主动脉瓣感染性心内膜炎瓣膜置换术后远期效果

 目的 探讨自体主动脉瓣单独受累感染性心内膜炎（IE）对外科主动脉瓣置换术（SAVR）远期预后的影响。方法 回顾性分析2013年1月—2017年12月在首都医科大学附属北京安贞医院行SAVR的自体主动脉瓣单独受累IE患者的病历资料,同时采用倾向性评分匹配（PSM）非IE对照组患者,对所有入组患者进行长期随访,观察术后生存率及并发症累积发生风险,中位随访时间为69个月。结果 共纳入2 821例患者,其中IE SAVR患者143例（IE组）,非IE的SAVR患者2 678例（对照组）。IE组患者长期生存率低于非IE配对对照组,差异有统计学意义（P=0.044）。IE患者SAVR手术后更容易发生缺血性脑卒中事件,差异有统计学意义（P=0.035）,且缺血性脑卒中事件为影响患者生存的独立危险因素（P=0.014）,发生缺血性脑卒中患者的死亡风险更高（HR=2.811;95%CI：1.233~6.408）。IE组患者大出血累积发生率和主动脉瓣再手术率与非IE配对对照组比较,差异均无统计学意义（均P>0.05）,且均不是影响患者生存的独立危险因素（均P>0.05）。结论 与非IE对照组患者相比,自体主动脉瓣单独受累IE患者行SAVR后发生死亡、缺血性卒中的风险更高。应加强对IE患者行SAVR后的密切随访,重点预防脑卒中等并发症。     

Functional vascular alterations associated with aortic valve stenosis

Degenerative changes, atherosclerotic process and calcification of valvular leaflets are mostly responsible for valvular aortic valve stenosis, but congenital bicuspid aortic valve and rheumatic fever in history are also known predisposing factors. Aortic valve stenosis is frequently associated with different functional vascular alterations. The aim of this review is to demonstrate these vascular alterations evaluated by non-invasive methods and underlying physiologic and pathophysiologic processes.     

Transcatheter aortic valve implantation in patients with severe symptomatic aortic valve stenosis: systematic review of cost-effectiveness analysis

The European Journal of Health Economics - Transcatheter aortic valve implantation (TAVI) is a less invasive and costly treatment for patients with severe aortic stenosis (AS). This study aimed to...     

Surgery of aortic valve stenosis with porcelain aorta under hypothermic circulatory arrest

This is a case report of a 52 year-old male patient with severe calcific aortic valve stenosis, associated with extended circular calcification of the ascending aorta and the aortic arch. Six months ago the patient underwent an explorative sternotomy in another institute, but the aortic valve replacement was not performed regarding the great risk of the porcelain aorta. The patient's complaints became more severe, so the authors recommended the excision both of the stenotic aortic valve and the calcified ascending aorta and replacement with a mechanical valve and vascular prosthesis. The operation was performed in deep hypothermia and total circulatory arrest with help of cardiopulmonary bypass. The calcified ascending aorta was excised without crossclamping. The vascular graft used for replacement of the ascending aorta was anastomosed to the proximal part of the aortic arch, then it was clamped and the extracorporal circulation was started again with rewarming of the patient. The aortic valve was replaced with a 21 mm St. Jude HP mechanical valve prosthesis in the usual manner. At last, the graft was anastomosed supracoronary to the proximal stump of the ascending aorta. Extracorporal circulation was discontinued without any difficulties. Apart from a few days of somnolence, the patient's recovery was uneventful, he was discharged from hospital on the 12th postoperative day. Three months after the surgery he had no complaints and returned to work without any problems.     

Listeria endocarditis causing aortic root abscess and a fistula to the left atrium.

We report the case of a 74-year-old man who presented with endocarditis on a porcine aortic valve replacement. Five of six blood cultures grew listeria monocytogenes. Transoesophageal echocardiography demonstrated the presence of a cavity posterior to the aortic annulus, apparently communicating with the left atrium. The patient underwent successful aortic valve re-replacement. Listeria endocarditis is rare with only 58 reported cases in the literature and is associated with high mortality.     

Experimental validation of the fluid–structure interaction simulation of a bioprosthetic aortic heart valve

Experiments performed on a 19 mm diameter bioprosthetic valve were used to successfully validate the fluid–structure interaction (FSI) simulation of an aortic valve at 72 bpm. The FSI simulation was initialized via a novel approach utilizing a Doppler sonogram of the experimentally tested valve. Using this approach very close quantitative agreement (≤12.5 %) between the numerical predictions and experimental values for several key valve performance parameters, including the peak systolic transvalvular pressure gradient, rapid valve opening time and rapid valve closing time, was obtained. The predicted valve leaflet kinematics during opening and closing were also in good agreement with the experimental measurements.     

Congenital aortic valve stenosis with left ventricular dysfunction: effect of percutaneous valvuloplasty

Two girls aged 6 and 15 years with severe congenital valvular aortic stenosis and left ventricular (LV) dysfunction underwent successful balloon aortic valvotomy (BAV). Both patients had severe symptoms at the time of initial evaluation. The electrocardiograms showed LV hypertrophy and cardiac enlargement (cardiothoracic ratio 0.7 and 0.65) was evident in the chest roentgenograms. Immediately after BAV, the aortic valve peak-to-peak gradients decreased from 60 to 8 mmHg and 120 to 30 mmHg respectively, the LV end-diastolic pressures decreased from 47 to 13 mmHg and 40 to 15 mmHg, the LV ejection fractions improved from 40 to 65% in the second girl. On follow-up (30 and 36 ms respectively), both patients were asymptomatic with normalization of LV function and without a change in the residual gradient a cross the aortic valve.     

