The patients with mechanical prosthetic valve replacement need anticoagulant therapy for all their life. The incidence of thromboembolism and anticoagulation-related bleeding events still account for major postoperative complications after mechanical heart valve replacement. Most of the complications happen in the first half year after operation. Therefore, early anticoagulation therapy is very important. Of course, so far most guidelines focus stating their opinions on long-term anticoagulant therapy. However, there is no consensus about anticoagulant therapy in the early period of postoperation. In this review, we summarize early anticoagulant therapy of the patients with mechanical heart valve replacement through consulting domestic and abroad relevant research in recent years and give an overview of the present situations of early anticoagulant therapy.
Abstract: Objective To observe the longterm condition of patients after mitral valve replacement with or without mild aortic valve regurgitation (AR) and discuss whether treatment of AR is necessary during the course of mitral valve replacement. Methods From March 1999 to April 2004, 88 patients who underwent mitral valve replacement (with or without mild AR before surgery) in West China Hospital of Sichuan University were followed up for 5 years or more. The patients were divided into two groups according to whether they had mild AR based on the result of preoperative echocardiography examination. In the AR group, there were 35 patients including 7 males and 28 females aged 49.26±11.87. By the New York Heart Association (NYHA) grading system before surgery, 4 patients were classified as Class Ⅱ, 26 Class Ⅲ and 5 Class Ⅳ. In the nonAR group, there were 53 patients including 7 males and 46 females aged 48.59±10.22. Using the NYHA grading system before surgery, we found there were 7 patients with Class Ⅱ cardiac function, 39 Class Ⅲ and 7 Class Ⅳ. After operation, all patients were followed up regularly and 5 years after surgery, patients were examined by echocardiography again. Results The followup period ranged from 5 to 9 years (6.39±1.26). There was no statistical difference in gender (P=0.394), age (P=0.841), preoperative cardiac function (P=0.960) and cardiac rhythm (P=0.732) between the two groups. For the AR group, after operation, NYHA heart function, left ventricle ejection fraction (LVEF) and left ventricle fraction shortening (LVFS) significantly increased or improved(Plt;0.05). In the nonAR group, after operation, NYHA heart function and LVEF significantly improved (Plt;0.05), while LVFS had no significant change (Pgt;0.05). Left [CM(159mm]ventricular dimensions (LVD) and aortic dimensions between the two groups had no significant difference afteroperation (Pgt;0.05). There was no significant difference in the number of AR cases before and after surgery (Pgt;005) in the AR group, while there was a significant difference in the nonAR group (Plt;0.05). Conclusion For patients with mild AR who underwent mitral valve surgery 5 to 9 years ago, there is little change in their AR condition. There is no need to treat mild AR preventively during the course of mitral valve replacement.
Abstract: Objective To summarize the experiences of radiofrequency modified maze procedure for atrial fibrillation (AF) in patients with mitral valve diseases. Methods From May 2003 to December 2008, 122 patients, including 31 males and 91 females, with permanent AF underwent radiofrequency modified maze procedure as a combined operation with mitral valve replacement. Their age ranged from 23 to 65 years old (47±10 years). The duration of AF varied from 0.5 to 32.0 years (6.5±5.7 years). There were 57 cases of stenosis, 7 cases of regurgitation and 58 cases of both stenosis and regurgitation. Ablation lines were made with Cardioblate (Medtronic, monopolar, 25.30 W, 180.240 ml/h). After rightsided maze procedure was finished, aorta was crossclamped and cold crystalloid or blood cardioplegia were delivered for myocardial protection. Left atrial incision was performed through the interatrial groove or interatrial septum. The ablation lines were created to encircle the orifices of the left and right pulmonary veins respectively. The ablation lines were also performed from the left encircling line to the posterior mitral valve annulus and to the orifice of left atrial appendage respectively. An ablation line was used to connect the circumferential line of left and right pulmonary veins. The left atrial appendage was tied and concomitant operations were performed. Amiodarone was given to the patients after operation and regular follow-up was done. Results There were four perioperative deaths including 2 cases of multiple organ failure, 1 case of mechanic valve obstruction and 1 sudden death. Follow-up was done to 115 patients for 1.5-7.0 years (4.8±2.6 years) with three cases lost. During the followup period, four patients died, including 3 sudden deaths and 1 case of prosthetic obstruction. Eightyseven patients (78.4%, 87/111) recovered to sinus rhythm; 22 patients still had AF; 1 patient had atrial flutter; and 1 patient required a permanent pacemaker one year after the operation. Diameter of left atrium after operation (0.5-7.0 years) was decreased compared with that before operation（44.90±7.50 mm vs. 54.30±10.80 mm，t＝10.641，P＝0.000）. Conclution Radiofrequency modified maze procedure for AF in patients with mitral valve disease is relatively safe. But heart rhythm instability, tachyarrhythmia and recurrent AF are not rare for those patients. Therefore, the surgical indication of AF should be individualized.
