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老年危重心瓣膜病的外科治疗与围术期处理

目的　总结老年危重心瓣膜病患者的手术治疗和围术期处理经验。　方法　回顾性分析 2008年6月至2010年6月中国医科大学附属第一医院37例60岁以上老年危重心瓣膜病患者手术治疗的临床资料，其中男21例，女16例；年龄60～79 （67.3±6.9）岁。二尖瓣病变15例，主动脉瓣病变8例，主动脉瓣＋二尖瓣病变14例；合并左心房血栓9例，三尖瓣反流11例。　结果　围术期死亡3例，其中死于术后肺部感染1例，多器官功能衰竭1例，脑梗死1例。术后发生并发症18例，包括呼吸道并发症、室性心律失常、低心排血量综合征和急性肾功能衰竭等，经相应的治疗治愈。随访26例，随访时间6～23个月，心功能分级（NYHA）Ⅰ级13例，Ⅱ级12例，Ⅲ级1例。　结论　完善的术中操作、加强围术期处理，可有效降低老年危重心瓣膜病患者术后并发症的发生和病死率。

Application and Significance of Coronary Angiography Prior to Heart Valve Replacement for Patients with Rheumatic　Valvular Heart Disease

Objective To explore clinical application and significance of coronary angiography （CAG） prior to heart valve replacement for patients with rheumatic valvular heart disease （RVHD）. Methods We retrospectively analyzed clinical data of 313 RVHD patients who underwent heart valve replacement in the First Affiliated Hospital of Chongqing Medical University from January 2002 to June 2012. All the patients received screening CAG before surgery. According to CAG results，313 patients were divided into two groups. In the coronary artery lesion （CAL） group，there were 29 patients including 17 male and 12 female patients with their age of 60.0±5.2 years. In the non-coronary artery lesion （non-CAL）group，there were 284 patients including 98 male and 186 female patients with their age of 57.0±5.4 years. Surgicaloutcomes were compared between the two groups. Univariate analysis and multivariate logistic regression were performed to analyze risk factors of CAL for RVHD patients. Results CAG showed 29 patients with CAL，and the overall prevalence of CAL was 9.27%. In CAL group，11 patients underwent concomitant coronary artery bypass grafting with 2.2 grafts for each patient on the average. Postoperatively 1 patient （3.45%） died of low cardiac output syndrome （LCOS）. In non-CAL group，5 patients （1.76%） postoperatively died mainly because of LCOS，ventricular fibrillation，sudden cardiac arrest or respiratory failure. Cardiopulmonary bypass time and aortic cross-clamp time of CAL group were significantly longer than those of non-CAL group （P＜0.05）. There was no statistical difference in postoperative mortality，incidence of LCOS，acute renal failure，respiratory failure，reexploration for bleeding，intraoperative blood loss，mechanical ventilation time or hospital stay between the two groups（P＞0.05）. There was no significant correlation between the types of valvular lesions and CAL. Age≥ 55 years （OR=5.534，P=0.005），male gender （OR=2.335，P=0.038） and diabetes mellitus （OR=4.265，P=0.006） were independent risk factors of CAL for RVHD patients undergoing heart valve replacement. Conclusion For RVHD patients with independent risk factors of CAL （age≥55 years，male gender and diabetes mellitus），CAG must beseriously considered before heart valve replacement. RVHD patients with CAL can obtain similarly satisfactory surgicaloutcomes of heart valve replacement as RVHD patients without CAL by appropriate surgical strategy and strengthened perio-perative management.

