主动脉瓣关闭不全合并巨大左心室外科治疗的危险因素分析及远期结果

目的探讨主动脉瓣关闭不全合并巨大左心室患者外科治疗的适应证、危险因素及远期结果。方法回顾性分析了2004年3月至2012年12月共收治主动脉瓣关闭不全合并巨大左心室患者42例(左心室舒张期末内径≥70mm和左心室收缩期末内径≥50mm)的临床资料。其中男38例、女4例,年龄16~73(45.86±14.99)岁。所有患者均行主动脉瓣置换术,术前、术后1周、术后3个月行超声心动图检查,并对患者随访12~132个月,分析影响术后心功能恢复及导致死亡的危险因素。结果术后早期死亡1例,远期死亡5例。41例患者术后1周经胸超声心动图检查,左心室舒张期末内径(62.00±13.21)mm、左心室收缩期末内径(50.71±14.02)mm、左心室舒张期末内径指数(35.23±8.58)mm/m~2、左心室收缩期末内径指数(28.92±9.08)mm/m~2,与术前相比均明显减小(P0.01)。左心室射血分数(46.41%±12.4%)明显低于术前(P0.01)。术前心功能分级、射血分数、左心室舒张期末内径、左心室舒张期末内径指数是预测术后早期左心室功能恢复的预测因子。左心功能不全及室性心律失常是导致术后死亡的危险因素。术后1年、5年、10年生存率分别为92.9%、90.2%和83.8%。结论大多数主动脉瓣关闭不全合并巨大左心室患者仍有手术指征,术后疗效满意。但术前左心功能不全、室性心律失常是影响手术疗效和远期存活的危险因素。     

亚急性心肌梗死合并重度缺血性功能性二尖瓣关闭不全的处理方式探讨

目的 探讨亚急性心肌梗死合并重度二尖瓣关闭不全患者的处理方法及手术时机. 方法 2005年1月至2011年12月北京安贞医院采用外科手术治疗89例亚急性心肌梗死合并重度二尖瓣关闭不全患者[男66例,女23例；平均年龄64(55～73)岁].所有患者手术前先用药物治疗3个月后行单纯冠状动脉旁路移植术,二尖瓣病变未做处理.就诊时、术前和术后6个月做超声心动图检查,观察二尖瓣反流情况,并检测左心室收缩期末内径、左心室舒张期末内径和左心室射血分数(LVEF). 结果 无手术死亡,无围术期心肌缺血和其它严重并发症发生.随访81例(91.0％),随访时间6～60个月,术后6个月二尖瓣反流面积[(3.1±1.3) cm2 vs.(5.6±2.3)cm2]、左心室舒张期末内径[(51.3±4.2) mm vs.(54.3±5.5)mm]和左心室收缩期末内径[(31.7±3.9) mm vs.(34.6±4.3) mm]均较术前明显减小(P＜0.05),而术后6个月LVEF与术前比较差异无统计学意义(59.1％±3.9％vs.58.9％±5.6％,P＞ 0.05).术后3年起,随访患者每年行冠状动脉血管CT检查1次,未发现移植血管存在明显狭窄(狭窄＞50％). 结论 对亚急性心肌梗死合并重度二尖瓣关闭不全患者,适当的延缓手术,结合正确的药物治疗,可能不再需要同期处理二尖瓣病变,可降低手术风险,减少医疗费用.     

老年患者单纯主动脉瓣置换术术后人工瓣膜-患者的不匹配发生率及术后早期结果的研究

目的分析单纯主动脉瓣病变的老年患者主动脉瓣置换术后人工瓣膜-患者不匹配(PPM)现象及PPM对术后早期心功能及左心室重构的影响。方法回顾性分析2016年1~12月我院连续134例单纯主动脉瓣病变行主动脉瓣置换术65岁以上患者的临床资料,其中男73例、女61例,年龄65~79(69.7±3.6)岁。分析他们的临床及超声心动图数据,有效瓣口面积指数(EOAI)≤0.85 cm2/m2定义为PPM。对比主动脉瓣狭窄与主动脉瓣关闭不全患者术后PPM发生率,并对比机械瓣与生物瓣术后效果。结果 80例主动脉瓣狭窄患者中有26例发生PPM(发生率32.5%),54例主动脉瓣关闭不全患者中7例发生PPM(发生率13.0%),差异具有统计学意义(P0.05)。重度PPM 8例(发生率6.0%),1例患者术后早期死亡。结论单纯主动脉瓣反流行主动脉瓣置换术后PPM的发生率低于主动脉瓣狭窄的患者。     