三阶段法处理主动脉瓣狭窄患者瓣膜置换术中顽固性心室颤动

目的 研究主动脉瓣狭窄患者瓣膜置换术中顽周性心室颤动的处理.方法 100例因主动脉瓣狭窄行主动脉瓣置换术的患者进入研究.主动脉开放后心室颤动的患者进行三个阶段的处理过程:第一阶段为常规处理:包括调整内环境,升温,给予利多卡因100mg,20～30 W/s除颤;仍然呈现心室颤动的患者进行第二阶段处理:静脉注射去甲肾上腺索提高平均动脉压,将平均动脉压维持于70～90mmHg(1mm Hg=0.133 kPa),再次除颤;仍无反应患者进行第三阶段处理:给予硫酸镁1 g和/或胺碘酮150 mg治疗后再次除颤.比较各阶段患者术前的左室质量指数以及复苏成功时的平均动脉压、血钾水平、鼻咽温、红细胞压积.结果 所有患者均复苏成功.自动复跳的患者有56例,进行第一阶段处理的患者有16例,进行第二阶段处理的患者有10例,进行第三阶段处理的患者有18例.自动复跳以及进行第一阶段处理的患者术前左室质量指数[(184±43)、(178±51)g/m~2]显著低于进行第二、三阶段处理的患者[(237±61)、(242±46)g/m~2],P<0.05;进行第二、三阶段处理的患者平均动脉压显著高于自动复跳以及进行第一阶段处理的患者.结论 三阶段法处理可以用于主动脉瓣狭窄患者瓣膜置换术中主动脉开放后的顽同性心室颤动.     

主动脉瓣畸形患者感染心内膜炎病原菌分布及耐药性监测

目的 探讨主动脉畸形患者感染心内膜炎的病原菌分布特点及其耐药性,对临床治疗进行指导.方法 选取二叶式主动脉瓣畸形感染心内膜炎患者153例,对其临床资料进行回顾性分析,并行病原菌分离和耐药性分析.结果 153例患者共检出病原菌161株,其中革兰阳性菌123株,占76.40％,革兰阴性菌30株,占18.63％,真菌8株,占4.97％,排名前5位病原菌依次为酿脓链球菌、凝固酶阴性葡萄球菌、金黄色葡萄球菌、大肠埃希菌、铜绿假单胞菌,分别占37.27％、24.22％、13.04％、9.32％、3.73％;酿脓链球菌、凝固酶阴性葡萄球菌及金黄色葡萄球菌对利奈唑胺、万古霉素和替考拉宁的耐药率均为0,酿脓链球菌对青霉素、头孢曲松、头孢噻肟以及左氧氟沙星的耐药性相对较低＜7.00％,而对克林霉素和红霉素的耐药性相对较高＞50.00％;凝固酶阴性葡萄球菌仅对利福平较为敏感,耐药率＜6.00％,而对青霉素类药物、头孢类药物和红霉素均表现出了很高的耐药性,耐药率＞80.00％;金黄色葡萄球菌除对青霉素耐药性特别高以外,对其他药物的耐药率均＜30.00％,其中对头孢唑林、头孢呋辛、庆大霉素以及利福平的耐药性＜10.00％.结论 二叶式主动脉瓣畸形感染心内膜炎患者病原菌存在多样性,在治疗的早期可根据经验给予联合用药治疗,并根据细菌培养和药敏试验结果随时对药物进行调整.     

Predictors of health-related quality of life decline after transcatheter aortic valve replacement in older patients with severe aortic stenosis

Background

Transcatheter aortic-valve implantation (TAVI) has been shown to improve survival and quality of life in patients with severe aortic stenosis. However, one-third of patients have poor outcome as death, functional decline or quality of life (QoL) decline. The aim of this study was to determine cardiac and geriatric predictors of physical and mental QoL decline 6 months after a TAVI procedure in patients aged 75 and older.

Methods

Between January 2013 and June 2014, we did a prospective and multicenter study including patients ≥ 75 years old referred for TAVI. The primary outcome was the measure of QoL, assessed by the Short Form 36 survey (SF-36), before and 6 months after the intervention. Association between QoL decline and baseline characteristics including cardiac and geriatric factors was analysed by logistic regression models.

Results

Mean age of the 150 patients studied was 83.7 years old and 56% were men. The primary end point, mean SF-36 physical summary score, significantly improved between baseline and 6-month (33.6 vs. 36.4, p=0.003) whereas mental component score significantly decreased (48.2 vs. 36.4, p-value<0.001). However, patients with presence of depressive symptoms before the intervention had mental QoL improvement at six months (OR 0.04 [0.01-0.19], p-value<0.001) and no significant geriatric predictors were associated with physical QoL decline.

Conclusion

The mental QoL significantly decreased and patients with preoperative depressive symptoms had mental QoL improvement at six months. Researches are needed to confirm that mental QoL of patients with depressive symptoms can be improved by TAVI.