80例双瓣替换术的体会

自１９８６年９月至１９９３年７月，为风湿性心脏瓣膜病人施行主动脉瓣，二尖瓣双瓣替换术８０例，手术死亡率３．７５％（３／８０）。８０例中男３８例，女４２例，年龄平均３５．４３岁，心功能Ⅱ级２例，Ⅲ级４５例，ＩＶ级３３例。围术期行血流动力学监测７２例。本组术后发生多脏器功能不全６例。作者对双瓣替换术中常遇到的难点及处理，术后多脏器功能不全（ＭＯＤ）的防治以及如何降低手术死亡率等问题进行了讨论。     

感染性心内膜炎伴瓣膜病变的外科治疗

自１９８９年９月～１９９３年７月对２０例感染性心内膜炎伴瓣膜病变病人施行瓣膜替换术，其中主动瓣替换术８例二尖瓣替换术６例，双瓣替换术６例，无手术死亡，随访３～３８个月疗效满意，作者认为瓣膜替换术对治疗感染性心内膜炎心瓣膜失功者，是一种有挽救生命方法，并对手术时机的选择及术前后抗生素应用进行讨论。     

人工心脏瓣膜替换术后抗凝治疗并发症

自１９８０年至１９９２年１０月我们行人工心脏瓣膜替换术３７０例，康复出院３２９例，经３月至１２５月随访，有２例失访，共发生与抗凝治疗有关并发症１７例（５．２％或１．４８％病人－年），死亡１２例（３．６％或１．０３％病人－年），其中血栓栓塞６例（１．８２％），死亡３例（０．９１％）；抗凝出血１１例（３．３４％），死亡９例（２．７３％）。抗凝治疗并发症中出血明显多于血栓栓塞，并发症发生时间主要在术后３个月内（含术后９４天），占８９％。     

生物瓣失功再次换瓣的临床实践

生物瓣替换术后的衰败使病人面临再次换瓣手术，与第１次手术相比，再次换瓣操作困难，并发症和死亡率明显增多。现报告我们为６２例生物瓣失功病人再次换瓣的临床体会。临床资料１９７９年２月至１９８９年１２月，应用自制牛心包瓣行心瓣膜替换共２５１例（２５个瓣膜）...     

风心病二尖瓣狭窄合并小左心室的瓣膜替换术

１９８７～１９９３年３８９例二尖瓣狭窄（ＭＳ）行二尖瓣替换术（ＭＶＲ）的病人中有小左室者１２６例，其中左室萎缩２８例。心功能ＩＩＩ级７６例、ＩＶ级３５例，重度肺动脉高压６４例。手术死亡率９５％，明显高于同期非小左室病人。主要死亡原因为右心衰、急性左心衰及瓣膜功能障碍。晚期死亡率为１６％／病人－年，１、５年生存率为９６５％和８８４％。术后心脏超声显示小左室及左室萎缩者均出现左室构形和功能的重建，后者重建过程较长。结果表明，小左室主要影响术后早期效果，重度ＭＳ合并小左室，尤其是伴有严重肺动脉高压及左室萎缩，是手术的高危指标。     

尿激酶治疗心脏瓣膜替换术后血栓

尿激酶治疗心脏瓣膜替换术后血栓陈若为王迅心脏瓣膜替换术后血栓栓塞是较严重的并发症之一。我们成功地应用尿激酶溶栓疗法对２例术后血栓病人进行了治疗，随访１年，效果良好。例１女，４０岁。１９９４年５月行主动脉瓣替换术，术后口服华法林每日１．２５ｍｇ抗凝，恢...     