风湿性心瓣膜病二尖瓣置换术中并发血管麻痹综合征一例

复发性心瓣膜病患者再次心瓣膜置换术的临床分析

摘要： 目的 总结复发性心瓣膜病患者再次行心瓣膜置换术的临床经验。 方法 回顾性分析1998年1月至2008年12月第四军医大学西京医院收治的319例复发性心瓣膜病再次行心瓣膜置换术患者的临床资料，男138例，女181例；年龄12～73岁(43.2±13.5岁)。需再次手术的原因为：心瓣膜成形术后、生物瓣衰坏、瓣周漏等。两次手术间隔时间3个月～25年(18.7±8.3年)。 结果 全组共死亡25例，其中手术死亡4例，早期死亡21例。主要死亡原因为：低心排血量综合征、室性心律失常、多器官功能衰竭等。其余294例患者治愈出院。随访252例，随访率85.7％，随访时间6个月～11年(9.6±7.1年)；失访42例。随访期间死亡17例，死于心力衰竭9例，人工瓣膜感染性心内膜炎2例，颅内出血、脑栓塞3例，消化道出血1例，原因不明2例。长期生存的235例患者中心功能恢复至Ⅰ～Ⅱ级183例，Ⅲ级29例。 结论 尽管复发性心瓣膜病患者心功能和全身状况均较差，手术操作较困难，但适时而妥善的外科手术仍可获得良好的效果。

风湿性心瓣膜病三尖瓣关闭不全的外科治疗

目的 总结风湿性心瓣膜病三尖瓣关闭不全（ TI）手术治疗的临床经验，以提高对该类患者的治疗效果。 方法 1999年1月至2009年1月安徽医科大学第一附属医院对167例风湿性心瓣膜病累及三尖瓣患者行手术治疗，其中男76例，女91例；年龄16.0～75.0岁（40.7±10.4岁）；病程2.0～35.0年（13.2±3.8年）。112例轻度至中度三尖瓣反流采用改良或节段性De Vega成形术，40例中度或中度至重度三尖瓣反流采用Kay或改良Kay成形术；12例因瓣环扩张明显、反流量大，行人工瓣环成形术，三尖瓣置换术3例。术后观察三尖瓣反流情况，随访超声心动图结果。 结果 术后早期死亡6例，其中死于心搏骤停1例，肾功能衰竭2例，脑血管意外1例，心室破裂1例，纵隔感染致败血症1例。1例术中因低心排血量使用主动脉内球囊反搏（IABP）治疗，治愈出院。随访159例，随访时间3～123个月，失访2例。随访期间心功能分级(NYHA)Ⅰ级115例，Ⅱ级32例，Ⅲ级12例。三尖瓣轻度反流15例，中度反流5例，重度反流2例。随访期间三尖瓣隔瓣与前瓣瓣环间直径（2.1±0.3 cm vs. 3.5±0.4 cm, P=0.000）、三尖瓣瞬时反流量(1.8±0.6 ml vs. 7.8±3.5 ml, P=0.001)和右心房容积（54.2±18.4 ml vs. 67.8±22.5 ml, P=0.012）较术前明显减少或缩小； 射血分数（56.1%±7.2% vs. 54.3%±6.5%,P=0.313）较术前有所提高。 结论 心脏瓣膜病中TI需引起重视，应选择适宜的方法积极治疗。

Nontransplantation Surgical Cardiac Remodeling Operation for Endstage Cardiac Valve Disease