Objective To summarize the clinical characteristics and management experiences of patients with severe tricuspid regurgitation (TR) after mitral valve surgery. Methods Thirty patients were followed up and reviewed for this report. There were 1 male and 29 female patients whose ages ranged from 32 to 65 years (47.1±92 years). A total of 28 patients had atrial fibrillation and 2 patients were in sinus rhythm. There were 13 patients of mild TR, 10 patients of moderate TR and 7 patients of severe TR at the first mitral valve surgery. Five patients received the tricuspid annuloplasty of De Vega procedure at the same time, 2 patients received Kay procedure. The predominant presentation of patients included: abdominal discomfort (93.3%, 28/30), edema (66.7%,20/30), palpitation (56.7%, 17/30), and ascites (20%, 6/30). Results Nine patients underwent the secondary surgery for severe TR. The secondary surgery included tricuspid valve replacement (6 cases), mitral and tricuspid valve replacement (2 cases) and Kay procedure (1 case). Eight patients were recovered and discharged and 1 patient died from the bleeding of right atrial incision and low output syndrome. Twentyone patients received medical management and were followed up. One case was lost during followup. Conclusion Surgery or medical management should be based on the clinical characteristics of patients with severe TR after mitral valve surgery. It should be based on the features of tricuspid valve and the clinical experience of surgeon to perform tricuspid annuloplasty or replacement.
Objective To report the preliminary results of intraoperative saline-irrigated radiofrequency modified maze procedure for chronic atrial fibrillation (AF) in mitral valve diseases. Methods From May 2003 to April 2004 forty-one patients underwent intraoperative saline-irrigated modified maze procedure. The patients included 13 male and 28 female. Their age ranged from 27-65 years (46±10 years). The duration of AF varied from 5 months to 15 years (4.5±3.6 years).The left atrial diameter varied from 37-93 mm (54±11mm). There were mitral stenosis 20, mitral regurgitation 1 and mitral stenosis with regurgitation 20 cases. Cardiopulmonary bypass (CPB) was established as usual. Ablation lines were made with Cardioblate (Medtronic, 25-30 W, 180-240ml/h). Having finished right-sided maze procedure, the aorta was cross-clamped and cold crystalloid or blood cardioplegia were used for myocardial protection. Left atrial incision was performed through the interatrial groove. The ablation lines were created to encircle the orifices of the left and right pulmonary veins respectively. The ablation lines were also performed from the left encircling line to the posterior mitral valvular annulus and to the orifice of left atrial appendage respectively. A ablation line was used to connect left and right pulmonary veins circumferential line. Concomitant procedures were performed (there were double valve replacement 10 cases, mitral valve replacement 31 cases, tricuspid annuloplasty 6 cases, removing the left atrial thrombi 6 cases). Results CPB time varied from 71-160 min (105±24 min) and cross-clamping time varied from 32-106 min (62±20 min). The ablation time varied from 4-22 min (11±4 min). One patient died during hospitalization and the death was caused by acute mechanic valve obstruction. During follow-up at discharge and 3 months 35% patients (14/40) were free of AF and the others were not. But at 6 months 67% patients (10/15) were free of AF. Conclusion The intraoperative saline-irrigated radiofrequency modified maze procedure is comparatively simpler and its efficacy is satisfactory.
