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人工瓣膜心內膜炎伴較大贅生物二例

Factors Determining Left Atrial Reverse Remodeling after Mitral Valve Replacement

ObjectiveTo observe the changes of left atrial geometry before and after mitral valve replacement in patients with different types of mitral valve disease and different heart rhythm, and to identify factors determining left atrial remodeling after mitral valve replacement. MethodsA total of 215 consecutive patients of mitral valve replacement in Department of Thoracic and Cardiovascular Surgery of West China Hospital, Sichuan University from January 2003 to March 2008 were selected and followed up for this study. There were 52 male and 163 female patients with their age of 40.58±10.54 years (ranged, 18-67 years). St. Jude Medical mechanical valves were used. According to the type of mitral valve diseases (mitral stenosis (MS) or mitral regurgitation (MR)) and heart rhythm (atrial fibrillation (AF) or sinus rhythm (SR)), patients were divided into 4 groups. There were 54 patients with MS and SR (including 13 male and 41 female patients with their age of 39.31±9.46 years), 56 patients with MS and AF (including 14 male and 42 female patients with their age of 41.12±10.72 years), 52 patients with MR and SR (including 12 male and 40 female patients with their age of 39.71±10.09 years), 53 patients with MR and AF (including 13 male and 40 female patients with their age of 40.19±11.87 years). All patients had routine examinations and echocardiogram preoperatively and two years after surgery. Left atrial anteroposterior diameter (LAD), left atrial area (LAA), left atrial volume (LAV) and left atrial volume index (LAVi) were used to analyze the changes of left atrial geometry. ResultsThere was no in-hospital death. Major postoperative complications included low cardiac output syndrome in 5 patients, pneumonia in 6 patients. LAVi were lower in mitral stenosis patients than that in mitral regurgitation patients (P<0.05), LAVi were lower in patients with sinus rhythm than that in patients with atrial fibrillation (P<0.05). Two years after mitral valve replacement, the extent of left atrial reverse remodeling were significantly greater in mitral regurgitation patients than in mitral stenosis patients (P<0.05), and the extent of left atrial reverse remodeling were significantly greater in patients with sinus rhythm than that in patients with atrial fibrillation (P<0.05). ConclusionsAge, atrial fibrillation, preoperative left atrial volume, mitral regurgitation, left ventricle end-diastolic diameter are important influencing factors of left atrial reverse remodeling after mitral valve replacement.

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。