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Changes of Left Ventricular Morphology and Contractile Function after Heart Valve Replacement of Patients with Valvular Heart Disease and Giant Left Ventricle：A Systematic Review

Objective To conduct a systematic review to evaluate preoperative and postoperative changes of echocardiography indexes which reflect left ventricular morphology and contractile function after heart valve replacement of　patients with valvular heart disease with giant left ventricle. Methods We electronically searched CBMdisc， VIP database，Wanfang database， CNKI database， PubMed and ScienceDirect from time of establishment of each database to June 2012 to identify literatures addressing heart valve replacement for patients with valvular heart disease and giant left ventricle. Quality　of included literatures was evaluated， and relevant data were extracted to conduct meta-analysis. Preoperative and postoperative changes of echocardiography indexes of patients undergoing heart valve replacement were compared. R2.15.2 software was used for statistical analysis. Results Twelve retrospective cohort studies were included in this study involving 833 patients. The quality of included literature was relatively high. Meta-analysis showed that left ventricular end-diastolic　diameter （LVEDD） at 2 weeks， 6 months， 1 year， 2 to 3 years postoperatively were reduced by 11.72 mm［95% CI （9.52，13.92）， P＜0.001］， 20.02 mm ［95% CI （18.28， 21.76）， P＜0.001］， 22.48 mm ［95% CI （19.55， 25.40）， P＜0.001］ and 24.69 mm ［95% CI （22.21， 27.18）， P＜0.001］ respectively compared with preoperative value. Left ventricularend-systolic diameter （LVESD） at 2 weeks， 6 months， 1 year， 2 to 3 years postoperatively were reduced by 7.74 mm ［95% CI （3.76， 11.72）， P＜0.001］， 15.54 mm ［95% CI （12.55， 18.54）， P＜0.001］， 18.84 mm ［95% CI （15.54， 21.14），P＜0.001］ and 21.02 mm［95% CI （17.67， 24.37）， P＜0.001］ respectively compared with preoperative value. Compared　with preoperative value， left ventricular ejection fraction （LVEF） decreased by 7% at 2 weeks postoperatively ［95% CI （1%， 12%）， P=0.013］， increased by 9% at 6 months postoperatively ［95% CI （-14%， -3%）， P=0.002］， increased by 11% at 1 year postoperatively ［95% CI （-22%， 0%）， P=0.041］， and increased by 13% at 2-3 years postoperatively ［95% CI （4%， 21%）， P=0.004］. Compared with preoperative value， left ventricular fraction shortening （LVFS） decreased by 0.05 at 2 weeks postoperatively ［95% CI （0.03， 0.07）， P＜0.001］， increased by 0.02 at 6 months postoperatively ［95% CI （0.00， 0.04）， P=0.055］， increased by 0.03 at 1 year postoperatively ［95% CI （0.00， 0.06）， P=0.035］， and increased by 6% at 2-3 years postoperatively ［95% CI （0.02， 0.11）， P=0.008］. Conclusions LVEED and LVESD of patients with valvular heart disease and giant left ventricle continuously decrease after heart valve replacement， especially in the first 6 months postoperatively， and return to normal in 2 to 3 years. LVEF and LVFS decrease in the first 2 weeks postoperatively， then start to increase， are higher than preoperative values at 6 months， and return to normal in 2 to 3 years. Heart valve replacement is conducive for the recovery of left ventricular morphology and systolic function of patients with valvular　heart disease and giant left ventricle.

重症心脏瓣膜病合并巨大左心室患者的外科治疗

Progress in Evaluating Quality of Life in Postoperative Patients with Valvular Heart Disease Using SF-36 Health Survey

Abstract：　Quality of life （QOL） refers to an individual’s perception and subjective evaluation of their health and well-being, and has become an important index to evaluate the outcomes of clinical treatment in the last past decades. There are a large number of different instruments to evaluate QOL, and the 36-Item Short Form Health Survey （SF-36） is currently one of the most widely used instruments. In recent years, SF-36 has been used to evaluate QOL of valvular heart disease patients to investigate the risk factors those influence their postoperative QOL, provide more preoperative evaluation tools for clinical physicians, and improve postoperative outcomes of patients with valvular heart disease. However, it is now just the beginning to use SF-36 to examine QOL of valvular heart disease patients. Because of significant differences in sample size, follow-up period, country and culture, current research has some controversial results. This review focuses on the progress in evaluating QOL in postoperative patients with valvular heart disease using SF-36.

