瓣膜原因而再次手术者.结论 术前充分调整心功能,选择适当的手术时机,加强术中心肌保护,不断改进和提高手术技巧,加强围术期管理,是提高老年心脏瓣膜病变患者手术成功率的关键因素.