二尖瓣成形术116例

目的　为了评价二尖瓣成形术的临床效果 ,对近年来 14岁以上行二尖瓣成形术患者的临床资料进行总结。　方法　二尖瓣病变患者 116例 ,诊断为二尖瓣狭窄 1例 ,二尖瓣狭窄合并关闭不全 6例 ,其余均为单纯二尖瓣关闭不全。超声心动图检查示左心房内径平均 4 8± 10 mm,左心室舒张期末内径平均 6 2± 10 mm。二尖瓣成形术方法 :腱索转移 2例 ,腱索折叠 10例 ,后叶楔形切除 6 7例 ,瓣环环缩 82例。　结果　全组无手术死亡 ,1例术后第 2天出现心力衰竭行二尖瓣置换术。出院前超声心动图示左心房内径平均为 37± 9m m,左心室舒张期末内径平均为 5 1±7mm ,与术前相比均明显缩小。　结论　二尖瓣成形术应根据二尖瓣病变的特征进行选择 ,对非风湿性二尖瓣病变行二尖瓣成形术可取得较满意的临床效果。     

应用人工腱索行二尖瓣成形术治疗原发性感染性心内膜炎患者的中远期疗效

目的评估应用人工腱索行二尖瓣成形术治疗原发性感染性心内膜炎二尖瓣反流患者的中远期疗效。方法回顾性分析我院2012年1月至2015年12月28例原发性感染性心内膜炎二尖瓣关闭不全患者行二尖瓣成形术的临床资料,男17例、女11例,年龄18~69(52.0±15.4)岁。19例为中度关闭不全,9例为重度关闭不全;术前心功能(NYHA)Ⅱ级6例,Ⅲ级14例,Ⅳ级8例;急性期手术2例,亚急性期及慢性期手术26例。同期行冠状动脉旁路移植术1例,主动脉瓣置换术6例,主动脉瓣成形术5例,三尖瓣成形术20例,心房颤动射频消融术5例。结果所有患者术后均予以随访,随访时间6~55(30.5±6.4)个月。术后心功能均明显改善。术后随访左心大小较术前进行性显著减小,左心房内径由术前的(51.78±17.50)mm降低至术后的(36.64±8.50)mm(P0.05),左心室舒张期末内径由术前的(57.70±7.49)mm降低至术后的(49.30±5.05)mm(P0.05);左心室射血分数值进行性显著提升,由术前的53.86%±8.16%提高到术后的59.14%±4.23%(P0.05),无明显反流16例,轻度反流8例,轻-中度反流2例,中度反流1例,复发心内膜炎1例,再次手术1例。无死亡,无瓣膜反流加重。无血栓形成、栓塞等相关并发症的发生。结论应用人工腱索行二尖瓣成形术治疗原发性感染性二尖瓣关闭不全,手术效果安全、可靠,中远期疗效满意,值得推广应用。     

心脏瓣膜病合并巨大左心室的外科治疗

我科1999年1月至2003年6月,对18例心脏瓣膜病伴巨大左心室的患者进行手术治疗,占同期心脏瓣膜病手术的10.6%(18/170),现报道如下。1临床资料与方法1.1一般资料本组18例,男14例,女4例;年龄25～65岁;身高150～178cm;体重37～70kg;病程1～20年。其中先天性心脏病2例,风湿性心脏病13例,心瓣膜退行性病变3例。超声心动图(UCG)检查示左心室舒张期末内径(LVEDD)71～98mm(79.6±6.7mm),左心室射血分数(LVEF)0.33～0.66(0.52±0.10)。病变类型:二尖瓣病变8例,主动脉瓣病变6例,主动脉瓣和二尖瓣联合病变4例,其中5例有明显的三尖瓣关闭不全,心功能…     