风湿性心脏瓣膜病合并右心室功能不全的外科治疗

目的 为了提高风湿性心脏瓣膜病合并右心室功能不全患者的治愈率，总结诊断治疗效果。 方法 回顾性分析上海交通大学医学院附属新华医院2006年1月至2010年6月期间收治24例左心瓣膜病合并右心室功能不全患者的临床资料，其中男17例，女7例；年龄41～66岁。均行心瓣膜置换术及三尖瓣成形术。 结果 24例患者术后均出现不同程度的中心静脉压(CVP)升高(CVPgt;25 cm H2O)、右心室体积增大等右心衰竭表现。术后早期死亡4例，死于感染1例，持续低氧血症1例，低心排血量2例。随访15例，随访6～50个月，随访期间死亡1例，死因不明。其余患者均生存，生活质量良好，无右心室功能不全的临床表现，9例患者无三尖瓣反流，4例轻度反流，1例中度反流。 结论 术中加用三尖瓣成形环保证三尖瓣功能是治疗右心室功能不全的解剖基础，充分的术前准备、术后强心治疗及对右心室前后负荷的调整是治疗该类患者右心室功能不全的重要因素。

Surgical Therapy for Valve Diseases Combined with Coronary Heart Diseases in Patients Over or Below 70 Years Old

Surgical Therapy for Valve Diseases Combined with Coronary Heart Diseases in Patients Over or Below 70 Years Old YU Lei, GU Tianxiang, SHI Enyi, XIU Zongyi, FANG Qin, ZHANG Yuhai. (Department of Cardiac Surgery, The No. 1 Hospital of China Medical University, Shenyang 110001, P.R. China)Corresponding author: GU Tianxiang, Email: cmugtx@sina.comAbstract： Objective To summarize the experiences of valve replacement combined with coronary artery bypass grafting (CABG) in senile patients by comparing clinical outcomes of valve diseases combined with coronary heart diseases in patients over or below 70 years old. Methods We retrospectively analyzed the clinical data of 49 patients who received valve replacement combined with CABG in our department from May 1999 to December 2007. Based on the age, the patients were divided into ≥70 years group (17 cases) with its patients at or above 70 years old and lt;70 years group (32 cases) with its patients younger than 70. The percentage of chronic obstructive pulmonary diseases (COPD) before surgery in ≥70 years group was higher than that in lt;70 years group(Plt;0.05). No significant difference was found in the other relevant factors between the two groups. The clinical index of patients in the two groups were compared and analyzed. Results There were significant differences between the two groups in such factors as the percentage of biovalve use (82.4% vs. 12.5%, χ2=23.311, P=0.000), the time of mechanic ventilation (34.5±29.3 h vs. 18.0±16.1 h, t=-2.542,P=0.014), the time of ICU stay (4.4±1.5 d vs. 3.3±0.7 d, t=-3.522, P=0.001), the time of hospital stay (21.4±7.7 d vs. 18.1±1.8 d, t=-2.319, P=0.025), the percentage of IABP use (29.4% vs. 6.3%, χ2=4.862, P=0.037), the percentage of pulmonary function failure (35.3% vs. 6.3%, χ2=6.859, P=0.009), the percentage of acute renal failure (23.5% vs. 3.1%, χ2=5.051, P=0.025), and the percentage of cerebrovascular accident (11.8% vs. 0.0%, χ2=3.933, P=0.048). There was no significant difference between the two groups in factors like the anastomosis of distal graft (2.5±3.1 vs. 2.4±14, t=0.301, P=0.758), the time of aortic occlusion (89.3±25.4 min vs. 88.5±31.0 min, t=0.108,P=0.913), the time of cardiopulmonary bypass (144.6±44.8 min vs. 138.3±52.9 min, t=0.164, P=0.871) and the mortality (5.9% vs. 6.3%, χ2=0.002,P=0.959). The perioperative myocardial infarction rate was zero in both groups. ≥70 years group patients were followed up for 2 months to 9 years with only 1 case missing. One patient who had undergone mechanic valve replacement died of cerebral hemorrhage 1.5 years after operation. Two died of heart failure and lung cancer 3 months and 6 years after operation respectively. For all the others, the cardiac function was at class Ⅰ to Ⅱ and their life quality was significantly improved. The follow up time of lt;70 years group was 1 month to 6 years and 5 cases were missing. Four patients who had undergone mechanic valve replacement died of complications in relation to anticoagulation treatment. One died of severe low cardiac output. Another died of traffic accident. Conclusion Surgery operation and effective perioperative treatment are key elements in improving surgery successful rate and decreasing mortality in patients with valve and coronary artery diseases. Valve replacement combined with CABG is safe for patients older than 70 years old.