Objective To evaluate the effectiveness and prospect of nontransplantation surgical cardiac remodeling for endstage cardiac valve disease by performing the remodeling operation (including anatomical and functional remodeling) after strict perioperative adjustment for endstage cardiac valve disease. Methods We retrospectively analyzed the clinical data of 31 patients, including 14 males and 17 females, with endstage cardiac valve disease who were treated with surgical cardiac remodeling operation from December 2005 to July 2009 in the 2nd Hospital of Anhui Medical University . Their age ranged from 27 to 74 years with an average age of 40.4 years. Continuous renal replacement therapy (CRRT) was carried out 3 days before surgery in all patients and intraaortic balloon pumping (IABP) was performed 1-3 days before operation in 9 patients. Among the patients, there were 13 patients of mitral valve replacement (MVR), 7 patients of aortic valve replacement (AVR), 4 patients of tricuspid valve replacement (TVR), and 7 patients of double valve replacement (DVR). At the same time, all patients underwent ventricular or atrial volume reduction operation, including 19 patients of left atrial partial excision or plication, 7 patients of partial left ventricular excision, 5 patients of left atrial and left ventricular volume reduction operation, 21 patients of partial right atrial excision, and 3 patients of partial right ventricular excision. Besides, there were 5 patients of De Vega plasty, 14 patients of annuloplasty and3 patients of coronary artery bypass grafting (CABG). The echocardiogram was used to observe the change of heart function, atrium and ventricular in patients on postoperative and follow -up period. Results After surgery, one patient died of low cardiac output syndrome, and one other patient gave -up because of incision and mediastinum infection after reoperation for hemorrhage. Twentynine patients were followed -up for 3 to 12 months with 1 case lost. During the follow- -up, 3 patients died, of whom 2 died of deterioration of heart function and 1 died of sudden stroke. In the 12th month during the follow -up, heart function of all other 25 patients showed obvious improvements with 12 classⅠ, 7 classⅡ, 3 classⅢ and 3 classⅣ heart function according to NYHA classification. At the end of the follow -up, ejection fraction (5400%±800% vs. 2500%±300%) and cardiac index ［3.30±0.50 L/(min·m2) vs. 1.10±0.30 L/(min·m2)］ were significantly higher than those before operation (P＜0.05), whereas left ventricular end diastolic diameter (5200±1000 mm vs. 9500±1200 mm) and left atrial diameter (3900±800 mm vs. 7000±1200 mm) both decreased significantly than those before operation (P＜0.05). Conclusion Cardiac remodeling operation for endstage cardiac valve disease after active adjustment and preparation can achieve similar results to operation for severe valve diseases, providing a new choice for endstage heart disease.

直视双极射频消融术治疗心瓣膜病合并慢性心房颤动

目的 介绍直视双极射频消融术治疗心瓣膜病合并慢性心房颤动（AF）的初步体会，探讨控制慢性AF的有效方法。 方法 2005年5月至2007年11月，对23例心瓣膜病合并慢性AF患者采用直视双极射频消融术治疗，在常温体外循环心脏跳动下进行右心房的消融，然后在中度低温心脏停搏下做左、右肺静脉口和左心耳的消融隔离，最后行心瓣膜置换术。 结果 射频消融时间18～26 min。术后因特发性血小板减少致消化道大出血住院死亡1例，生存的22例患者随访3～30个月，出院时、3个月、1年和2年窦性心律转复率分别是81.8%、86.4%、82.4%和77.8%，无Ⅲ度房室传导阻滞、病窦综合征和栓塞等并发症发生。 结论 直视双极射频消融术治疗心瓣膜病合并慢性AF操作简单、效果满意、并发症较少。

急诊外科手术治疗危重心瓣膜病192例

目的 总结危重心瓣膜病患者行急诊手术的临床经验，以提高其疗效和治愈率。 方法 自1996年10月至2007年11月对192例危重心瓣膜病患者施行了急诊手术。所有患者均为心瓣膜病合并严重心力衰竭，心功能分级（NYHA）为Ⅲ~Ⅳ级。经内科治疗2~7 d无效时采取急诊手术治疗；行二尖瓣置换术76例次，主动脉瓣置换术64例次，双瓣膜置换术43例次，三尖瓣置换术4例次，三尖瓣成形术45例次，左心房血栓清除和左心房减容 术各5例次，冠状动脉旁路移植术5例次，其他心血管手术9例次。 结果 术中和术后早期分别死亡3例和8例，总手术死亡率为5.7%（11/192），主要死亡原因为术中不能脱离体外循环机、术后发生低心排血量综合征和突发心室颤动等。随访168例，随访时间1个月~11年，失访13例。随访期间死亡8例，主要死于左心衰竭、瓣周漏或心内膜炎复发、尿毒症、夹层动脉瘤等。长期生存160例，心功能恢复至Ⅰ级132例，Ⅱ级15例，Ⅲ级13例；生活质量较术前有所提高。 结论 危重心瓣膜病患者经内科治疗无效时急诊手术具有良好的疗效，是较好的治疗选择。

