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风湿性二尖瓣、主动脉瓣与三尖瓣联合病变的外科治疗

目的总结心脏联合瓣膜病变外科治疗的经验。方法227例风湿性二尖瓣、主动脉瓣与三尖瓣联合瓣膜病变患者，术前心功能Ⅱ级31例，Ⅲ级132例，Ⅳ级64例，行主动脉瓣、二尖瓣双瓣膜置换术（DVR）106例，DVR＋三尖瓣置换术2例，DVR＋三尖瓣成形术119例；同期行左心房血栓摘除术62例，左心房折叠术8例，改良迷宫手术2例。结果术后早期死亡10例，其中死于心力衰竭6例，心搏骤停2例，细菌性心内膜炎1例，药物过敏1例，其余217例患者治愈出院。随访181例，随访时间3个月～13年，心功能Ⅰ～Ⅱ级149例，Ⅲ级23例，Ⅳ级9例；其中1例因心力衰竭死亡。结论幼年期即出现明显心功能不全的联合心脏瓣膜病变患者，于中年就诊时要慎重手术；作三尖瓣成形术前，应常规测试瓣膜关闭不全部位，再酌情选择成形术式；术前给予强心利尿等治疗，使心功能明显改善后再行手术治疗，有利于心功能的恢复；出院后定期随访，继续给予药物治疗，保护心功能。

风湿性心瓣膜病二尖瓣置换术中并发血管麻痹综合征一例

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.

60岁以上心瓣膜病患者的外科治疗与随访

目的 总结≥60岁心瓣膜病患者的外科治疗经验及随访结果，以提高手术疗效。 方法 2000年7月至2008年12月, 86例≥60岁的心瓣膜病患者接受了心瓣膜置换术治疗，其中男43例，女43例；年龄60~74岁，平均年龄63.8岁。二尖瓣病变55例，主动脉瓣病变9例，二尖瓣及主动脉瓣双瓣膜病变21例，三尖瓣病变1例；风湿性心瓣膜病65例，退行性心瓣膜病21例。心房颤动59例，窦性心律27例。心功能分级(NYHA)Ⅲ级79例，Ⅳ级7例。行二尖瓣置换术55例，双瓣膜置换术21例，主动脉瓣置换术9例，二尖瓣置换术后三尖瓣置换术1例；同期行三尖瓣成形术16例，改良射频迷宫术8例，左心房血栓清除术7例。 结果 围术期因心律失常死亡1例。术后有3例患者因胸骨哆开而再次行胸骨固定术，１例患者因瓣周漏而再次行心瓣膜置换术，3例患者因呼吸功能不全行气管切开术。85例患者均治愈出院。术后左心房内径（51.1±13.8 mm vs.56.2±17.2 mm,P=0.001）和右心房内径(48.8±9.6 mm vs. 52.1±13.9 mm,P=0.012)较术前明显缩小，左心室、右心室内径、射血分数和缩短分数与术前比较差异均无统计学意义（Pgt;0.05）。随访84例，随访时间2~96个月(24±22个月)，失访1例。随访期间有1例患者于术后5个月因抗凝强度不足发生左心房血栓，经治疗后血栓消失；另1例术后6年因抗凝强度不足发生脑梗死，经住院治疗肢体偏瘫未能恢复。 结论 只要适当把握手术指征和手术时机，注重术前准备及围术期处理，对≥60岁患者行心瓣膜置换术效果良好。术后与抗凝有关的主要问题为抗凝不足。对这些患者术后应加强国际标准化比率(INR)监测及持续的心功能调整。

生物瓣心瓣膜置换术后远期疗效

目的评价生物瓣心瓣膜置换术后远期疗效。方法1979年1月至2001年12月施行生物瓣心瓣膜置换术303例，按年龄分为两组，≥55岁者123例（≥55岁组）；（55岁者180例（〈55岁组）。其中160例早期使用经戊二醛处理的猪主动脉瓣，143例使用经环氧氯丙烷改性的新型猪主动脉瓣。所有心瓣膜置换术均在全身麻醉体外循环下进行。结果术后早期死亡9例，随访267例（90．8％），随访时间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例出现瓣膜衰坏，40例再次手术；5年、10年、15年累计瓣膜未衰坏率分别为90．1％±2．2％、79．4％±3．6％和36．8％±1．6％。且≥55岁组患者瓣膜未衰坏率高于（55岁组（P〈0．05）。经环氧氯丙烷改性的新型生物瓣10年瓣膜未衰坏率明显高于早期戊二醛处理的生物瓣。全组血栓发生率低，15年为0．014％。发生感染性心内膜炎7例，3例治愈，4例死亡。结论人工生物瓣心瓣膜置换术后疗效良好，尤其适合老年患者。经环氧氯丙烷改性的新型生物瓣有较强的抗衰坏能力；术后发生感染性心内膜炎应予以足够的重视。

重症风湿性心瓣膜病的外科治疗

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.

