老年心脏瓣膜置换术患者的围手术期处理

目的分析老年患者心脏瓣膜置换术的治疗效果，总结围手术期处理经验。方法回顾性分析徐州医学院附属医院2011年1月至2014年5月施行心脏瓣膜置换术的47例老年患者的临床资料，其中男19例、女28例，年龄60～79岁；风湿性心脏病35例，退行性心脏瓣膜病10例，先天性主动脉瓣二叶畸形2例；术前心功能分级（NYHA）Ⅱ级23例，Ⅲ级19例，Ⅳ级5例。体外循环下行心瓣膜置换术，或同期行三尖瓣成形术（TVP）、左心房血栓清除术、冠状动脉旁路移植术（CABG）。观察手术早期病死率、并发症及心功能改善情况。结果全组行二尖瓣置换术（MVR）27例，主动脉瓣置换术（AVR）15例，MVR＋AVR5例，同期行TVP4例，左心房血栓清除术3例，CABG6例。全组手术时间138～412（196±52）min，体外循环时间48～301（108±33）min，主动脉阻断时间34～196（87±21）min，住院时间12～31（19±5）d。无术中死亡病例，术后早期死亡2例（4．3％），死亡原因为左心功能衰竭和多器官功能衰竭。术后发生并发症23例（51．1％），包括呼吸功能不全6例，肺部感染5例，心律失常5例，切口感染2例，胸腔积液2例，低心排血量综合征2例，肾功能不全1例。通过电话、网上视频、来院复查等方式随访生存患者45例，随访时间1～32个月，随访率100％，心功能改善至I级11例、Ⅱ级32例、Ⅲ级2例。结论针对老年瓣膜疾病的特点，提高手术技巧，改善围手术期处理，可有效降低病死率，减少并发症。

Perioperative Management of Elderly Patients Undergoing Heart Valve Replacement

Objective To investigate clinical outcomes and summarize perioperative management experience of heart valve replacement （HVR） in elderly patients. Methods We retrospectively analyzed clinical data of 47 elderly pa- tients undergoing HVR in Affiliated Hospital of Xuzhou Medical College from January 2011 to May 2014. There were 19 male and 28 female patients with their age of 60-79 years. There were 35 patients with rheumatic heart disease, 10 patients with degenerative valvular disease, and 2 patients with congenital bicuspid aortic valve. Preoperatively, there were 23 patients in NYHA functional class 11, 19 patients in class 11I, and 5 patients in class 1V. All the patients received HVR under cardiopulmonary bypass （CPB）, and some patients received concomitant tricuspid valvuloplasty （TVP）, left atrial thrombectomy or coronary artery bypass grafting （CABG）. Postoperative mortality, morbidity and heart function improve- ment were evaluated. Results Twenty-seven patients received mitral valve replacement （MVR）, 15 patients received aortic valve replacement （AVR）, and 5 patients received MVR＋AVR. Concomitantly, 4 patients received TVP, 3 patients received left atrial thrombeetomy, and 6 patients received CABG. Operation time was 138-412 （ 196 ± 52） minutes, CPB time was 48-301 （ 108 4±33 ） minutes, aortic cross-clamping time was 34-196 （ 87 4±21 ） minutes, and length of hospital stay was 12-31 （19 4± 5） days. There was no intraoperative death, and 2 patients （4.3%） died postoperatively because of left ventricular failure and multiple organ dysfunction syndrome respectively. Twenty-three patients （ 51.1%） had postoperative complications including respiratory failure in 6 patients, pulmonary infection in 5 patients, arrhythmias in 5 patients, wound infection in 2 patients, pleural effusion in 2 patients, low cardiac output syndrome in 2 patients, and acute renal failure in 1patient. Forty-five survival patients were followed up by telephone, online video and at th