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重癥風濕性心瓣膜病的外科治療

直視雙極射頻消融術治療心瓣膜病合并慢性心房顫動

目的 介紹直視雙極射頻消融術治療心瓣膜病合并慢性心房顫動（AF）的初步體會，探討控制慢性AF的有效方法。 方法 2005年5月至2007年11月，對23例心瓣膜病合并慢性AF患者采用直視雙極射頻消融術治療，在常溫體外循環心臟跳動下進行右心房的消融，然后在中度低溫心臟停搏下做左、右肺靜脈口和左心耳的消融隔離，最后行心瓣膜置換術。 結果 射頻消融時間18～26 min。術后因特發性血小板減少致消化道大出血住院死亡1例，生存的22例患者隨訪3～30個月，出院時、3個月、1年和2年竇性心律轉復率分別是81.8%、86.4%、82.4%和77.8%，無Ⅲ度房室傳導阻滯、病竇綜合征和栓塞等并發癥發生。 結論 直視雙極射頻消融術治療心瓣膜病合并慢性AF操作簡單、效果滿意、并發癥較少。

60歲以上心瓣膜病患者的外科治療與隨訪

目的 總結≥60歲心瓣膜病患者的外科治療經驗及隨訪結果，以提高手術療效。 方法 2000年7月至2008年12月, 86例≥60歲的心瓣膜病患者接受了心瓣膜置換術治療，其中男43例，女43例；年齡60~74歲，平均年齡63.8歲。二尖瓣病變55例，主動脈瓣病變9例，二尖瓣及主動脈瓣雙瓣膜病變21例，三尖瓣病變1例；風濕性心瓣膜病65例，退行性心瓣膜病21例。心房顫動59例，竇性心律27例。心功能分級(NYHA)Ⅲ級79例，Ⅳ級7例。行二尖瓣置換術55例，雙瓣膜置換術21例，主動脈瓣置換術9例，二尖瓣置換術后三尖瓣置換術1例；同期行三尖瓣成形術16例，改良射頻迷宮術8例，左心房血栓清除術7例。 結果 圍術期因心律失常死亡1例。術后有3例患者因胸骨哆開而再次行胸骨固定術，１例患者因瓣周漏而再次行心瓣膜置換術，3例患者因呼吸功能不全行氣管切開術。85例患者均治愈出院。術后左心房內徑（51.1±13.8 mm vs.56.2±17.2 mm,P=0.001）和右心房內徑(48.8±9.6 mm vs. 52.1±13.9 mm,P=0.012)較術前明顯縮小，左心室、右心室內徑、射血分數和縮短分數與術前比較差異均無統計學意義（Pgt;0.05）。隨訪84例，隨訪時間2~96個月(24±22個月)，失訪1例。隨訪期間有1例患者于術后5個月因抗凝強度不足發生左心房血栓，經治療后血栓消失；另1例術后6年因抗凝強度不足發生腦梗死，經住院治療肢體偏癱未能恢復。 結論 只要適當把握手術指征和手術時機，注重術前準備及圍術期處理，對≥60歲患者行心瓣膜置換術效果良好。術后與抗凝有關的主要問題為抗凝不足。對這些患者術后應加強國際標準化比率(INR)監測及持續的心功能調整。

Application Value of Intraoperative Epicardial Echocardiography in Cardiac Surgery

Objective To investigate the effect of applying intraoperative epicardial echocardiography (IEE) on preoperative monitoring and evaluating the clinical result of cardiac surgery. Methods We retrospectively analyzed the clinical data of 248 patients treated in the Affiliated 105 Hospital of People’s Liberation Army and the First Affiliated Hospital of Anhui Medical University from June 2008 to May 2015. There were 108 males and 140 females. The age ranged from 7 months to 71 years. There were 113 patients diagnosed with the congenital heart disease (CHD) at the mean age of 11.89±14.74 years. There were 135 patients diagnosed with valvular heart disease at the mean age of 47.20±14.57 years. All patients underwent IEE during operation. Results In 113 patients with CHD, we found new deformities and corrected preoperative diagnosis before cardiopulmonary bypass (CPB) and we identified surgical complications after CPB by IEE. Other deformities and left atrial thrombus were found in 135 patients with valvular heart disease by IEE before CPB. After CPB, paravalvular leak and mitral regurgitation were found, therefore we took action immediately. Conclusions IEE can improve the preoperative diagnosis and reduce perioperative complications, which has value of application during cardiac surgery.

