心脏跳动下重症心脏瓣膜置换术的麻醉处理

<正> 重症心脏瓣膜置换术病人病情重,手术风险大,麻醉管理复杂,手术麻醉死亡率及并发症发生率较高。1999年元月至今我们采用心94脏不停跳技术,施行重症换瓣手术麻醉50例,使患者顺利度过手术麻醉关,效果显著。     

心脏瓣膜置换术患者围手术期的护理干预

目的总结心脏瓣膜置换术患者围手术期的护理体会。方法对24例心脏瓣膜置换术患者给予术前心理支持和完善各项准备及术后病情观察与监测、用药指导等各项措施,观察护理效果。结果本组24例患者均顺利完成手术,术后发生1例心律失常,经对症处理及护理后痊愈,未发生低心排综合征、肺部感染等并发症,均治愈出院。结论心脏瓣膜置换术患者积极实施围手术期各项护理措施,对提高手术效果,减少术后并发症及病死率具有重要作用。     

巨大心脏瓣膜病变的手术治疗

目的总结巨大心脏瓣膜病变瓣膜置换术的疗效,探讨手术方法和要点以及围术期的处理。方法自2003年1月至2006年12月共完成巨大心脏(心胸比例CTR>0.7)瓣膜置换术64例,其中,二尖瓣置换39例,双瓣置换15例,主动脉瓣置换9例,三尖瓣置换1例,共置换机械瓣63例,生物瓣1例(三尖瓣)。同期行左心房血栓清除14例,左房壁部分切除术8例,三尖瓣De Vega成形18例。结果死亡4例,死亡率6.25%,分别死于多器官功能衰竭综合征、低心排综合征、心室颤动及急性肾功能衰竭,其余患者均治愈出院。结论完善围术期处理、注意术中心肌保护以及病变的合理矫治,是降低手术死亡率、减少术后并发症的关键。     

心脏瓣膜置换术围手术期心肌保护的观察

随机将１００例心脏瓣膜置换术患者分为治疗组，对照组。治疗组于围手术期行系统的心肌保护治疗，对照组只限于术中低温和冷停搏液灌注作心肌保护。结果表明，治疗组自动复跳明显高于对照组，早期并发症及死亡率低于对照组，死亡率，我们认为强调围手术期心肌氧供需平衡的调节和治疗、麻醉方法的选择、体外循环技术操作及心脏复跳后一系列的心肌保护措施是手术成功的重要保证。     

心脏人工机械瓣膜功能障碍再手术治疗34例分析

人工机械瓣膜功能障碍是人工瓣膜置换术后最严重并发症之一，病死率高，尽早再手术治疗是挽救患者生命的惟一有效方法。我院自1993年6月至2004年7月共为34例人工机械瓣膜功能障碍的患者行再次换瓣手术治疗，现将人工机械瓣膜功能障碍的原因、诊断、再次换瓣手术处理的经验和教训总结报道如下。     

再次与多次心脏瓣膜置换术132例

心脏瓣膜置换术后病人因发生人工瓣膜内源性、外源性功能障碍或并发症 ,以及再发其他瓣膜病变 ,均需行再次瓣膜置换术。现将我们近 10年再次或多次瓣膜置换术病例总结报道如下。资料和方法　 1992年 1月至 2 0 0 1年 12月 ,我们共实施再次与多次心脏瓣膜置换术 132例 ,占同期瓣膜置换术病人的 4 35 %( 132 30 33例 )。其中男 5 9例 ,女 73例 ;年龄 14～ 70岁 ,平均 45岁。术前心功能 (NYHA)II级 16例 ,III级 75例 ,IV级 41例。再次换瓣主要原因与两次手术间隔时间见表 1。其中二尖瓣生物瓣衰败 6 6例 ,二尖瓣、主动脉瓣生物瓣衰败1例 …     

瓣膜置换术后并发心脏压塞的原因分析与护理

目的 探讨瓣膜置换术后并发心脏压塞的观察与护理措施.方法 回顾分析7例瓣膜置换术后出现心脏压塞的临床资料,总结出现此并发症的原因并提出相应的护理对策.结果 心脏压塞发生于二尖瓣置换术后2例,主动脉瓣置换术后2例,联合瓣膜病变行双瓣置换术后3例.经积极治疗和护理,5例康复出院,2例死亡.结论 心脏压塞是瓣膜置换术后严重并发症,术后严密的病情观察,及时主动有效的护理,是挽救患者生命、降低病死率的关键.     

