【作者】 林志钦；

【导师】 林峰；

【作者基本信息】 福建医科大学 ， 外科学， 2015， 硕士

【摘要】 目的分析二尖瓣置换术后远期再行主动脉瓣置换术的原因、诊疗及疗效,探讨二尖瓣置换术后再行主动脉瓣置换术的手术经验、围术期处理,为临床诊疗提供参考及借鉴。方法回顾性分析自2008年1月1日至2014年12月31日期间就诊福建医科大学附属协和医院心脏外科55例曾行二尖瓣机械瓣置换术史因再发主动脉瓣膜病变而入院接受主动脉瓣置换术的患者资料,其中男21例、女34例,年龄(50.6±7.0)岁,距离首次心脏手术时间15.4±5.4年,所行手术包括主动脉瓣置换术(AVR)51例,双瓣置换术(DVR)4例,同期行三尖瓣成形术10例,同期行左房折叠1例。瓣膜全部为双叶机械瓣。治疗前后参照纽约心脏病协会(NYHA)心功能标准对患者进行心功能评级。对所有出院患者进行门诊复查和电话随访。结果二尖瓣置换术后再发主动脉瓣病变而需行主动脉瓣置换术的主要原因包括主动脉瓣风湿性病变加重(70.90%)、退行性主动脉瓣病变(25.50%)、感染性心内膜炎赘生物形成(3.60%)。住院期间死亡2例,死亡原因为多脏器功能衰竭,围手术期死亡率3.64%。非死亡病例中ICU监护时间1-7d,平均2.4±1.1d,住院时间10-44d,平均住院日20.5±10.1d。术后发生并发症者25例(45.5%),术后平均随访时间30月,随访期间无死亡,病人临床症状缓解明显,心功能得到一定程度恢复,其中心功能I级者11例,心功能II级者32例,心功能III级者10例。术前术后彩色超声心动图检查部分指标对比示:术后1周即可发现LVEDD和LA较术前明显回缩(P<0.05),而LVEF、LVFS、心功能分级手术前后差异均无显著性(P>0.05),出院后3月LVEDD、LA、LVEF、LVFS、LVFS、心功能分级恢复程度显著(P<0.05)。结论1、主动脉瓣风湿性病变加重、退行性主动脉瓣病变、感染性心内膜炎赘生物形成这三方面是二尖瓣置换术后再发主动脉瓣病变而需行主动脉瓣置换术的主要原因。2、重视术前高危因素的存在、术前注意改善心功能、选择正确的手术时 机、术中注意心肌保护、合理的手术方法及适当的围手术期治疗,二尖瓣置换术后再行主动脉瓣置换能取得良好的手术效果。3、术后应做好出院指导及随访等工作,二尖瓣置换术后远期再行主动脉瓣置换术近期疗效显著,但远期疗效有待进一步研究。更多还原

【Abstract】 Objective: To analyze the causes, treatment and curative effect of cases undergoing aortic valve replacement in the long term after mitral valve replacement. To provide treatment experience of the cases for clinical diagnosis and treatment.Methods: Clinical data of 55 patients who underwent aortic valve replacement because of aortic valve disease in the long term after mitral valve replacement in the Union Hospital of Fujian Medical University from January 1, 2008 to December 31, 2014 were retrospectively analyzed. Of them there were 21 males and 34 females with a mean age of(50.6±7.0) years old. For them It was 15.4±5.4 years after the first heart operation. The second heart surgical included aortic valve replacement(AVR) in 51 cases, double valve replacement(DVR) in 4 cases, tricuspid valve plasty in 10 cases, left atrial folding in 1 case. Bileaflet mechanical valves were used for replacement in all cases. Heart function was compared before and after operation according to the New York Heart Association(NYHA).All patients were followed by clinic interview or telephone.Results: The main reasons of the cases undergoing aortic valve replacement in the long term after mitral valve replacement including rheumatic disease exacerbation(70.90%), aortic valve deterioration(25.5%), infective endocarditis vegetations(3.60%). 2 patients died of multiple organ failure, operation mortality was 3.64%. The time staying in the intensive unit(ICU) was 1-7days, an average of 2.4±1.1 days. The time staying in the hospital was 10-44 days, an average of 20.5±10.1 days. Postoperative complications occurred in 45 patients(45.5% patients). the average follow-up time was 30 months, and no deaths happened during follow-up. The clinicalmanifestations of the patients relieved obviously. The heart function was recovered to a certain extent, the number of preoperative heart function grade I,II,III,IV was 11,32,10 and 0. Through comparing preoperative and postoperative echocardiography data of the survival cases, we found :for about 1 week after operation, the LVEDD and the LA showed significant retraction comparing with the preoperative data(P < 0.05), while LVEF, LVFS and cardiac function grade had no significant difference comparing with the preoperative data(P>0.05). For 3 months after discharge, the LA, the LVEF, the LVEDD,the LVFS and heart function grade showed significant Recovery(P<0.05).Conclusion: 1. Rheumatic disease exacerbation, aortic valve deterioration, infective endocarditis vegetations were the three causes for the cases undergoing aortic valve replacement in the long term after mitral valve replacement. 2. With the enough attention to risk factors before operation, the improvement of heart function before operation, the right choice of operation time, the competent myocardial protection, the reasonable surgical method and the right perioperative treatment, the surgery of aortic valve replacement in the long term after mitral valve replacement can achieve a good effect. 3. Postoperative guidance should be given for the discharged patients and the follow-up should be taken,The short-term effect of this operation is remarkable,but the long-term effect needs to be further studied.更多还原