儿童替换猪生物瓣膜15例疗效观察

作者自１９７８年７月至１９８２年１１月用ＧＤ－Ｉ型猪生物瓣膜为１５例８～１４岁儿童进行瓣膜替换术，其中二尖瓣替换１３例，主动脉瓣替换１例，三尖瓣替换１例。手术死亡率为６．７％。随访３～１０年，近期疗效满意，远期疗效较差。主要原因是生物瓣膜失功能，其生物瓣膜衰坏率达１９．３７％病人年，远较成年人替换猪生物瓣膜的衰坏率３．６９％病人年为高。本文对儿童替换猪生物瓣膜较早出现失功能的原因进行了探讨。     

原发性感染性心内膜炎的外科治疗（附102例报告）

回顾性分析原发性感染性心内膜炎１０２例，其中主动脉瓣病变７１例，二尖瓣病变１６例，主动脉瓣与二尖瓣联合病变６例，三尖瓣病变５例，肺动脉瓣病变４例。按照病人术前心功能状态，分为：（１）急性心功能不全组（２５例）；（２）慢性心功能不全组（７７例）。施行主动脉瓣替换术７１例，二尖瓣替换术１６例，双瓣替换术６例，三尖瓣修复成形术５例，肺动脉瓣成形术４例。术后早期死亡９例（８．８％）。９３例生存者随访时间３个月～１６年，平均随访时间４．３年。晚期死亡６例，其中２例为人工瓣膜心内膜炎，复发率为２％。作者对手术时机与手术方式的选择作了讨论，并介绍了围术期处理的经验。     

主动脉瓣替换术后近期及晚期左心室功能随访

目的：评价主动脉瓣替换（ＡＶＲ）术后左心功能的近期及其远期效果。方法：对１９７８年１２月至１９９６年１２月期间连续１２９例单纯行ＡＶＲ的病人进行分析。结果：术前Ｂ超示左心室舒张末期内径（ＬＶＥＤＤ）、收缩末期内径（ＬＶＥＳＤ）分别为（６４．５±９．３）ｍｍ、（４４．７±９．９）ｍｍ,术后１４天至３个月分别为（５１．９±７．２）ｍｍ、（３１．５±４．５）ｍｍ（Ｐ＜０．０１）;术后１～２年分别为（４７．６±６．１）ｍｍ、（２９．５±５．４）ｍｍ（Ｐ＜０．０１）。手术死亡率３．９％。术后随访６个月至１６年,平均４．４年,累计随访５０１病人·年。晚期死亡６例（１．２％病人·年）,５年及１０年生存率分别为８９．３％、７７．３％。血栓栓塞及与抗凝有关的出血率分别为０．８％病人·年、１．０％病人·年。结论：ＡＶＲ术后９５％病人的心功能恢复至Ｉ或Ｉ级,长期效果满意。故主动脉瓣病变、ＬＶＥＤＤ扩大并出现症状的病人,应行主动脉瓣替换术。     

改良迷宫术治疗心房纤颤的远期疗效

目的：评价改良迷宫术治疗心房纤颤的远期疗效。方法：１９９４年３月到１９９６年７月采用改良迷宫术－－按Ｃｏｘ经典迷宫手术原理用冷冻代替部分手术切割,治疗风湿性心脏膜瓣病合并心房纤颤１８例。同期行二尖瓣替换术１４例,又瓣膜替换术４例,三尖瓣成形术８例,左房血栓清除４例。结果：本组无手术死亡随访２５￣５２个月,平均３６．１个月,随访率１００％。远期死亡１例。生存１７例,心功能Ⅰ级８例,Ⅱ级９例;均持续窦     

心房纤维颤动的外科治疗

３例采用改良迷宫术探索进行心房纤颤外科治疗获成功。病人术前均为风湿性心脏病，心功能Ⅲ－Ⅳ级，心房纤颤病史３－１０年，左房直径５２－５８ｍｍ，心胸比率０．６４－０．７０。在进行改良迷宫术的同时，２例行二尖瓣替换，１例行双瓣替换及三尖瓣环缩。术后２例自动复跳，１例电击除颤复跳。３例术后早期均为窦性心律。２例术后３年恢复良好，正常心律，心功能Ｉ级；１例术后３个月死于脑血管意外。文中重点介绍了手术方法，提     