Objective To investigate the effect of early postoperative enteral nutrition support on the balance of free amino acid spectrum in plasma for patients with cardiac valve replacement during perioperative period. Methods (Forty-seven) patients undergoing cardiac valve replacement were divided into two groups randomly, the routine diet group and the Nutrison Fibre group. The levels of free amino acids in plasma were measured with pre-column derivatization of high-performance liquid chromatography. Results During perioperative period most free amino acids in plasma decreased significantly in the routine diet group (Plt;0.05). Despite some free amino acids in plasma decreased significantly in the Nutrison Fibre group(Plt;0.05), all free amino acids in plasma returned to (Pgt;05) or were higher than the preoperative levels in the postoperative sixth day (Plt;0.05). At the same postoperative points, most free amino acids in plasma in the Nutrison Fibre group were higher than that of the routine diet group (Plt;0.05). Conclusions The levels of free amino acids in plasma decrease significantly in patients with cardiac valve replacement after operation. Early postoperative Nutrison Fibre enteral nutrition support is helpful for keeping the balance of free amino acids in plasma for patients with cardiac valve replacement.
Objective To explore the impact of the women taking warfarin throughout pregnancy after mechanical valve replacement on the children’s physical and mental development.Methods A total of 12 children whose mothers had taken mechanical valve replacement before pregnancy were enrolled in the experimental group in this study, for determination of their physical and mental development. The following indicators were measured: a) Physical development indexes: height, weight, sitting height, head circumference, chest circumference; b) Mental development indexes: intelligence quotient (IQ), and development quotient (DQ) which included adaptability, big movement, fine motor, language, and individual-society. According to the 1?∶?2 matching ratio, 24 children of the healthy women were selected in the control group, and then the difference of each index between the two groups was analyzed. Results In the aspects of both physical development indexes and mental development indexes, there were no significant differences in the children aged 0 to 3 yrs, 4 to 6 yrs, and 6 to 12 yrs in the two groups (Pgt;0.05). Conclusion After mechanical valve replacement, women taking oral anticoagulant warfarin in daily dose not exceeding 5mg are safe, and there are no negative effects on children’s physical and mental development.
Objective To evaluate the long-term anticoagulation outcomes of target international normalized ratio (INR) 1.60 to 2.20 and weekly dosage adjustment of warfarin in patients after mechanical heart valve replacement. Methods Outpatients after mechanical heart valve replacement at least 6 months were registered continually from July 2011 to July 2016 in department of cardiothoracic surgery at Zigong No.4 People's Hospital and West China Hospital. There were 1 690 females (70.62%) and 703 males (29.38%) with a median age of 47 years, ranging from 14 to 80 years. All patients were followed up for 6-61 months. Target INR was 1.60 to 2.20 and warfarin dosage were adjusted weekly. Unexpected bleeding, thrombogenesis and thromboembolism, time in therapeutic range (TTR) and fraction of TTR (FTTR) were recorded and calculated to evaluate the outcome of anticoagulation management. Results A total of 2 393 patients with 26 521 INR values were included for data analysis. INR values varied from 0.90-8.39 (1.82±0.45) and required weekly doses of warfarin were 1.75-61.25 (21.72±7.39) mg. TTR of target INR and acceptable INR was 59.38% (1 449 514.0 days/2 441 060.0 days) and 73.57% (1 795 971.0 days/2 441 060.0 days), respectively. FTTR of target INR and acceptable INR were 50.71% (13 450 times/26 521 times), 65.25% (17 305 times/26 521 times). During the follow-up , anticoagulation-related complications included: cerebral infarction in 21 patients (complete recovery in 18 patients, physical activity disorder in 3 patients), cerebral hemorrhage in 4 patients (death in 1 patient, complete recovery in 3 patients), severe gastrointestinal bleeding in 3 patients (completely recovered) and uterine bleeding in 1 patient (surgical removal of the uterus). Conclusion Target INR 1.60–2.20 and warfarin weekly dosage adjustment for patients after mechanical heart valve replacement is reasonable and safe.
The incidence of postoperative excessive bleeding and reexploration is relatively high, and it will bring a series of serious complications, such as an additional surgery, a longer intensive care unit stay, longer time on mechanical ventilation, an increase need of allogeneic blood product transfusions and increased mortality. However, the understanding of postoperative excessive bleeding and reexploration in China is significantly different from the international level, and the understanding of postoperative excessive bleeding and reexploration after cardiac surgery in clinical work is still not enough. This review will focus on some problems, such as related factors analysis of postoperative excessive bleeding, hemostatic process optimization and the serious complications of reexploration after cardiac surgery.