改良保留前叶技术在二尖瓣置换术中的应用

目的 总结改良保留前叶技术在二尖瓣置换术中的临床应用和体会,提高临床治疗效果,降低术后死亡率和并发症发生率。 方法 纳入2005年5月至2012年12月北京安贞医院采用改良保留二尖瓣前叶的瓣膜置换术128例患者,作为改良组,同期行主动脉瓣置换术14例;其中男49例、女79例,年龄（45.0±12.3）岁。同期纳入行常规二尖瓣置换术的患者128例作为对照组,其中男55例、女73例,年龄（48.0±8.4）岁。两组患者术前情况差异无统计学意义（P＞0.05）。 结果 改良组无围手术期死亡,6例开胸止血,4例出现低心排血量,5例并发肺部感染,1例行气管切开,3例出现肾功能衰竭。对照组早期死亡5例,3例死于左心室后壁破裂,2 例死于严重低心排血量。5例开胸止血,12例出现低心排血量,4例并发肺部感染,6例出现肾功能衰竭。术后6个月心脏超声心动图随访结果显示改良组术后左心室射血分数、左心室舒张期末内径、收缩期末内径均较对照组有改善,其中两组左心室射血分数和收缩期末内径差异有统计学意义（P＜0.05）,两组左心室舒张期末内径差异无统计学意义（P＞0.05）。改良组术前、术后射血分数、舒张期末内径、收缩期末内径差异均有统计学意义（P＜0.05）,对照组术前、术后舒张期末内径差异有统计学意义（P＜0.05）,射血分数和收缩期末内径差异无统计学意义（P＞0.05）。 结论 改良保留前叶的二尖瓣置换术近期效果良好,方法简便易行,适合各种类型的二尖瓣病变,尤其是退行性病变和感染性心内膜炎。     

缺血性二尖瓣关闭不全的外科治疗

目的总结缺血性二尖瓣关闭不全的外科治疗经验.方法 12例缺血性二尖瓣关闭不全患者,其中二尖瓣大量反流9例,中量反流3例,均有心肌梗死史,术前心功能Ⅱ级4例,Ⅲ级4例,Ⅳ级4例,均接受冠状动脉旁路移植术和同期保留二尖瓣和瓣下结构的二尖瓣置换术.结果 1例术后并发肺部感染死亡,其余患者均痊愈出院,出院时心功能为Ⅰ～Ⅱ级.随访3～59个月,无远期死亡,亦无抗凝和机械瓣膜引起的并发症,患者心功能仍为Ⅰ～Ⅱ级.术后早期超声心动图检查示左心室舒张期末内径和左心房舒张期末内径均较术前缩小(P<0.05).结论缺血性心脏病伴缺血性中至重度二尖瓣反流行冠状动脉旁路移植术加二尖瓣置换术疗效可靠.     

小左心室患者瓣膜置换术后早期心脏形态及功能的变化

目的 研究小左心室患者心脏瓣膜术后早期形态学及左心室收缩功能变化.方法 2003年1月至2008年8月,51例合并小左心室的风湿性瓣膜病患者接受二尖瓣置换术.男性7例,女性44例,年龄31～69岁,平均(48±5)岁.病程5～49年,平均(18±9)年.患者病变以重度二尖瓣狭窄为主.同期行主动脉瓣置换术6例,冠状动脉旁路移植术1例,三尖瓣成形术48例,左心房血栓清除术36例,左心房折叠术42例.结果 围手术期死亡2例(3.9%),1例因不能脱离辅助循环死亡,1例于术后10 d死于继发的多脏器功能衰竭.术后早期发生重度低心排血量14例(27.5%),多器官功能不全11例,频发室性心律失常5例.术前及术后早期(7～14 d)行超声心动图.左心室舒张末期内径术前(36.5±3.2)mm,术后(38.6±5.3)mm;左心室舒张末期容积指数术前(45.9±3.8)ml/m2,术后(48.2±7.4)ml/m2;差异无统计学意义.手术前后射血分数为48.6%±6.7%和52.8%±8.3%,缩短分数为25.5%±3.3%和27.1%±1.3%,差异无统计学意义.结论 小左心室患者瓣膜术后早期易发生低心排血量.左心室舒张末期内径术后早期一般不会立即恢复.     