Atrioventricular valve replacement in patients with a single ventricle

BACKGROUND: Significant atrioventricular valve (AVV) insufficiency has been associated with increased mortality and morbidity in patients with single ventricle. Although many patients can be managed with valvuloplasty alone, some patients require AVV replacement. The optimal timing, outcome, and risk factors for AVV replacement in this population have not been described. METHODS: We retrospectively reviewed our experience with AVV replacement in patients with single ventricle from January 1984 to August 2000. Outcome variables included mortality and valve-related complications. RESULTS: Seventeen patients required AVV replacement. Prosthetic valve types included: St. Jude's valve in 14, Bjork-Shiley in 1, Hall-Kaster in 1, and Carpentier-Edwards in 1. Valve size ranged from 17 to 33 mm, Median age at valve replacement was 3.0 years (range 7 days to 17.3 years). Of the 16 subjects with normal atrioventricular conduction preoperatively, 7 (44%) developed postoperative complete heart block. Hospital mortality was 29%. Hospital mortality decreased significantly from 56% in 1984 to 1993 to no deaths from 1994 to 2000 (p = 0.03). Younger age (less than 2 years) at operation was also a risk factor for hospital mortality (p = 0.03). There were four late deaths in this series and 1 patient underwent heart transplantation. Of the surviving patients, none has required replacement of the prosthetic valve. No patients have had cerebrovascular accident subsequent to AVV replacement. Functional status is New York Heart Association functional class I in 5, class II in 1, and Class III in 1. CONCLUSIONS: Atrioventricular valve replacement can be performed in patients with single ventricle with acceptable morbidity and mortality. The development of postoperative complete heart block is common. Survival after AVV replacement has improved in recent years, and intervention before patients develop ventricular dysfunction and atrial arrhythmias may further improve outcome.     

合并恶液质的风湿性心脏瓣膜病的外科治疗

目的　总结风湿性心脏瓣膜病合并心源性恶液质病人的围手术期治疗经验。方法　回顾性分析近 6年 42例心脏恶液质瓣膜患者的围手术期治疗。结果　术后早期死亡 4例( 9 .5 2 % ) ,2 0例术后出现并发症 ,3 8例患者出院时肝脾明显缩小 ,食欲好转 ,血红蛋白、血浆蛋白及肝、肾功能正常。随访 10个月～ 6年 ,心功能恢复至Ⅰ级 2 4例 ,Ⅱ级 14例。结论　充分的术前准备、围术期营养支持 ,正确地选择好手术时机 ,加强术中处理 ,积极治疗术后并发症是提高手术疗效的关键。     

Evaluation of clinical treatment of atrial fibrillation associated with rheumatic mitral valve disease by radiofrequency ablation.

OBJECTIVES: The aim of this clinical study was to evaluate the effectiveness and advantages of the radiofrequency ablation maze procedure in the treatment of atrial fibrillation associated with rheumatic mitral valve disease. METHODS: We developed one kind of modified Cox III maze procedure with the use of radiofrequency ablation in the treatment of atrial fibrillation associated with rheumatic mitral valve disease and compared the outcome of 96 patients of atrial fibrillation associated rheumatic mitral valve disease who underwent radiofrequency ablation maze procedure plus mitral valve replacement with that of 87 patients with atrial fibrillation associated rheumatic mitral valve disease who had mitral valve replacement during the same interval by the same surgeon. The patients in the two groups were similar in age, gender, preoperative New York Heart Association class and duration of preoperative atrial fibrillation. RESULTS: No operative deaths occurred in the study group and the control group. Duration of cardiopulmonary bypass (137.63 +/- 10.82 vs. 90.95 +/- 7.65 min, P<0.01) and duration of aortic crossclamping (56.96 +/- 6.19 vs. 32.66 +/- 3.55 min, P<0.01) were prolonged in the study group. Blood loss from chest tubes was similar in the two groups (494.06 +/- 100.44 vs. 476.09 +/- 115.84 ml, P=0.263). Freedom from atrial fibrillation in the study group was 77% 3 years after the operation compared with 25% in the control group (P<0.01). CONCLUSIONS: The addition of the radiofrequency ablation maze procedure to mitral valve replacement is safe and effective in the treatment of atrial fibrillation associated with rheumatic mitral valve disease.     