Application and Significance of Coronary Angiography Prior to Heart Valve Replacement for Patients with Rheumatic　Valvular Heart Disease

Objective To explore clinical application and significance of coronary angiography （CAG） prior to heart valve replacement for patients with rheumatic valvular heart disease （RVHD）. Methods We retrospectively analyzed clinical data of 313 RVHD patients who underwent heart valve replacement in the First Affiliated Hospital of Chongqing Medical University from January 2002 to June 2012. All the patients received screening CAG before surgery. According to CAG results，313 patients were divided into two groups. In the coronary artery lesion （CAL） group，there were 29 patients including 17 male and 12 female patients with their age of 60.0±5.2 years. In the non-coronary artery lesion （non-CAL）group，there were 284 patients including 98 male and 186 female patients with their age of 57.0±5.4 years. Surgicaloutcomes were compared between the two groups. Univariate analysis and multivariate logistic regression were performed to analyze risk factors of CAL for RVHD patients. Results CAG showed 29 patients with CAL，and the overall prevalence of CAL was 9.27%. In CAL group，11 patients underwent concomitant coronary artery bypass grafting with 2.2 grafts for each patient on the average. Postoperatively 1 patient （3.45%） died of low cardiac output syndrome （LCOS）. In non-CAL group，5 patients （1.76%） postoperatively died mainly because of LCOS，ventricular fibrillation，sudden cardiac arrest or respiratory failure. Cardiopulmonary bypass time and aortic cross-clamp time of CAL group were significantly longer than those of non-CAL group （P＜0.05）. There was no statistical difference in postoperative mortality，incidence of LCOS，acute renal failure，respiratory failure，reexploration for bleeding，intraoperative blood loss，mechanical ventilation time or hospital stay between the two groups（P＞0.05）. There was no significant correlation between the types of valvular lesions and CAL. Age≥ 55 years （OR=5.534，P=0.005），male gender （OR=2.335，P=0.038） and diabetes mellitus （OR=4.265，P=0.006） were independent risk factors of CAL for RVHD patients undergoing heart valve replacement. Conclusion For RVHD patients with independent risk factors of CAL （age≥55 years，male gender and diabetes mellitus），CAG must beseriously considered before heart valve replacement. RVHD patients with CAL can obtain similarly satisfactory surgicaloutcomes of heart valve replacement as RVHD patients without CAL by appropriate surgical strategy and strengthened perio-perative management.

风湿性心瓣膜病三尖瓣关闭不全的外科治疗

目的 总结风湿性心瓣膜病三尖瓣关闭不全（ TI）手术治疗的临床经验，以提高对该类患者的治疗效果。 方法 1999年1月至2009年1月安徽医科大学第一附属医院对167例风湿性心瓣膜病累及三尖瓣患者行手术治疗，其中男76例，女91例；年龄16.0～75.0岁（40.7±10.4岁）；病程2.0～35.0年（13.2±3.8年）。112例轻度至中度三尖瓣反流采用改良或节段性De Vega成形术，40例中度或中度至重度三尖瓣反流采用Kay或改良Kay成形术；12例因瓣环扩张明显、反流量大，行人工瓣环成形术，三尖瓣置换术3例。术后观察三尖瓣反流情况，随访超声心动图结果。 结果 术后早期死亡6例，其中死于心搏骤停1例，肾功能衰竭2例，脑血管意外1例，心室破裂1例，纵隔感染致败血症1例。1例术中因低心排血量使用主动脉内球囊反搏（IABP）治疗，治愈出院。随访159例，随访时间3～123个月，失访2例。随访期间心功能分级(NYHA)Ⅰ级115例，Ⅱ级32例，Ⅲ级12例。三尖瓣轻度反流15例，中度反流5例，重度反流2例。随访期间三尖瓣隔瓣与前瓣瓣环间直径（2.1±0.3 cm vs. 3.5±0.4 cm, P=0.000）、三尖瓣瞬时反流量(1.8±0.6 ml vs. 7.8±3.5 ml, P=0.001)和右心房容积（54.2±18.4 ml vs. 67.8±22.5 ml, P=0.012）较术前明显减少或缩小； 射血分数（56.1%±7.2% vs. 54.3%±6.5%,P=0.313）较术前有所提高。 结论 心脏瓣膜病中TI需引起重视，应选择适宜的方法积极治疗。

连续缝合法行双瓣膜置换术

目的 总结连续缝合法行双瓣膜置换术的经验。方法 将40例风湿性心瓣膜病患者随机分为两组，每组20例。连续缝合组：二尖瓣置换术和主动脉瓣置换术均采用连续缝合法。对照组：二尖瓣置换术用连续缝合，主动脉瓣置换术用间断带垫片褥式缝合。结果 与对照组比较，连续缝合组平均主动脉阻断时间为55分钟，心肺转流时间为84分钟，较对照组缩短33.7%和34.3%，术后需正性肌力药物减少，呼吸机辅助时间缩短，并发症减少，住院时间缩短(P＜0.05)，均无瓣周、瓣缘漏发生。结论 双瓣膜置换术中采用连续缝合法可显著减少心肌缺血时间和心肺转流时间,减少心肌损伤和术后并发症发生，是一种简便有效的方法。