机械及生物主动脉瓣病人选择及手术方式实施

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1、 20082008年年1212月月 上海上海cases199019902007 2007 西京医院心血管外科手术量情况西京医院心血管外科手术量情况52%23%8%7%10%20072007年西京医院年西京医院 32253225例心脏手术分布图例心脏手术分布图人工瓣膜的优缺点人工瓣膜的优缺点优优 点点结构故障少结构故障少 无须再次手术无须再次手术缺缺 点点需终身抗凝需终身抗凝 抗凝相关并发症抗凝相关并发症优异的血流动力学优异的血流动力学无需抗凝治疗无需抗凝治疗 瓣膜钙化瓣膜钙化瓣膜衰败瓣膜衰败 需再次手术需再次手术9143 982 19881988年年5 5月至月至20082008年年5 5月西

2、京医院月西京医院 82068206例患者应用例患者应用1012510125枚人工瓣膜种类分布枚人工瓣膜种类分布总体随访率为总体随访率为 91.2%累及随访达累及随访达 49232 病人病人年年 并发症并发症血栓栓塞血栓栓塞出血出血 机械瓣机械瓣(病人病人年年)1.81.8 2.12.1 生物瓣生物瓣(病人病人年年)0.210.21 0.480.48 90.1%86.4%69.1%生物瓣置换生物瓣置换1515年随访的年随访的Kaplan-Mier Kaplan-Mier 生存曲线生存曲线89.2%84.5%68.6%机械瓣置换机械瓣置换1515年随访的年随访的Kaplan-Mier Kaplan

3、-Mier 生存曲线生存曲线n年龄年龄 60 岁岁 n不伴有房颤不伴有房颤n无血栓栓塞的风险无血栓栓塞的风险n进行三尖瓣置换时进行三尖瓣置换时 n具有生育要求的年轻女性患者具有生育要求的年轻女性患者 西京医院选择人工瓣膜的原则西京医院选择人工瓣膜的原则 选择生物瓣选择生物瓣n有效开口面积指数（有效开口面积指数（IEOA）=0.85 n小于主动脉直径小于主动脉直径2 mmn在小主动脉根患者选择在小主动脉根患者选择19mm 的人工瓣膜，必要时根部加宽的人工瓣膜，必要时根部加宽 n应用瓣膜尺寸小于国外报道，与应用瓣膜尺寸小于国外报道，与我国西部身高体重特征有关我国西部身高体重特征有关 人工瓣膜的大小

4、选择人工瓣膜的大小选择我院我院14221422例主动脉瓣置换的型号分布图例主动脉瓣置换的型号分布图主动脉瓣主动脉瓣n成人二尖瓣一般置换多为成人二尖瓣一般置换多为27mm瓣膜瓣膜 n合并左室小或者左心功能不合并左室小或者左心功能不全，应使用较小型号的瓣膜全，应使用较小型号的瓣膜n45kg以下小左室患者以下小左室患者22例例 n3-12月婴儿应用月婴儿应用19mm瓣膜瓣膜3例例 人工瓣膜的大小选择人工瓣膜的大小选择我院我院53215321例二尖瓣置换的型号分布图例二尖瓣置换的型号分布图二尖瓣二尖瓣讨讨 论论n推荐选择主动脉瓣小于二尖瓣推荐选择主动脉瓣小于二尖瓣4mm，如，如二尖瓣二尖瓣27mm主动

5、脉瓣主动脉瓣23mm；或二；或二尖瓣尖瓣25mm主动脉瓣主动脉瓣21mm。n主动脉瓣较小时，不宜置换过大二尖瓣，主动脉瓣较小时，不宜置换过大二尖瓣，否则左心室负荷过重，易于出现左心功否则左心室负荷过重，易于出现左心功能衰竭。能衰竭。二尖瓣、主动脉瓣同期置换的瓣膜匹配二尖瓣、主动脉瓣同期置换的瓣膜匹配 讨讨 论论n生物瓣膜钙化和衰坏较快，选择机械瓣生物瓣膜钙化和衰坏较快，选择机械瓣n再次手术置换较大瓣膜再次手术置换较大瓣膜 n小儿基本可以接受华法林抗凝治疗小儿基本可以接受华法林抗凝治疗 n应当尽量通过成形来修复应当尽量通过成形来修复 婴幼儿瓣膜置换的选择婴幼儿瓣膜置换的选择讨讨 论论n首次手术治