Mitral valve repair and replacement for rheumatic disease

OBJECTIVES: Mitral valve repair may be technically feasible in patients with suitable anatomy, but the appropriateness of repair for rheumatic disease remains controversial. We evaluated our late outcomes after mitral repair and replacement for rheumatic disease. METHODS: Five hundred seventy-three patients underwent mitral valve surgery for rheumatic disease at our institution from 1978-1995. Follow-up was 98% complete (mean, 68 +/- 46 months). Survival and morbidity were evaluated by Kaplan-Meier analysis and Cox regression, including propensity score analysis. RESULTS: Mean age was 54 +/- 14 years, 55% of patients had congestive heart failure, 22% were undergoing redo mitral valve surgery, and 9% also underwent coronary bypass. Mitral stenosis was present in 53%, regurgitation in 15%, and both in 32%. Valve repair was performed in 25%, bioprosthetic replacement was performed in 28%, and a mechanical valve was placed in 47%. Patients undergoing repair were younger and less likely to be undergoing reoperation or to have atrial fibrillation than those undergoing replacement (P =.001). The operative mortality rate was 4. 2%. Better late cardiac survival was independently predicted by valve repair rather than replacement (P =.04) after adjustment for baseline differences between patients. Freedom from reoperation was greatest (P =.005) but that from thromboembolic complications was worst (P <.0001) after mechanical valve replacement. Twenty-three patients underwent reoperation after initial repair, with no operative deaths. CONCLUSIONS: Mechanical valves minimize reoperation but limit survival and increase thromboembolic complications. Patients undergoing valve repair had improved late cardiac survival independent of their preoperative characteristics. Rheumatic mitral valves should be repaired when technically feasible, accepting a risk of reoperation, to maximize survival and reduce morbidity.     

Tricuspid valve replacement with a mitral homograft in children with rheumatic tricuspid valvulopathy

OBJECTIVE: Tricuspid valve replacement in children is associated with a nonnegligible complication rate because of specific disadvantages of mechanical or biologic prostheses. The objective of this study was to examine the midterm clinical outcomes of tricuspid valve replacement with a mitral homograft in 8 children with unreparable rheumatic tricuspid valve involvement. METHODS: Between 1993 and 2003, tricuspid valve replacement with a mitral homograft was performed in 8 patients (2 male and 6 female patients; mean age, 14.2 years) with rheumatic tricuspid valve disease. All patients were in New York Heart Association class III or IV. In all patients with rheumatic valve disease, conservative operations had previously been performed on the tricuspid valve during concomitant left-sided surgical intervention. Mean follow-up was 56 +/- 12 months and was complete. RESULTS: There were no operative or late deaths. All patients were alive at the most recent follow-up contact and were in New York Heart Association functional class I or II. None of the patients required homograft-related reoperation. At the most recent echocardiograhic examination, 6 patients had trivial residual tricuspid regurgitation, and 2 had mild tricuspid regurgitation. None of the patients had maximal transvalvular tricuspid gradients greater than 2 mm Hg during their yearly follow-up visits. CONCLUSION: On the basis of our midterm results, tricuspid valve replacement with a mitral homograft in children seems to be a valuable alternative surgical option.     

60例感染性心内膜炎的临床诊断与外科治疗

目的总结感染性心内膜炎的临床诊断和外科治疗经验。方法回顾分析2000年1月～2006年8月在我院接受手术治疗的60例感染性心内膜炎患者的临床资料,其中男46例,女14例;年龄9～58岁,平均年龄34.3岁。术前血培养60例,阳性25例(41.7%),其中链球菌12例,葡萄球菌6例,其他细菌7例。超声心动图提示有心内膜赘生物或瓣膜穿孔42例,其中累及二尖瓣9例,主动脉瓣26例,二尖瓣主动脉瓣同时受累6例,三尖瓣1例。合并原发心脏疾病28例,其中先天性心脏病16例,风湿性心脏病9例,二尖瓣脱垂3例。对60例患者全程采用大剂量敏感抗生素治疗。择期手术55例,急诊手术5例。手术中清除所有感染灶,同期矫治心内畸形16例,行心瓣膜置换术41例,三尖瓣修复成形术1例。结果术后早期死亡3例。随访51例(89.5%),随访时间5～71个月,无心内膜炎复发,心功能恢复至级38例,级13例。结论早期诊断,掌握适当的手术时机,联合内科治疗和外科手术,可取得较好的治疗效果。     