瓣膜置换术后并发心脏压塞的原因分析与护理

目的探讨瓣膜置换术后并发心脏压塞的观察与护理措施。方法回顾分析7例瓣膜置换术后出现心脏压塞的临床资料。总结出现此并发症的原因并提出相应的护理对策。结果心脏压塞发生于二尖瓣置换术后2例．主动脉瓣置换术后2例，联合瓣膜病变行双瓣置换术后3例。经积极治疗和护理。5例康复出院，2例死亡。结论心脏压塞是瓣膜置换术后严重并发症，术后严密的病情观察，及时主动有效的护理。是挽救患者生命、降低病死率的关键。     

1 003例瓣膜置换手术围手术期处理

目的总结1003例心脏瓣膜置换手术病例临床特点及围手术期处理经验。方法手术在体外循环中度低温下进行，其中单纯二尖瓣置换术（MVR）555例，主动脉瓣及二尖瓣置换术（BVR）273例，主动脉瓣置换术（AVR）139例，三尖瓣置换术（TVR）26例，三瓣置换术10例。全组病人按≤40岁、41—59岁、≥60岁分为3组，分别为152、572、279例。结果975例（97．2％）恢复出院，死亡28例（2．8％）。3组死亡率分别为3．3％，1．7％，4．7％。死因分别为呼吸循环衰竭11例、多脏器功能衰竭10例、室性心律失常5例、肾功能衰竭2例。发生各种并发症74例次。结论瓣膜置换术是治疗瓣膜病变的有效手段，选择适当的手术时机，改进和完善体外循环技术，加强术中心肌保护，不断改进和提高手术技巧，尽量保留瓣下结构的二尖瓣置换术，能减少瓣膜置换术的手术风险，提高手术疗效。主动脉瓣置换时应尽量去除钙化的瓣叶，置入大一号的瓣膜，减少跨瓣压差，有利于左室重构。术中应常规探查三尖瓣，对瓣环明显扩大的病人予以三尖瓣成形术。心脏大的病人尤应注意围术期电解质的变化，防止发生恶性心律失常。生物瓣的术后抗凝较机械瓣方便，并发症也少，应提高生物瓣的应用比例。围手术期处理得当，可减少术后并发症及降低病死率，老年病人术前合并症多、病情重，应加强围手术期监护。     

肺高压患者非心脏手术的围术期麻醉进展

背景 肺高压(pulmonary hypertension,PH)患者行非心脏手术期间并发症发病率和病死率显著增高,围术期的麻醉处理是麻醉医师面临的挑战之一. 目的 综述近年PH及相关麻醉管理的研究文献,为麻醉医师的临床工作提供理论参考. 内容 阐述PH的定义及诊断,围术期并发症和死亡的预测因素,术前准备与评估,麻醉方式、麻醉管理以及严重并发症的处理. 趋向 随着对PH研究的深入,非心脏手术围术期麻醉管理会得到进一步优化,从而减少并发症和死亡的发生率.     

When and how does nonstructural mechanical prosthetic heart valve dysfunction occur?