风湿性瓣膜病二尖瓣与主动脉瓣置换术1154例长期效果分析

目的　评价风湿性联合瓣膜病二尖瓣与主动脉瓣双瓣置换术的近期与远期疗效 ,分析影响手术疗效的因素。　方法　回顾性分析 1981年 5月～ 2 0 0 1年 5月 2 0年间 ,115 4例风湿性心脏病患者行双瓣膜置换术的临床资料和长期随访结果 ,其中二尖瓣与主动脉瓣均为狭窄病变者 2 5 3例 ,二尖瓣狭窄合并主动脉瓣关闭不全者 345例 ,二尖瓣关闭不全合并主动脉瓣狭窄者 119例 ,二尖瓣与主动脉瓣均为关闭不全者 437例 ;合并三尖瓣病变的占 5 4 0 0 %( 75 7例 ) ,其中器质性病变 7 2 7%( 84例 ) ,功能性关闭不全 5 8 31%( 6 73例 ) ;合并中度以上肺动脉高压者 339例 ;术前NYHA心功能分级Ⅲ级与Ⅳ级者分别为 873例和 186例。应用侧倾碟瓣或双叶机械瓣施行瓣膜置换术 ,合并三尖瓣功能或器质性病变者 ,同期行瓣膜成形手术。　结果　本组患者术后住院病死率为 6 5 0 %( 75 / 115 4)。早期死亡的主要原因为低心排出量综合征、顽固性心律失常、肾功能或呼吸功能衰竭 ,以及抗凝有关的出血等。长期生存 10 79例 ,随访时间为 8个月～ 2 0年 ,平均随访时间为 4 5 %病人·年。晚期死亡 6 6例 ( 0 39%病人·年 ) ;5、10与 15年累计生存率分别为 ( 89 46± 1 35 ) %、( 86 5 0± 1 91) %与 ( 6 7 86±6 16 ) %。生存的 92 9例患     

Open heart surgery in the elderly

Of 3254 open heart surgical cases performed since 1972, 126 patients (3.9%) were 70 years of age or older. The mean age was 72 years, the oldest being 82. Sixty-seven per cent were male. The following procedures were performed: coronary artery bypass grafting (CABG) 51, aortic valve replacement (AVR) 44, AVR + CABG 16, mitral valve replacement (MVR) 3, MVR + CABG 6, MVR + AVR 4, and other, 2. Of those undergoing CABG, 33% came from the Coronary Care Unit and 24% had left main coronary artery stenosis. There was one peri-operative death (2.0%). Of those undergoing AVR, 43% had coronary artery disease and 13% triple vessel disease. Operative mortality for AVR, and AVR + CABG was 11.4% (5/44) and 18.8% (3/16), respectively. Twenty-six per cent of operative survivors had significant postoperative complications (excluding atrial arrhythmias). The postoperative hospital stay for CABG, AVR and other cases was 11, 13 and 16 days, respectively. Seven year survival of all patients was 61.2 +/- 6.5% (+/- 1 SE) and for AVR +/- CABG was 51.5 +/- 8.6%. Five year survival for CABG was 83.9 +/- 6.3%. We conclude that, in selected cases, CABG can be performed safely in the elderly. Although valvular and combined surgery may result in significant morbidity and mortality, the satisfactory long term results in survivors justifies surgery in this group of patients.     

St. Jude Medical valve replacement: clinical experience with 1,039 patients

St. Jude Medical valve replacement was performed in 1,039 patients; 320 had aortic (AVR), 543 mitral (MVR), and 176 had double valve replacement (DVR). There were 44(4.2%) early deaths. Follow-up extended in 995 patients from 10 to 130 months, with a cumulative period of 2,730 patients-years. The overall survival rates of AVR, MVR, and DVR patients at 10 years were 60.5%, 89.6%, 90.3% respectively. The linearized incidences of valve thrombosis, thromboembolism, anticoagulation-related hemorrhage, prosthetic valve endocarditis, and significant hemolysis were as follows: 0.11%/pt-yr, 1.33%/pt-yr, 0.04%/pt-yr, 0.18%/pt-yr, and 0.11%/pt-yr, respectively. There were no structural failure after 10 years follow-up. Reoperation (explant and re-replacement or suture repair) was required in 10 patients. Seven of them had periprosthetic leakage, 2 had valve thrombosis, and one underwent reoperation because of a technical error. Actuarially over 98% of patients were free of valve-related mortality at 10 years. St. Jude Medical valve is an excellent alternative for use in the surgical treatment of valvular heart disease.     

