双瓣置换围术期处理

目的总结1989年1月～1998年12月双瓣置换围术期处理经验。方法 10年中207例患者施行主动脉瓣、二尖瓣人工机械瓣双瓣置换术。强调对重症患者术前准备充分是围术期成功的关键之一。心肌保护运用仁济医院心肌保护液加山莨菪碱，心脏停搏后切开主动脉直接予冠状动脉开口灌注心肌保护液；置换二尖瓣时保留二尖瓣后瓣及瓣下结构；对中度以上返流的三尖瓣做Kay氏法成形；常规切除右侧心包和纵隔胸膜使心包腔与右侧胸腔相通，术后加强ICU综合处理。结果前5年118例术死亡9例，死亡率7.6％。后5年89例中死亡3例，死亡率3.4％。207例总的围术期死亡率5.8％。前5年118例术中自动复跳33例，占27.9％；后5年89例术中自动复跳47例，占52.8％。随访185例，4～120个月，平均随访58±21个月，5年以上生存92例。结论对围术期处理的重视，术前准备充分，合理的手术方法和心肌保护，可以减少围术期并发症，降低双瓣置换手术围术期的死亡率。

Perioperative Management of Combined Aortic and Mitral Valve Replacement

Objective To summarize the experiences of perioperative management for combined aortic and mitral valve replacement from Jan. 1989 to Dec. 1998 Methods In the 10-year 207 cases undergoing combined aortic and mitral valve replacement (DVR) period from 1989 to 1998 were studied. Perioperative management included in fusion of conventional Renji cardioplegia with additional anisodamine, preservation of the posterior mitral leaflet and subvalvular apparatus, Kay's valvuloplasty for moderate and severe tricuspid regurgitation, partial to resection of the right mediastinal pleura and drainage of the right chest, and intensive postoperative care in the ICU. St-Jude and Medtronic Hall mechanical valves were used in 199 patients. Results In the first 5 years, 9 of 118 patients died (mortality 7.6％). During the later 5 years 3 patients died out of 89 cases (mortality 3.4％), the total mortality rate was 5.8％. 33 of 118 cases and 47 of 89 cases had spontaneous resceneption of sinus rhythm. 4～120 months follow-up for 185 patients (average 58±21 months), showed 92 cases survived 5 years and longer. Conclusion Intensive preoperative prepanration, rational operative methods and myocardial protection could reduce both perioperative mortality and postoperative complications.