心脏瓣膜术后心室辅助治疗

目的 总结瓣膜病变术后重症心衰病人置入心室辅助(VADs)装置时,心脏瓣膜或人工瓣膜处理方法及围术期抗凝管理的经验.方法 回顾1994年1月到2008年6月,宾夕法尼亚大学附属医院心脏中心157例置入VADs病人中,10例为瓣膜术后重症心衰者.对于二尖瓣和三尖瓣病变,无论成形或置换,置入VADs时均未处理原瓣膜或人工瓣膜(环).5例主动脉瓣病变病例置入VADs时,2例用生物瓣膜取代了原机械瓣膜,1例未处理原来生物瓣膜,1例未处理原机械瓣膜,1例取出机械瓣膜,用牛心包封闭主动脉根部.结果 所有病人置入VADs术后应用抗凝治疗.10例病人中,停VAD出院和VAD姑息治疗各1例;转心脏移植4例;4例死亡,3例为多器官衰竭,1例为血栓栓塞事件.结论 瓣膜病变术后置入VADs总的生存率是60%,与非瓣膜病心衰病人置入VADs相比,未增加手术风险.

Abstract：

Objective An increasing number of patients requiring ventricular assist devices (VAD) have had previous valvular corrections,including valve repair,and valve replacement with mechanical or bioprosthetic valves.The operative and peri-operative management of these patients has been varied.Methods A retrospective study of VADs between Jan 1994 and June 2008 revealed 10 patients with previous prosthetic valves requiring management during and after VAD placement.Three patients were supported post-cardiotomy after valve surgery.Two patients were supported due to cardiogenic shock postopera-tively.Four patients were supported as a bridge to transplantation.One patient was supported as a destination therapy.Results The mitral valve was left untreated during VAD implantation regardless of valve repair or replacement.For aortic valves,the mechanical aortic valve was replaced with tissue valve in two patients and left untreated in one case.One patient had tricuspid valve repair previously and was left untouched.All patients with prosthetic valves in aortic,mitral and tricuspid position during VAD support received anticoagulation therapy.There were 4 deaths,and 4 went on to transplantation.One patient weaned from VAD and discharge from hospital.One patient received HeartMate Ⅰ as destination therapy.The most common causes of death were multisystem organ failure and sepsis.One patient had a thromboembolic event.Conclusion The survival rate of 60% is encouraging when compared to overall survival rates.The most common cause of death was multisystem organ failure.Patients with prosthetic valves may be safely managed during VAD support.

VAD implantation in cardiac failure patients with prosthetic valves

Objective An increasing number of patients requiring ventricular assist devices (VAD) have had previous valvular corrections,including valve repair,and valve replacement with mechanical or bioprosthetic valves.The operative and peri-operative management of these patients has been varied.Methods A retrospective study of VADs between Jan 1994 and June 2008 revealed 10 patients with previous prosthetic valves requiring management during and after VAD placement.Three patients were supported post-cardiotomy after valve surgery.Two patients were supported due to cardiogenic shock postopera-tively.Four patients were supported as a bridge to transplantation.One patient was supported as a destination therapy.Results The mitral valve was left untreated during VAD implantation regardless of valve repair or replacement.For aortic valves,the mechanical aortic valve was replaced with tissue valve in two patients and left untreated in one case.One patient had tricuspid valve repair previously and was left untouched.All patients with prosthetic valves in aortic,mitral and tricuspid position during VAD support received anticoagulation therapy.There were 4 deaths,and 4 went on to transplantation.One patient weaned from VAD and discharge from hospital.One patient received HeartMate Ⅰ as destination therapy.The most common causes of death were multisystem organ failure and sepsis.One patient had a thromboembolic event.Conclusion The survival rate of 60% is encouraging when compared to overall survival rates.The most common cause of death was multisystem organ failure.Patients with prosthetic valves may be safely managed during VAD support.