60岁以上心瓣膜病患者的外科治疗与随访

目的 总结≥60岁心瓣膜病患者的外科治疗经验及随访结果，以提高手术疗效。 方法 2000年7月至2008年12月, 86例≥60岁的心瓣膜病患者接受了心瓣膜置换术治疗，其中男43例，女43例；年龄60~74岁，平均年龄63.8岁。二尖瓣病变55例，主动脉瓣病变9例，二尖瓣及主动脉瓣双瓣膜病变21例，三尖瓣病变1例；风湿性心瓣膜病65例，退行性心瓣膜病21例。心房颤动59例，窦性心律27例。心功能分级(NYHA)Ⅲ级79例，Ⅳ级7例。行二尖瓣置换术55例，双瓣膜置换术21例，主动脉瓣置换术9例，二尖瓣置换术后三尖瓣置换术1例；同期行三尖瓣成形术16例，改良射频迷宫术8例，左心房血栓清除术7例。 结果 围术期因心律失常死亡1例。术后有3例患者因胸骨哆开而再次行胸骨固定术，１例患者因瓣周漏而再次行心瓣膜置换术，3例患者因呼吸功能不全行气管切开术。85例患者均治愈出院。术后左心房内径（51.1±13.8 mm vs.56.2±17.2 mm,P=0.001）和右心房内径(48.8±9.6 mm vs. 52.1±13.9 mm,P=0.012)较术前明显缩小，左心室、右心室内径、射血分数和缩短分数与术前比较差异均无统计学意义（Pgt;0.05）。随访84例，随访时间2~96个月(24±22个月)，失访1例。随访期间有1例患者于术后5个月因抗凝强度不足发生左心房血栓，经治疗后血栓消失；另1例术后6年因抗凝强度不足发生脑梗死，经住院治疗肢体偏瘫未能恢复。 结论 只要适当把握手术指征和手术时机，注重术前准备及围术期处理，对≥60岁患者行心瓣膜置换术效果良好。术后与抗凝有关的主要问题为抗凝不足。对这些患者术后应加强国际标准化比率(INR)监测及持续的心功能调整。

生物瓣心瓣膜置换术后远期疗效

目的评价生物瓣心瓣膜置换术后远期疗效。方法1979年1月至2001年12月施行生物瓣心瓣膜置换术303例，按年龄分为两组，≥55岁者123例（≥55岁组）；（55岁者180例（〈55岁组）。其中160例早期使用经戊二醛处理的猪主动脉瓣，143例使用经环氧氯丙烷改性的新型猪主动脉瓣。所有心瓣膜置换术均在全身麻醉体外循环下进行。结果术后早期死亡9例，随访267例（90．8％），随访时间3～20年，5年生存率94．1％±2．3％，10年生存率85．0％±2．7％，15年生存率78．3％±1．2％。51例出现瓣膜衰坏，40例再次手术；5年、10年、15年累计瓣膜未衰坏率分别为90．1％±2．2％、79．4％±3．6％和36．8％±1．6％。且≥55岁组患者瓣膜未衰坏率高于（55岁组（P〈0．05）。经环氧氯丙烷改性的新型生物瓣10年瓣膜未衰坏率明显高于早期戊二醛处理的生物瓣。全组血栓发生率低，15年为0．014％。发生感染性心内膜炎7例，3例治愈，4例死亡。结论人工生物瓣心瓣膜置换术后疗效良好，尤其适合老年患者。经环氧氯丙烷改性的新型生物瓣有较强的抗衰坏能力；术后发生感染性心内膜炎应予以足够的重视。