Objective: We diseuss the clinical aspects related to mechanical valve dysfunction based upon 20 years' experience of our cases.Methods: Between January 1982 and December 2001, 21 patients underwent surgical interventions because of mechanical valve dysfunction. Thirteen men and 8 women (mean age 47±20, range 3–75 years-old), were included.Results: Mitral valve dysfunction was observed in 12 patients. Prosthetic valve stenosis occurred in 6 patients between 2 and 224 months, and paravalvular leaks in 4 between 1 and 71 months after surgery. The other 2 patients suffered from hemolytic anemia with mild paravalvular leaks between 102 and 104 months after surgery. Aortic valve dysfunction was observed in 8 patients including 3 stenotic lesions between 48 and 97 months and 5 paravalvular leaks between 3 and 150 months after surgery. Tricuspid regurgitation was seen in 1 patient with a huge right atrium at 42 months after surgery. Early death was seen in 1 patient. Late death occurred in 1 patient, 17 years after operation. Survival, including early death, was 95.2% at 10 and 15 years. One valve-related complication of bioprosthetic valve endocarditis at the mitral and tricuspid positions occurred 12 years after a reoperation. The freedom from complications was 95.2% at 10 years, and 76.2% at 15 years.Conclusions: Paravalvular leaks without overt endocarditis had latency periods of up to 12 years, and pannus formation was observed 20 years after surgery. Early and late clincal results after surgery for mechanical valve dysfunction were excellent.     

Clinical features of third open-heart valve surgery at the same valve position

Objective: Recently, there has been an increase in case of repeated open-heart valve surgery and the clinical results of the second surgery are only slightly worse than those of the first surgery. However, clinical results of the third open-heart valve surgery at the same position are rarely reported. Clinical features of third open-heart valve surgery at the same position are discussed in this study.Methods: Between 1995 and 2004, 16 patients underwent third open-heart valve surgery at the same valve position under cardiopulmonary bypass. The average age of the 16 patients, 12 females and 4 males, was 56±15 years. Clinical features of the 16 cases were retrospectively analyzed.Results: Mechanical valve nonstructural dysfunction was the most common valve malady, followed by bioprosthetic valve dysfunction. The duration of surgery from skin incision to establishment of the cardiopulmonary bypass was 94±42 minutes. Myocardial ischemia time was 137±38 minutes and extracorporeal circulation time was 212±82 minutes. Early mortality was seen in 1 patient (6.25%) and late mortality was seen in 1 patient.Conclusion: Mechanical valve nonstructural valve dysfunction leads to repeated valve surgery. The clinical results of the third open-heart valve surgery at the same valve position are acceptable, and the mid-term survival is excellent.     

Tricuspid valve replacement with the St. Jude Medical valve

A study was conducted on 20 patients who underwent tricuspid valve replacement (TVR) with the St. Jude Medical (SJM) valve. Isolated TVR was performed on 9 patients, and additional mitral, or mitral and aortic valve replacements were performed on 11 patients. Four patients (20%) died in the early postoperative period, but there were no deaths related to the SJM valve in the tricuspid position. The mean follow-up period of the 16 survivors was 74.4 months, and there have been no deaths during the follow-up period. The postoperative actuarial survival rate was 80%, 10 years after surgery. Three patients, representing 0.25%/patient-months, developed valve thrombosis, the valve thrombosis-free rate being 72.8%, 10 years after surgery, while entrapment of a leaflet by endothelial pannus was found in one patient, representing 0.08%/patient-months. Thus, the incidence of all prosthetic valve-related complications was 0.34%/patient-months, and the postoperative complication-free rate was 65.3%, 10 years after surgery. The medium-term follow-up study of TVR with the SJM valve revealed no prosthetic valve-related deaths and a relatively low incidence of prosthetic valve-related complications. However, as with other mechanical valves, valve thrombosis was a major risk posed by the SJM valve in the tricuspid position.     