右腋下小切口心脏直视手术3 012例的临床应用

目的 总结右腋下小切口在心脏直视手术中应用的临床经验。 方法 2001年11月至2008年7月我们采用右腋下小切口施行心脏直视手术3 012例，男1 834例，女1 178例；年龄8个月～78岁，平均年龄124岁。行室间隔缺损修补术1 999例（干下型109例），房间隔缺损修补术677例（同期行三尖瓣或二尖瓣成形术107例、行部分型肺静脉畸形引流29例），法洛三联症矫治术43例，法洛四联症矫治术35例，右室双腔心矫治术33例，房室管畸形矫治、肺动脉瓣狭窄交界切开、右心室流出道狭窄疏通、三尖瓣下移畸形行11/2心室矫治或三尖瓣置换术等共123例，二尖瓣成形术28例，二尖瓣置换术74例。 结果 全组均顺利完成手术，早期死亡5例（0.17%），死亡原因分别为灌注肺、鱼精蛋白严重过敏、术中损伤左冠状动脉、低心排血量及脑血栓昏迷。二次开胸止血8例（0.26%），切口感染6例（0.20%），肺不张、灌注肺、低心排血量、感染性心内膜炎、急性肾功能衰竭（ARF）等并发症24例（0.79%）；ARF患者均经连续床旁血液滤过治疗痊愈，其余患者经对症支持治疗痊愈。通过门诊复查、电话等形式随访1~82个月，共随访2 765例，失访247例；3例室间隔缺损出现小型残余漏，2例二尖瓣成形术后出现轻中度二尖瓣关闭不全，1例Ebstein畸形行三尖瓣成形术后出现轻中度三尖瓣关闭不全，其他患者无异常。 结论 右腋下小切口应用于心脏直视手术，有创伤小、失血少、切口美观等优点，但应严格掌握手术适应证。

心瓣膜置换术的影响因素分析

目的 探讨心瓣膜置换术的危险因素，以提高手术治愈率。 方法 回顾性分析2005年1月至2007年12月我院施行507例心瓣膜置换术患者的临床资料，其中男236例，女271例；病种为风湿性心脏病394例，先天性心脏病87例，退行性病变19例，细菌性心内膜炎6例，梅毒1例。对心瓣膜置换术的潜在危险因素进行单因素分析，采用logistic回归进行多因素分析。 结果 术后顺利恢复482例（95.0%）；术后发生并发症25例，其中治愈16例，死亡9例，病死率1.77%；治愈498例（98.22%）。随访480例，随访率96.38%（480/498），其中心功能Ⅰ级182例，Ⅱ级298例。经对列表进行单因素分析及多因素logistic回归分析结果，心功能Ⅳ级，年龄≥70岁，合并慢性阻塞性肺病，合并肾功能不全，左心室舒张期末内径(LVEDD)≥70 mm,心瓣膜置换术＋冠状动脉旁路移植术（CABG）,二次手术，主动脉阻断时间＞2 h,体外循环时间＞3 h是影响心瓣膜置换术的独立危险因素。 结论 临床工作中重视影响心瓣膜置术的独立危险因素的处理，对提高其疗效有重要意义。

米力农对合并肺动脉高压瓣膜病患者体外循环期间肺氧合功能的影响

目的 探讨体外循环(CPB)期间米力农对心脏瓣膜病患者肺氧合功能是否具有保护效应及预给药对肺保护作用的影响。 方法 将30例合并肺动脉高压瓣膜病患者，按照米力农的给药方法不同随机分为3组，每组10例。Ⅰ组、Ⅱ组分别于麻醉诱导前、CPB后并行阶段泵入米力农，泵速均为0.5μg／kg·min；对照组给予生理盐水，以相同速度泵入。于麻醉诱导后（T1）、开胸时（T2）、停CPB（T3）、术毕（T4）及术后4h（T5）测定3组的血流动力学和血气指标，计算氧合指数(OI)和肺内动静脉分流率（Qs/Qt）。 结果 3组患者T1时肺动脉收缩压(SPAP)、肺血管阻力(PVR)和Qs/Qt均高于正常,组间比较差异无统计学意义（Pgt;0.05）。与T1比较，T2时各指标差异无统计学意义，在T3、T4、T5后各时点心脏指数(CI)均明显增高（Plt;0.05）；PVR、SPAP逐渐降低（Plt;0.05）；Ⅰ组停机后OI值较T1增高（Plt;0.05），Qs/Qt降低（Plt;0.05）。在T3、T4、T5时，Ⅰ组的PVR，Qs/Qt和OI与其它两组同期比较差异有统计学意义（Plt;0.05）。 结论 米力农能够改善重症心脏瓣膜病患者CPB期间肺部氧合功能，术前预给药可能有利于发挥肺保护效应。