二尖瓣主动脉瓣三尖瓣同时置换治疗重症风湿性瓣膜病

目的　总结二尖瓣主动脉瓣三尖瓣同期置换治疗重症风湿性心脏瓣膜病的手术疗效。方法　 1999年 6月至 2 0 0 1年 6月 94 1例病人进行瓣膜置换术 ,其中 2 4例同期进行二尖瓣、三尖瓣和主动脉瓣置换 ,占瓣膜置换病人的 2 5 5 %。 2 4例病人中女 17例 ,男 7例 ;年龄 18～ 5 9岁 ,平均 36岁 ;体重 37～ 5 6kg。其中 8例曾行二尖瓣闭式扩张术、11例合并左房血栓、16例病人合并有肝肿大 (肋下 2～ 8cm)和下肢水肿、8例合并有腹水。X线胸片示心胸比率为 0 6 6～ 0 91。超声检查示三尖瓣均有严重反流 ,反流面积为 4 2～ 34 0cm2 ,平均 (16 8± 9 3)cm2 。术前心功能III级 9例 ,VI级 15例。 6例病人因药物不能控制心衰而行急诊换瓣手术。结果　死亡 1例 ,死亡率为 4 2 %。术后 1周、3、6个月复查超声心动图示各心腔内径较术前明显缩小。出院者均得到随访 ,随访时间 2 0～ 36个月 ,平均 2 6 4个月。术后心功能I～II级2 0例 ,III级 4例。术后 3～ 12个月复查超声心动图未见机械瓣功能障碍及血栓形成。结论　对于联合瓣膜病变 ,三尖瓣有严重器质性病变的病人 ,在进行二尖瓣主动脉瓣置换的同时进行三尖瓣置换 ,有利于术后右心功能的恢复 ,能更好地改善心脏的血流动力学特性 ,改善心功能 ,并有利于术后病人的康     

左心瓣膜置换术后远期三尖瓣关闭不全的外科处理

目的探讨左心瓣膜置换术后远期三尖瓣关闭不全(TR)发生的可能机制以及外科治疗方法的选择和结果.方法 56例左心瓣膜置换术后远期发生TR行再次瓣膜手术的病人,10例人工瓣膜功能正常(A组)者中行二尖瓣置换(MVR)4例,主动脉瓣、二尖瓣双瓣置换(DVR)6例;46例人工瓣膜功能障碍(B组)者中MVR 36例,主动脉瓣置换(AVR)4例, DVR 6例.在A、B两组中,46例第1次手时三尖瓣未见明显异常,10例第1次手术时已行DeVega三尖瓣成形(TVP),第2次手术时发现缝线断裂3例,缝线撕脱7例.56例TR病人再次手术时9例行三尖瓣替换(TVR),其中6例三尖瓣呈风湿性改变;47例行TVP.结果 TVP和TVR各死亡1例,病死率3.6%.54例获随访,随访时间6～132个月,平均(79.4±34.8)个月.8例TVR病人术后心功能恢复良好,46例TVP者40例为轻度TR,5例出现中度TR,仍需强心、利尿药维持,1例再次出现重度TR.结论左心瓣膜置换术后远期TR可能与持续肺动脉高压、右心室不可逆损害、三尖瓣风湿性病变、左心功能的恢复情况以及持续心房纤颤有关.重度功能性TR和三尖瓣风湿性病变者行TVR的疗效可靠.随访发现部分TVP病人功能性TR仍有逐渐加重趋势.