急診外科手術治療危重心瓣膜病192例

目的 總結危重心瓣膜病患者行急診手術的臨床經驗，以提高其療效和治愈率。 方法 自1996年10月至2007年11月對192例危重心瓣膜病患者施行了急診手術。所有患者均為心瓣膜病合并嚴重心力衰竭，心功能分級（NYHA）為Ⅲ~Ⅳ級。經內科治療2~7 d無效時采取急診手術治療；行二尖瓣置換術76例次，主動脈瓣置換術64例次，雙瓣膜置換術43例次，三尖瓣置換術4例次，三尖瓣成形術45例次，左心房血栓清除和左心房減容 術各5例次，冠狀動脈旁路移植術5例次，其他心血管手術9例次。 結果 術中和術后早期分別死亡3例和8例，總手術死亡率為5.7%（11/192），主要死亡原因為術中不能脫離體外循環機、術后發生低心排血量綜合征和突發心室顫動等。隨訪168例，隨訪時間1個月~11年，失訪13例。隨訪期間死亡8例，主要死于左心衰竭、瓣周漏或心內膜炎復發、尿毒癥、夾層動脈瘤等。長期生存160例，心功能恢復至Ⅰ級132例，Ⅱ級15例，Ⅲ級13例；生活質量較術前有所提高。 結論 危重心瓣膜病患者經內科治療無效時急診手術具有良好的療效，是較好的治療選擇。

復發性心瓣膜病患者再次心瓣膜置換術的臨床分析

摘要： 目的 總結復發性心瓣膜病患者再次行心瓣膜置換術的臨床經驗。 方法 回顧性分析1998年1月至2008年12月第四軍醫大學西京醫院收治的319例復發性心瓣膜病再次行心瓣膜置換術患者的臨床資料，男138例，女181例；年齡12～73歲(43.2±13.5歲)。需再次手術的原因為：心瓣膜成形術后、生物瓣衰壞、瓣周漏等。兩次手術間隔時間3個月～25年(18.7±8.3年)。 結果 全組共死亡25例，其中手術死亡4例，早期死亡21例。主要死亡原因為：低心排血量綜合征、室性心律失常、多器官功能衰竭等。其余294例患者治愈出院。隨訪252例，隨訪率85.7％，隨訪時間6個月～11年(9.6±7.1年)；失訪42例。隨訪期間死亡17例，死于心力衰竭9例，人工瓣膜感染性心內膜炎2例，顱內出血、腦栓塞3例，消化道出血1例，原因不明2例。長期生存的235例患者中心功能恢復至Ⅰ～Ⅱ級183例，Ⅲ級29例。 結論 盡管復發性心瓣膜病患者心功能和全身狀況均較差，手術操作較困難，但適時而妥善的外科手術仍可獲得良好的效果。

連續縫合法行雙瓣膜置換術

目的 總結連續縫合法行雙瓣膜置換術的經驗。方法 將40例風濕性心瓣膜病患者隨機分為兩組，每組20例。連續縫合組：二尖瓣置換術和主動脈瓣置換術均采用連續縫合法。對照組：二尖瓣置換術用連續縫合，主動脈瓣置換術用間斷帶墊片褥式縫合。結果 與對照組比較，連續縫合組平均主動脈阻斷時間為55分鐘，心肺轉流時間為84分鐘，較對照組縮短33.7%和34.3%，術后需正性肌力藥物減少，呼吸機輔助時間縮短，并發癥減少，住院時間縮短(P＜0.05)，均無瓣周、瓣緣漏發生。結論 雙瓣膜置換術中采用連續縫合法可顯著減少心肌缺血時間和心肺轉流時間,減少心肌損傷和術后并發癥發生，是一種簡便有效的方法。

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.