保留后瓣及瓣下结构的二尖瓣置换术临床分析

目的总结保留二尖瓣后瓣及瓣下结构二尖瓣置换术(MVR)的经验,评价其临床效果。方法回顾性分析首都医科大学北京安贞医院2006年1月至2011年3月行MVR患者1 035例的临床资料,其中男562例,女473例;年龄37～78(53.84±13.13)岁。风湿性心脏瓣膜病712例,退行性瓣膜病323例;二尖瓣狭窄为主389例,二尖瓣关闭不全为主646例;均排除冠状动脉疾病。不保留后瓣及瓣下结构的MVR(不保留组)457例,保留后瓣及瓣下结构的MVR(保留组)578例,两组患者术前情况差异无统计学意义。分析比较两组患者手术后并发症、死亡率,以及左心室大小与功能。结果不保留组与保留组患者的死亡率(2.63%vs.1.21%,P=0.091)及并发症发生率(8.53%vs.7.44%,P=0.519)差异无统计学意义,但不保留组左心室破裂发生率高于保留组(1.09%vs.0.00%,P=0.012);术后6个月心脏超声心动图提示左心室舒张期末内径(LVEDD)较术前缩小,但两组差异无统计学意义;两组患者左心室射血分数(LVEF)均较术前提高,保留组中二尖瓣关闭不全为主患者的LVEF优于不保留组(56.00%±3.47%vs.53.00%±3.13%,P=0.000),两组二尖瓣狭窄为主的患者中LVEF差异无统计学意义(57.00%±5.58%vs.56.00%±4.79%,P=0.066)。结论保留二尖瓣后瓣及瓣下结构的MVR安全有效,可以减少术后左心室破裂的发生并改善术后心功能。     

获得性心瓣膜病手术治疗34例报告

对３４例年龄≤１８岁的获得性心瓣膜病患者进行了手术治疗。病因为风湿性心脏病２６例，二尖瓣脱垂综合症７例，二尖瓣感染性心内膜炎１例。手术采用主动脉瓣置换４例，二尖瓣置换６例，双瓣置换１例，主动脉瓣置换并二尖瓣成形３例，二尖瓣置换并三尖瓣成形术５例，二尖瓣成形术１２例，二尖瓣成形并三尖瓣成形３例。术后早期死亡１例，低心排出量综合症１例，急性和迟发性心包填塞二次开胸止血各１例，Ⅲ度房室传导阻滞安置永久起搏器１例。本文就未成年人获得性心瓣膜病的病因、病理，手术策略及疗效进行了讨论     

Late results after heart valve surgery in the elderly

Heart valve surgery was performed in 133 patients over the age of 60 between 1976 and 1981. There were 54 men and 79 women. Their ages ranged from 60 to 74 years (mean age 64.3 years). In this study, 54 valve prostheses (15 porcine and 39 mechanical) in the aortic position, 79 prostheses (69 porcine and 10 mechanical) in the mitral position and 3 prostheses (3 porcine) in the tricuspid position were implanted in 121 patients. Fifteen patients (11.3%) died in the hospital. The hospital mortality was high in the cases of MVR (14.6%), MVR + TAP (12.5%) and emergency (50%). The mean follow-up was 37.2 months (range 4 to 129 months, total 367.3 patient-years). There were 10 late deaths (8.5%). Actuarial survival for hospital survivors at 5 years was 89.2 per cent. At follow-up, 95.8% of the surviving patients were in New York Heart Association functional class I or II. Valve-related complications were thromboembolism (2.0% pt/year), periprosthetic leak (1.7% pt/year), primary tissue failure (0.5% pt/year) and thrombosed valve (0.3% pt/year). Anticoagulant-related hemorrhage necessitating hospitalization occurred in 2 patients (1.0% pt/year). The freedom from all events at 5 years was 72.8 per cent. This study suggests that heart valve surgery in the elderly can be performed with an acceptable mortality. Advanced age alone should not be a contraindication to surgical management.     