血管内电凝瓣膜修复治疗下肢深静脉瓣膜功能不全的手术探讨

目的探讨股部小切口修复静脉瓣膜、血管内电凝曲张静脉治疗原发性下肢深静脉瓣膜功能不全的微创手术方法。方法选择67例原发性下肢深静脉瓣膜功能不全的病人,在硬膜外麻醉或腰麻下取股部小切口,行第一对股浅静脉瓣膜外修复,同时利用40 W手术电刀对迂曲扩张的浅静脉进行血管内电凝。总结手术入路和手术体会。结果患者术后7 d拆线,股部小切口愈合良好,下肢曲张浅静脉消失,无淋巴漏等并发症发生;随访1~5年,超声多普勒检查电凝后的大隐静脉和曲张浅静脉均已闭合,无曲张静脉复发现象,但有2例瓣膜修复处术后3年有轻度返流。结论股部小切口修复瓣膜结合血管内电凝曲张静脉,是一种较好的治疗下肢深静脉瓣膜功能不全的微创手术方法,操作简便、创伤小、恢复快、并发症少,值得推广应用。     

Transcatheter aortic valve implantation: Anesthetic experience of retrograde transfemoral approach with CoreValve ReValving System

ObjectivesValvular aortic stenosis (AS) is a major cardiac valvular disease in geriatric people. Conventional treatment for severe AS is aortic valve replacement through surgery. However, many geriatric patients are considered inoperable due to higher risks for surgery and anesthesia. Transcatheter aortic valve implantation (TAVI), a less invasive procedure, has rapidly developed in recent years as an alternative management option for high-risk AS patients. Herein, we describe our anesthetic experience in the TAVI procedure.MethodsWe included 11 patients who consecutively received transfemoral TAVI in the period from September 2010 to January 2011. All patients received general anesthesia with endotracheal intubation; arterial line placement and central venous catheter insertion were carried out for monitoring hemodynamics. Transesophageal echocardiography was applied for valve evaluation, hemodynamic monitoring, and intraoperative guidance. Patients were transferred to the intensive care unit for further care after surgery. The periprocedural events were recorded.ResultsThe mean age of these patients was 82 years. Morphology of the aortic valve in all patients was tricuspid, and the etiology of AS was degenerative calcification. During TAVI, all patients received bolus injections of 5–10 μg norepinephrine just before the rapid pacing stage in order to increase the mean arterial pressure. Only one patient needed continuous infusion of dopamine because of severe preoperative congestive heart failure, and another patient needed continuous infusion of norepinephrine due to relatively old age and suspected low systemic vascular resistance. After TAVI, all patients had the endotracheal tube extubated within 7 hours, except one because of preoperative ventilator dependence. Another male patient stayed in the intensive care unit for 8 days due to postoperative complete atrioventricular block, and he received permanent pacemaker implantation. There was no early mortality.ConclusionTAVI is another choice for AS patients who have a high perioperative risk. General anesthesia with endotracheal intubation and application of transesophageal echocardiography can facilitate the use of this new technique by cardiologists. Complete preprocedural evaluation and good intraprocedural cooperation are still the gold standards to achieve successful TAVI and patient safety.     

Early postpartum mitral valve thrombosis requiring extra corporeal membrane oxygenation before successful valve replacement

Pregnancy is associated with an increased risk of thrombosis in women with mechanical prosthetic heart valves. We present the case of a 29-year-old woman who developed early postpartum mitral valve thrombus after an elective cesarean delivery. The patient had a mechanical mitral valve and was treated with warfarin in the second trimester, which was replaced with high-dose dalteparin during late pregnancy. Elective cesarean delivery was performed under general anesthesia at 37 weeks of gestation. The patient was admitted to the intensive care unit for postoperative care and within 30 min she developed dyspnea and hypoxia requiring mechanical ventilation. She deteriorated rapidly and developed pulmonary edema, worsening hypoxia and severe acidosis. Urgent extra corporeal membrane oxygenation was initiated. Transesophageal echocardiography revealed a mitral valve thrombus. The patient underwent a successful mitral valve replacement after three days on extra corporeal membrane oxygenation. This case highlights the importance of multidisciplinary care and frequent monitoring of anticoagulation during care of pregnant women with prosthetic heart valves.     