Cardiac valve replacement improves sleep quality in patients with rheumatic valvular heart disease and central sleep apnea

ObjectiveTo observes the postoperative transformation of subjective and objective sleep quality and related influencing factors in patients with rheumatic valvular heart disease (RVHD) who were found with central sleep apnea (CSA) after cardiac valve replacement.MethodsA total of 262 patients undergoing cardiac valve replacement were screened for CSA by overnight polysomnography and 21 patients with CSA were enrolled and followed up successfully in the 3th, 6th and 12th month of postoperation from April 2010 to January 2013. The Pittsburgh Sleep Quality Index, Epworth Sleepiness, polysomnography and cardiac function were evaluated in preoperation and postoperation (in the 3th, 6th and 12th month).ResultsNew York Heart Association class ［preoperation and postoperation: (3.7±0.5), (2.3±0.6), (1.7±0.6), (1.6±0.7), F=81.124, P<0.05］ continuously decreased, left ventricular ejection fraction ［preoperation and postoperation: (58.5±6.8)%, (60.0±7.4)%, (60.9±5.6)%, (64.4±4.0)%, F=7.182, P<0.05］ steadily increased, six-minute walk distance ［preoperation and postoperation: (271.5±76.6), (422.1±71.9), (445.1±56.2), (454.5± 63.5) m, F=67.134, P<0.05］ constantly increased. During postoperative follow-up, sleep apnea-hypopnea index ［preoperation and postoperation: (26.2±13.4), (12.0±11.5), (8.6±7.5), (7.4±5.5)/h, F=20.548, P<0.05, central sleep apnea index ［preoperation and postoperation: (19.6±10.3), (0.5±1.5), (0.3±1.3), (0.2±0.7)/h, F=72.926, P<0.05］ and oxygen desaturation index ［preoperation and postoperation: (20.1±16.6), (10.8±9.5), (8.5±7.2), (6.1±5.1)/h, F=9.646, P<0.05］ sustained improved. Aroual index ［preoperation and postoperation: (23.1±12.1), (2.7±3.8), (3.5±4.8), (2.2±2.1)/h, F=58.370, P<0.05］ presented overall downward trend. Pittsburgh Sleep Quality Index scale ［preoperation and postoperation: (11.1±3.2), (8.2±3.3), (6.0±3.8), (4.4±2.5), F=27.670, P<0.05］ were constantly improved. Epworth Sleepiness scale ［preoperation and postoperation: (13.3±5.7), (6.9±4.5), (8.2±4.8), (6.1±3.7), F=15.994, P<0.05］ showed overall reduction.ConclusionThe sleep quality of patients with RVHD and CSA is improved after cardiac valve replacement, of which the trend is in keep with postoperative recovery of cardiac function.

生物瓣心瓣膜置換術后遠期療效

目的評價生物瓣心瓣膜置換術后遠期療效。方法1979年1月至2001年12月施行生物瓣心瓣膜置換術303例，按年齡分為兩組，≥55歲者123例（≥55歲組）；（55歲者180例（〈55歲組）。其中160例早期使用經戊二醛處理的豬主動脈瓣，143例使用經環氧氯丙烷改性的新型豬主動脈瓣。所有心瓣膜置換術均在全身麻醉體外循環下進行。結果術后早期死亡9例，隨訪267例（90．8％），隨訪時間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例出現瓣膜衰壞，40例再次手術；5年、10年、15年累計瓣膜未衰壞率分別為90．1％±2．2％、79．4％±3．6％和36．8％±1．6％。且≥55歲組患者瓣膜未衰壞率高于（55歲組（P〈0．05）。經環氧氯丙烷改性的新型生物瓣10年瓣膜未衰壞率明顯高于早期戊二醛處理的生物瓣。全組血栓發生率低，15年為0．014％。發生感染性心內膜炎7例，3例治愈，4例死亡。結論人工生物瓣心瓣膜置換術后療效良好，尤其適合老年患者。經環氧氯丙烷改性的新型生物瓣有較強的抗衰壞能力；術后發生感染性心內膜炎應予以足夠的重視。