6、疗时选择的标准和非感染性首次手术治疗时选择的标准和非感染性心内膜炎患者相似心内膜炎患者相似n对复发的感染性心内膜炎的患者应使用对复发的感染性心内膜炎的患者应使用生物瓣膜生物瓣膜n在有广泛的瓣环缺损和心室主动脉分离在有广泛的瓣环缺损和心室主动脉分离时，采用同种主动脉根部置换时，采用同种主动脉根部置换合并感染性心内膜炎的瓣膜置换选择合并感染性心内膜炎的瓣膜置换选择n同期置换多个瓣膜的选择同期置换多个瓣膜的选择 避免使用不同种类瓣膜进行同期置换避免使用不同种类瓣膜进行同期置换n育龄妇女瓣膜置换的选择育龄妇女瓣膜置换的选择 对有生育要求的年轻女性力争进行瓣对有生育要求的年轻女性力争进行瓣膜成形术，必要

7、时推荐应用生物瓣膜膜成形术，必要时推荐应用生物瓣膜进行瓣膜置换。进行瓣膜置换。特殊情况下人工瓣膜的选择特殊情况下人工瓣膜的选择双瓣同期置换术双瓣同期置换术四瓣膜同期置换四瓣膜同期置换(西京医院西京医院)二尖瓣发育不良并重度关闭不全二尖瓣发育不良并重度关闭不全婴幼儿换瓣婴幼儿换瓣Institute of Cardiovascular disease of PLADepartment of Cardiovascular Surgery,Xijing Hospital Fourth Military Medical University casesCardiac Operations Perform

8、ed in the Department of Cardiovascular Surgery in Xijing Hospital from 1990 to 2007 1999 2000 2001 2002 2003 2004 2005 2006 200752%23%8%7%10%Distribution of different types of 3225 cardiac operations in the Department of Cardiovascular Surgery Xijing Hospital in 2007AdvantageDisadvantageAdvantage an

9、d disadvantage of artificial valveLife-long anticoagulation Related complicationsFew structural deterioration Free from re-operationGood haemodynamics Free from anticoagulation Calcification Deterioration Re-operation9143 982 Distribution of 10125 artificial valves used in 8206 patients in Xijing Ho

10、spital from May,1988 to May,2008 ResultsResultsFollow-up rate was 91.2%Accumulated follow-up time is 49232 patientsyear ComplicationsThromboembolisisBleeding Mechanical(Patientsyear)1.8 2.1 Bioprosthetics(Patientsyear)0.21 0.48 90.1%86.4%69.1%Kaplan-Mier Survival Curve of bioprosthesis during 15 yea

11、rs follow-up89.2%84.5%68.6%Kaplan-Mier Survival Curve of mechanical valve during 15 years follow-upn 60 years old nComorbided without atrial fibrillation nNo risk factor for thromboembolismnTricuspid valve replacement nFemale patients with fertility require Principle for selection of mechanical or b

12、ioprosthetic valves in Xijing Hospital Bioprosthetic valve preferrednIndexed effective orifice area（IEOA）=0.85 n2 mm smaller than the radius of the aortic annulus n19mm in patients with small aortic root nOur sizes were smaller than that of western countriesSelection of the size for artificial valve

13、sAortic valveDistribution of the size of 1422 aortic valve replaced in our hospitalnMost selected mitral valve in adults is 27mm nSmaller valve preferred in patients with small left ventricle or heart insufficiencyn22 cases of valve replacement in patients under 45kgn3 cases of 19mm valve replacemen

14、t in 3-12 months old infantsDistribution of the size of 5321 mitral valve replaced in our hospitalMitral valveSelection of the size for artificial valvesDiscussionDiscussionnAortic valve 4mm smaller than mitral valve is recommended.I.E.27mm M23mm A；25mm M23mm A nWhen the aortic valve is small,big mi

15、tral valve should be avoided.Otherwise left ventricle overload will occur,leading to left heart failure.Match of concomitant Mitral and Aortic valve replacement nDue to the calcification and deterioration of bioprosthesis,mechanical valve is preferrednNeed for re-operationnValvuloplasty should be th

16、e first choice in children nWalfarin can usually be well tolerated in childrenChoice of valve replacement in infantsDiscussionDiscussionnThe criteria for first time is same to ordinary patientsnFor re-occurred patients,bioprosthesis is preferrednFor patients with extensive annular defect or the deta

17、chment between ventricle and aorta,root replacement would be selected Choice of valve replacement in patients with endocarditisDiscussionDiscussionnConcomitant multi-valve replacement Avoid select valves of different typesnFor young female patients with fertility require Valvuloplasty is the first choice Bioprosthesis can also be used when necessaryChoice of valve replacement in special situationConcomitant double-valve replacementConcomitant four-valve replacementCongenital mitral valve insufficiencyCongenital mitral valve insufficiencyValve replacement in infants