合并心脏恶病质瓣膜病的外科治疗

目的 为提高合并心脏恶病质瓣膜病患者外科治疗的成功率，探讨其围术期处理的特点。方法 符合心脏恶病质综合征诊断标准的21例心瓣膜病患者接受了手术治疗，其中二尖瓣置换术14例，主动脉瓣及二尖瓣置换术7例，同时三尖瓣成形术16例。结果 发生并发症13例，分别为低心排血量综合征、室性心律失常和多器官功能衰竭等；死亡6例，主要死亡原因为多器官功能衰竭。结论 合并心脏恶病质瓣膜病患者的外科治疗应注意围术期处理；术中应重视三尖瓣功能纠正及左、右心房折叠；术后注意低心排血量的治疗，积极防治多器官功能衰竭，加强营养支持。

Clinical Outcomes and Risk Factor Analysis of Patients with Valvular Heart Disease and Giant Left Ventricle Undergoing Heart Valve Replacement

ObjectiveTo investigate clinical outcomes and risk factors of patients with valvular heart disease (VHD) and giant left ventricle undergoing heart valve replacement (HVR). MethodsClinical data of 144 VHD patients with giant left ventricle who underwent HVR in Union Hospital of Tongji Medical College, Huazhong University of Science and Technology from January 2009 to December 2012 were retrospectively analyzed. There were 116 male and 28 female patients with their age of 15-69 (44.9±11.9) years and disease duration of 57.8±98.3 months (range, 1 month to 40 years). There were 92 patients with rheumatic VHD, 28 patients with degenerative VHD, 15 patients with congenital VHD, and 9 patients with infective endocarditis. A total of 137 patients who were discharged alive were followed up. Risk factors of postoperative mortality, morbidity and late death of VHD patients with giant left ventricle undergoing HVR were analyzed with t-test, chi-square test or Fisher's exact test, and logistic regression analysis. The life-table method was used to calculate long-term survival rate and draw the survival curve. ResultsMajor postoperative complications included low cardiac output syndrome (LCOS) in 19 patients (13.2%), ventricular arrhythmias in 56 patients (38.9%), prosthetic paravalvular leaks in 7 patients (4.9%), pleural effusion in 33 patients (22.9%), pericardial effusion in 8 patients (5.6%), liver failure in 23 patients (16.0%), and renal failure in 5 patients (3.5%). Seven patients (4.9%) died postoperatively. Logistic univariate analysis showed that advanced-age ( > 50 years), rheumatic VHD, higher preoperative NYHA class (Ⅲ or Ⅳ), long disease duration, poor preoperative left ventricular function[left ventricular ejection fraction (LVEF) < 40%], double valve replace-ment (DVR), other concomitant intracardiac procedures, prolonged cardiopulmonary bypass (CPB) time and aortic cross-clamping time, postoperative LCOS and ventricular arrhythmias were risk factors of early mortality of VHD patients with giant left ventricle undergoing HVR (P < 0.05). Logistic multivariate analysis showed that advanced age ( > 50 years), long disease duration, higher preoperative NYHA class (Ⅳ), poor preoperative left ventricular function (LVEF < 40%), DVR, prolonged CPB time were independent predictors of early mortality (P < 0.05). Logistic multivariate analysis showed that higher preoperative NYHA class (Ⅲ or Ⅳ), other concomitant intracardiac procedures, poor preoperative left ventricular function (LVEF < 50%) were independent predictors of postoperative LCOS (P < 0.05). Higher preoperative NYHA class (Ⅲ or Ⅳ) and preoperative non-sinus rhythm were independent predictors of postoperative ventricular arrhy-thmias (P < 0.05). Within 2 weeks after the operation, left ventricular end-diastolic dimension (LVEDD), left atrial diameter (LAD), LVEF and left ventricular fractional shortening (LVFS) were all significantly reduced compared with preoperative parameters (P < 0.05). Five patients died during follow-up. One-year, 2-year, 3-year and 4-year survival rates were 97.1%, 95.0%, 92.7% and 92.7% respectively. Preoperative LVEF, LVEDD and NYHA were significantly different between patients who died or survived during follow-up. ConclusionsHVR can produce low postoperative mortality, high long-term survival rates and satisfactory clinical outcomes for VHD patients with giant left ventricle. Advanced age ( > 50 years), long disease duration, higher preoperative NYHA class (Ⅳ), preoperative non-sinus rhythm, poor preoperative left ventricular function (LVEF < 40%), DVR and prolonged operation time may be risk factors of postoperative mortality and morbidity. Poor preoperative left ventricular function and significantly enlarged left ventricle may be risk factors of late death after HVR.