Stenosis of the bicuspid aortic valve with systemic lupus erythematosus

We herein present a rare case of severe aortic valve stenosis with a bicuspid valve in a patient with systemic lupus erythematosus. The symptoms resulted from aortic valve stenosis, such as chest pain, dyspnea and syncope, which subsided after the insertion of an intra-aortic balloon pump. Thereafter, a calcified bicuspid aortic valve was successfully replaced with a mechanical valve. The pathological findings of the resected valve included irregular fibrotic thickening and marked calcification without any vegetation or thrombus formation. The efficacy of an intra-aortic balloon pump for the relief of symptoms associated with severe aortic valve stenosis indicates its usefulness for such critically ill patients prior to undergoing valvular surgery.     

Obstruction of mechanical valve prostheses: Clinical diagnosis and surgical or nonsurgical treatment

Twenty patients underwent nonsurgical and/or surgical treatment for obstruction of mechanical prosthetic valves. The obstructed prosthetic valve was in the aortic position in 11 patients, in the mitral position in 5, and in the tricuspid position in 4. Twelve patients had a bileaflet valve (3 aortic, 5 mitral, 4 tricuspid), and 8 had a tilting disk valve (all aortic). The diagnosis of prosthetic valve obstruction was made by cineradiography and echocardiography. Thrombolytic therapy was instituted in a series of our 10 most recent patients (11 cases), except for one patient with acute renal failure, regardless of the position of the obstructed prosthetic valve. Successful thrombolysis was achieved in 6 cases (54.5%). Six patients required surgical treatment subsequent to either failed or incomplete thrombolysis, and one patient died of congestive heart failure 1 month after surgery. Nonfatal neurologic events occurred in 2 cases (18.2%). A total of 16 patients underwent surgical treatment. Two (12.6%) of the 16 patients died of causes unrelated to the operative procedures before discharge from the hospital. These results suggest that thrombolytic therapy appears to be an attractive nonsurgical alternative for valve thrombosis when the patient's clinical condition is not critical, and thus surgical treatment should only be performed in an emergency on seriously ill patients.     

Implantation of the CoreValve percutaneous aortic valve

Surgical aortic valve replacement is the only recommended treatment for significant aortic valve stenosis. Percutaneous aortic valve replacement appears to be a novel option for high-risk patients. We report the implantation of the ReValving system (CoreValve, Paris, France) in a 64-year-old woman who was refused aortic valve replacement surgery for critical aortic stenosis and left ventricular dysfunction because of severe pulmonary fibrosis. After anesthesia, the patient was put on femorofemoral cardiopulmonary bypass, and underwent a balloon valvuloplasty with subsequent retrograde aortic valve replacement by the ReValving system. Transesophageal echocardiographic monitoring of the patient's hemodynamics showed immediate improvements of the valvular area and left ventricular ejection fraction and only traces of paravalvular leaks. The patient was easily weaned from ventilation and resumed activity soon after the surgery. A multidisciplinary approach is presently necessary to offer a reliable and safe procedure.     

三尖瓣置换术后早期及晚期疗效

目的　总结三尖瓣置换术后早期及晚期疗效 ,并分析与早期病死率可能有关的危险因素。方法　行三尖瓣置换术 2 3例病人中男 11例 ,女 12例 ;年龄 12～ 5 6岁 ,平均 2 7岁。其中三尖瓣下移畸形17例、先天性三尖瓣发育不全 3例、风湿性病变 2例、感染性心内膜炎 1例。术前心功能II级 3例、III级13例 ,IV级 7例。结果　本组死亡 3例 ,早期病死率 13%。平均随访时间 80个月 (5～ 130个月 ) ,随访率95 %。晚期死亡 1例 (5 2 % )。1例于术后 86个月时因生物瓣失功再次行三尖瓣置换 ;1例右房血栓。术后生存者心功能I～II级 15例 ,III级 3例。多因素分析显示 ,心功能IV级 (P =0 0 2 )、严重腹水 (P =0 0 0 1)及置换机械瓣 (P =0 0 13)与术后早期病死率有显著相关。结论　三尖瓣置换术后早期及晚期效果良好。术前心功能IV级、严重腹水以及置换机械瓣对术后早期病死率有明显影响