機械及生物主動脈瓣-病人選擇及手術(shù)方式實施

第四軍醫(yī)大學(xué)西京醫(yī)院心血管外科易定華，俞世強，劉金成，金振曉等2008年12月上海cases52%23%8%7%10%人工瓣膜的優(yōu)缺點優(yōu)點缺點需終身抗凝抗凝相關(guān)并發(fā)癥優(yōu)異的血流動力學(xué)無需抗凝治療91439821988年5月至2008年5月西京醫(yī)院8206例患者應(yīng)用10125枚人工瓣膜種類分布總體隨訪率為91.2%累及隨訪達(dá)49232病人?年并發(fā)癥機械瓣(病人?年)生物瓣(病人?年)血栓栓塞1.8％0.21％出血2.1％0.48％90.1%86.4%69.1%生物瓣置換15年隨訪的Kaplan-Mier生存曲線89.2%84.5%68.6%機械瓣置換15年隨訪的Kaplan-Mier生存曲線年齡<60歲

并發(fā)房顫

有血栓栓塞的風(fēng)險首次感染性心內(nèi)膜炎的患者西京醫(yī)院選擇人工瓣膜的原則選擇機械瓣年齡>60歲不伴有房顫無血栓栓塞的風(fēng)險進(jìn)行三尖瓣置換時具有生育要求的年輕女性患者西京醫(yī)院選擇人工瓣膜的原則選擇生物瓣有效開口面積指數(shù)（IEOA）=0.85小于主動脈直徑2mm在小主動脈根患者選擇≥19mm的人工瓣膜，必要時根部加寬應(yīng)用瓣膜尺寸小于國外報道，與我國西部身高體重特征有關(guān)

人工瓣膜的大小選擇我院1422例主動脈瓣置換的型號分布圖主動脈瓣成人二尖瓣一般置換多為27mm瓣膜合并左室小或者左心功能不全，應(yīng)使用較小型號的瓣膜45kg以下小左室患者22例3-12月嬰兒應(yīng)用19mm瓣膜3例人工瓣膜的大小選擇我院5321例二尖瓣置換的型號分布圖二尖瓣討論推薦選擇主動脈瓣小于二尖瓣4mm，如二尖瓣27mm＋主動脈瓣23mm；或二尖瓣25mm＋主動脈瓣21mm。主動脈瓣較小時，不宜置換過大二尖瓣，否則左心室負(fù)荷過重，易于出現(xiàn)左心功能衰竭。二尖瓣、主動脈瓣同期置換的瓣膜匹配討論嬰幼兒瓣膜置換的選擇討論合并感染性心內(nèi)膜炎的瓣膜置換選擇特殊情況下人工瓣膜的選擇四瓣膜同期置換(西京醫(yī)院)二尖瓣發(fā)育不良并重度關(guān)閉不全嬰幼兒換瓣ThankYou!YiDinghua,LiuJincheng,YuShiqiang,YangJian,JinZhenxiao,etalInstituteofCardiovasculardiseaseofPLADepartmentofCardiovascularSurgery,XijingHospitalFourthMilitaryMedicalUniversityPatientSelectionandPracticePatterns:MechanicalversusBioprostheticsAorticValves

casesCardiacOperationsPerformedintheDepartmentofCardiovascularSurgeryinXijingHospitalfrom1990to2007

19992000200120022003200420052006200752%23%8%7%10%Distributionofdifferenttypesof3225cardiacoperationsintheDepartmentofCardiovascularSurgeryXijingHospitalin2007AdvantageDisadvantageAdvantageanddisadvantageofartificialvalveLife-longanticoagulationRelatedcomplicationsFewstructuraldeteriorationFreefromre-operationGoodhaemodynamics

FreefromanticoagulationCalcificationDeteriorationRe-operation9143982Distributionof10125artificialvalvesusedin8206patientsinXijingHospitalfromMay,1988toMay,2008ResultsFollow-upratewas91.2%Accumulatedfollow-uptimeis49232patients?yearComplicationsMechanical(Patients?year)Bioprosthetics(Patients?year)

Thromboembolisis1.8％0.21％Bleeding2.1％0.48％90.1%86.4%69.1%Kaplan-MierSurvivalCurveofbioprosthesisduring15years’follow-up89.2%84.5%68.6%Kaplan-MierSurvivalCurveofmechanicalvalveduring15years’follow-up<60yearsold

Comorbidedwithatrialfibrillation

RiskfactorforthromboembolismInfectiveendocarditis(Forthefirsttime)PrincipleforselectionofmechanicalorbioprostheticvalvesinXijingHospital

Mechanicalvalvepreferred>60yearsoldComorbidedwithoutatrialfibrillationNoriskfactorforthromboembolismTricuspidvalvereplacementFemalepatientswithfertilityrequirePrincipleforselectionofmechanicalorbioprostheticvalvesinXijingHospital

BioprostheticvalvepreferredIndexedeffectiveorificearea（IEOA）=0.852mmsmallerthantheradiusoftheaorticannulus>19mminpatientswithsmallaorticrootOursizesweresmallerthanthatofwesterncountriesSelectionofthesizeforartificialvalvesAorticvalveDistributionofthesizeof1422aorticvalvereplacedinourhospitalMostselectedmitralvalveinadultsis27mmSmallervalvepreferredinpatientswithsmallleftventricleorheartinsufficiency22casesofvalvereplacementinpatientsunder45kg3casesof19mmvalvereplacementin3-12months’oldinfantsDistributionofthesizeof5321mitralvalvereplacedinourhospitalMitralvalveSelectionofthesizeforartificialvalvesDiscussionAorticvalve4mmsmallerthanmitralvalveisrecommended.I.E.

27mmM＋23mmA；25mmM＋23mmA

Whentheaorticvalveissmall,bigmitralvalveshouldbeavoided.Otherwiseleftventricleoverloadwilloccur,leadingtoleftheartfailure.MatchofconcomitantMitralandAorticvalvereplacementDuetothecalcificationanddeteriorationofbioprosthesis,mechanicalvalveispreferredNeedforre-operationValvuloplastyshouldbethefirstchoiceinchildrenWalfarincanusuallybewelltoleratedinchildrenChoiceofvalvereplacementininfantsDiscussionThecriteriaforfirsttimeissametoordinarypatientsForre-occurredpatients,bioprosthesisispreferredForpatientswithextensiveannulardefectorthedetachmentbetweenventricleandaorta,rootreplacementwouldbeselected

ChoiceofvalvereplacementinpatientswithendocarditisDiscussionConcomitantmulti-valvereplacement

AvoidselectvalvesofdifferenttypesForyoungfemalepatientswithfertilityrequire

ValvuloplastyisthefirstchoiceB