Mitral valve replacement in children: predictors of long-term outcome

BACKGROUND: Mitral valve replacement (MVR) in children has been associated with a high complication rate. We sought to assess predictors of outcomes in children undergoing MVR. METHODS: A retrospective review of clinical, surgical, and echocardiographic records of patients undergoing MVR was performed. Between 1982 and 2000, 53 children underwent 76 MVR procedures at a median age of 5 years (range, 1 day to 18 years) and weight of 17 kg (range, 3 to 121 kg). Eighteen patients (34%) had more than one MVR. Previous cardiac surgery had been performed in 39 (74%), with 27 (51%) undergoing previous mitral repair. Patients were followed for 9.2 +/- 4.8 (range, 2 to 20) years. RESULTS: There were 14 patient deaths, with 6 patients dying within 30 days, and five transplants (36%). Ten-year freedom from reoperation was 66%. Long-term survivors were older at initial repair (7.0 vs 2.5 years, p = 0.02), with a lower incidence of residual cardiac lesions (3% vs 37%, p < 0.001) and a lower incidence of surgical procedures at the time of MVR (31% vs 63%, p = 0.04). Survivors had better left ventricular function preoperatively (ejection fraction, 68% vs 54%; p = 0.001) and placement of a prosthetic valve within 1 z-score of the echocardiographically measured mitral valve annulus (p = 0.02). CONCLUSIONS: Adverse outcome after MVR is common, particularly in the young child undergoing palliative surgery or requiring additional surgical procedures. Preoperative assessment of mitral valve size and ventricular function is essential for risk stratification of these patients.     

Elderly valve replacement with bioprostheses and mechanical prostheses. Comparison by composites of complications

AIM: The goal of aortic valve replacement (AVR) surgery in the elderly (= or >75 years) is to extend survival and minimize valve-related morbidity, mortality and reoperation. As the elderly population lives longer, those with implanted valves are at risk of suffering valve related complications. We hypothesize that bioprostheses are appropriate for the elderly. METHODS: The follow-up evaluation of 966 patients with valves (AVR, 666; mitral valve replacements [MVR], 226; multiple valve replacements [MR], 74) implanted between 1975 and 1999 was examined. There were 879 bioprotheses (BP) and 87 mechanical prostheses (MP). The mean age was 78.9+/-3.3 years (range 75-94.6 years). Concomitant coronary artery bypass was performed in AVR in 51.7%, MVR in 50.4% and MR in 28.4%. Valve type, valve lesion, coronary artery bypass (previous/concomitant), age and gender were considered as independent predictors of composites and survival. The total follow-up was 3905 patient-years. RESULTS: Early mortality was for AVR 9.6% (64), MVR 15.0% (34) and MR 25.7% (19). The late mortality was for AVR 8.8%, MVR 10.4% and MR 8.8%/patient-year. The only independent predictor of survival and valve-related mortality, morbidity and reoperation was age for survival in those with AVR, hazard ratio 1.15 [CL 1.03-1.27] p=0.0094). The BP reoperative rate was 0.5%/patient-year (reoperation was fatal in 6/15) of total, MP reoperative rate was 0% [reasons for reoperation structural valve deterioration (4), non-structural dysfunction (6), prosthetic valve endocarditis (5), reoperation fatality due to non-structural dysfunction (2), prosthetic valve endocarditis (4)]. Overall patient survival at 10 and 15 years, respectively, was 30.5+/-2.4% and 3.6+/-2.2% irrespective of valve position and type. Overall actual and actuarial freedom from valve-related morbidity at 15 years was 96.8+/-0.9% and 93.7+/-2.3%, respectively. Actual and actuarial overall freedom from valve-related mortality at 15 years was 84.3+/-2.4% and 58.4+/-0.9%, respectively. Overall actual and actuarial freedom from valve related reoperation at 15 years was 95.8+/-1.6% and 74.8+/-16.9%, respectively. CONCLUSIONS: BP valves are further confirmed to be a good option for AVR in patients = or >75 years of age.     

Heart Valve Replacement with the Hancock Bioprosthesis: A 6-Year Review

All patients who had a mitral or aortic Hancock valve replacement between June, 1974, and June, 1979, were reviewed. A total of 734 bioprostheses were implanted in 632 patients: 291 had mitral (MVR), 239 had aortic (AVR), and 102 had both mitral and aortic valve replacement (MVR + AVR). In 228 patients, an associated surgical procedure was necessary. It involved conservative valve operation in 205 of them. The hospital mortality was 9.6% (28) for MVR (11.5% with associated operation), 4.6% (11) for AVR (8.7% with associated operation), and 13.7% (14) for MVR + AVR (13.0% with associated operation).The follow-up period was between 1 and 6 years with a total follow-up of 934.6, 714.6, and 288.3 patient-years for MVR, AVR, and MVR + AVR, respectively. The late mortality was 0.96% (9), 1.53% (11), and 2.08% (6) per patient-year for MVR, AVR, and MVR + AVR, respectively. The thromboembolic rate was 1.49%, 0.14%, and 2.08% per patient-year for MVR, AVR, and MVR + AVR, respectively. There were twelve valve failures (six were due to rupture; four, thrombosis; one, insufficiency because of intrinsic failure; and one, stenosis without evident cause at reoperation). This represents a failure rate of 0.53%, 0.13%, and 2.08% per patient-year for MVR, AVR, and MVR + AVR, respectively. These results encourage us to continue our routine use of the glutaraldehyde xenografts as the safest valve substitute at present.     

二尖瓣置换术后远期功能性三尖瓣关闭不全的外科治疗

目的：报告二尖瓣置换（ＭＶＲ）术后远期三尖瓣关闭不全（ＴＲ）外科治疗的结果及作用,方法：３７例ＭＶＲ术后中重度ＩＲ病人,其中人工二尖瓣为生物瓣者１３,机械瓣２４例,有１１例行内科保守治疗,２６例行外科手术治疗,手术类型,ＭＶＲ加三尖瓣置换２例,ＭＶＲ加三法瓣成形１１例,三尖瓣置换３例,三尖瓣成型１０例,三尖瓣成形术包括改良Ｋay形成形１２例,改良ＤeVega成形术７例,加成形环的三尖瓣成形术２例,结果：１１例内科治疗者,７个月－７．５年后７６例死亡,病死率为５４．５％,26例手术治疗者,术后早期病死２例,病死率为７．７％,随访个月－１０．５年,晚期死亡例,仍中度ＴＲ２例,结论：ＭＶＲ术后远期ＴＲ的产生与不可逆的左心损害或（和）严重肺动脉高压有关,对重度ＴＲ伴有临床症状、左心功能基本正常者,行三尖瓣成形或三尖瓣置换术可取得良好的效果。     

Decreasing mortality for aortic and mitral valve surgery in Northern New England. Northern New England Cardiovascular Disease Study Group

BACKGROUND: Although numerous reports have documented declining mortality rates associated with coronary artery bypass surgery in recent years, it is unknown whether similar trends have occurred with valve surgery during this time. METHODS: We conducted a regional, prospective study to assess trends in patient casemix and in-hospital mortality rates over time with aortic valve replacement (AVR), mitral valve replacement (MVR), and mitral valve repair. Data were collected from all patients undergoing AVR (n = 2,596), MVR (n = 759), or mitral valve repair (n = 522) in Northern New England between January 1992 and December 1997. Logistic regression was used to identify significant predictors of in-hospital mortality and to calculate risk-adjusted mortality rates. RESULTS: For AVR, the trend in patient casemix was toward increased risk with increases in patient age and in the proportion of patients with: body surface area less than 1.7, diabetes, coronary artery disease, and prior valve surgery. A decrease was noted in the proportion of patients undergoing additional surgical procedures. For MVR, patient risk improved over the time period with fewer female patients and fewer patients with coronary artery disease. For mitral valve repair patient risk increased over the time period with increases in the proportion of patients with coronary artery disease, diabetes, and whose surgical priority was classified as urgent. In addition, there was a borderline significant increase in the proportion of mitral valve repair patients in New York Heart Association class IV preoperatively. Risk-adjusted mortality decreased 44% from 9.3% in 1992 through 1993 to 5.3% in 1996 through 1997 for patients undergoing AVR (p = 0.01) and decreased 53% from 13.6% in 1992 through 1993 to 8.2% in 1996 through 1997 for patients undergoing MVR (p = 0.01). We observed a statistically insignificant increase in risk-adjusted mortality over the time period for patients undergoing mitral valve repair (from 3.6% in 1992 through 1993 to 5.0% in 1996 through 1997; p = 0.34). CONCLUSIONS: Significant improvement in mortality rates with valve replacement was observed in northern New England during this time period. This improvement persisted following adjustment for changes in patient casemix over this time. These trends mirror improvements in mortality with other cardiac surgical interventions that have been observed in recent years in our region and nationally.