心臟瓣膜病再次手術(shù)的治療策略

廣東省人民醫(yī)院廣東省心血管病研究所盧聰中國(guó)瓣膜外科發(fā)展史中的幾個(gè)里程碑蔡用之：長(zhǎng)海醫(yī)院張寶仁：長(zhǎng)海醫(yī)院郭加強(qiáng)：阜外心血管病醫(yī)院羅征祥：廣東省人民醫(yī)院我院的經(jīng)驗(yàn)我院的經(jīng)驗(yàn)醫(yī)院名稱再次手術(shù)例數(shù)原因阜外醫(yī)院333a,b,c,d,e,f新橋醫(yī)院187f,a,d,g仁濟(jì)醫(yī)院203f,a,g,福建省立醫(yī)院104f,e,g,d,a,h包頭中心醫(yī)院165f,a,g,c,d,b,ea:生物瓣失功能，b:瓣周漏，c:自然瓣膜損壞，d:機(jī)械瓣功能障礙，e:感染性心內(nèi)膜炎，f:二尖瓣閉式擴(kuò)張，g:二尖瓣直視分離，h:其他,風(fēng)險(xiǎn)及對(duì)策機(jī)械瓣功能障礙機(jī)械瓣結(jié)構(gòu)原因機(jī)械瓣梗阻：

◆血管翳、纖維組織增生

◆血栓形成：多發(fā)生于3年內(nèi)梗阻原因MVRAVRTVR血栓形成35(71%)8(33%)4(100%)血管翳及纖維組織增生14(29%)16(67%)

機(jī)械瓣功能障礙

策略妊娠期機(jī)械瓣功能障礙原因：（1）妊娠期高凝狀態(tài)（2）擔(dān)心華法林的副作用（3）在妊娠早期停用或換用其他抗凝藥物我院臨床資料2000年2月至2006年12月，妊娠期發(fā)生機(jī)械瓣功能障礙病人7例，年齡22-32歲，平均26.4±2.6歲風(fēng)濕性心臟病5例，先天性心臟病2例心功能IV級(jí)4例，III級(jí)3例妊娠期>28周5例，<28周2例機(jī)械瓣血栓形成，機(jī)械瓣梗阻妊娠期機(jī)械瓣功能障礙外科治療方法妊娠期機(jī)械瓣功能障礙結(jié)果妊娠期機(jī)械瓣功能障礙外科決策機(jī)械瓣失功能+妊娠期<3月？機(jī)械瓣失功能+妊娠期在3-6個(gè)月？機(jī)械瓣失功能+妊娠期>6個(gè)月？妊娠期機(jī)械瓣功能障礙影響外科決策的因素妊娠期機(jī)械瓣功能障礙面臨的挑戰(zhàn)妊娠期機(jī)械瓣功能障礙是一個(gè)易受忽視的問(wèn)題顯著影響長(zhǎng)期生存率NathJ,etal,JAmCollCardiol,2004;43,405處理策略再次成形：Devega’s，瓣環(huán)成形，如何選擇瓣環(huán)種類(lèi)瓣膜置換：金屬瓣：血栓風(fēng)險(xiǎn)生物瓣：近幾年多采用有待解決的問(wèn)題二尖瓣成形失敗外科治療方法二尖瓣成形失敗如何預(yù)防二尖瓣成形失敗PostRepairPreRepair二尖瓣成形失敗展望EdwardsLifesciencesTHANKYOUStrategiesofRe-operationinHeartValveDiseaseCongLu,MDGuangdongGeneralHospitalGuangdongProvincialCardiovascularInstituteGuangzhou,ChinaGuangdongGeneralHospitalGuangdongProvincialCardiovascularInstituteRelevantHistoricMilestonesinChina1954Closedmitralcommissurotomy1958ThefirstapplicationofCPB1958OpenmitralcommissurotomybyCPB1965MitralvalvereplacementEminentPioneersandInstitutionsofChinaCaiYongzhiChanghaiHospital

ShanghaiZhangBaorenChanghaiHospital

ShanghaiGuoJiaqiangFuwaiCardiovascularHospital

BeijingLuoZhengxiangGuangdongGeneralHospital

GuangzhouOperationsandRe-operationsBythelate1990s,6000heartvalveoperationsperformedeachyearInrecentyears,thenumberofvalveoperationsperyearismorethan20000Withthenumberofheartvalvesurgeriesincreasing,re-operationofheartvalvediseasebecomesanunavoidableproblem

TheExperienceofOurHospitalHeartvalvesurgeriesinGuangdongGeneralHospitalfrom1997to2007TheExperienceofOurHospitalThetotaloperationsfrom1997to2007：

6703casesRe-operations：499cases

(7.4%)Perioperativemortalityofre-operations：8.8%CausesofRe-operationTheleadingcause：

Re-stenosisafterclosedmitralcommissurotomy（64.5%）Causesofre-operationofotherhospitalHospitalRe-operationcausesFuwaiHospital333a,b,c,d,e,fXinqiaoHospital187f,a,d,gRenjiHospital203f,a,g,FujianProvincialHospital104f,e,g,d,a,hBaotouCentralHospital165f,a,g,c,d,b,ea:bioprostheticfailure，b:perivalvularleakage，c:lesionofnaturalvalve，d:dysfunctionofmechanicalvalve，e:endocarditis，f:closedmitralcommissurotomy，g:openmitralcommissurotomy，h:othersRisksandStrategiesRisksarehigherofre-operationthaninitialoperation

◆pro-longedhistory

◆poorcardiacfunction

◆adhesion

◆bleedingAvarietyofmethodsandstrategiesofmanagementshouldbeappliedaccordingtodifferentcausesleadingtore-operationRestenosisafterClosedorOpenMitralCommissurotomy

WaswidelydonewithgoodresultsinChinaRestenosisisunavoidableCharacters：pro-longedhistory，oftenconcomitantwithtricuspidregurgitationStrategies：

◆re-repair

◆prostheticvalvereplacement：

bioprostheticvalvemechanicalprostheticvalveDysfunctionofMechanicalProstheticValveProstheticvalvestructureObstructionofmechanicalprostheticvalve

◆pannus,fibroustissueaccrementition

◆thrombogenesis:mostwithin3years postoperationCausesofobstructionMVRAVRTVRthrombogenesis35(71%)8(33%)4(100%)pannus,fibroustissue14(29%)16(67%)

DysfunctionofMechanicalProstheticValve

StrategiesThrombus：thromblysisreoperationPannus,fibroustissue：reoperationDifferenceofthetargetvalueofINRamongAVR,MVRandTVR

AVR： MVR： TVR：MechanicalvalvedysfunctioninpregnantwomenCauses

（1）hemostasischangesinpregnancy

Pregnancyisassociatedwitha20-200% increaseinlevelsoffibrinogenandfactorsII,VII,VIII,X,andXII

LockwoodCJ.ObstetGynecol2002;99:333.

（2）worryaboutthesideeffectofwarfarin

（3）discontinueanticoagulationtherapyinthe earlystageofpregnancyoruseother anticoagulantsMechanicalvalvedysfunctioninpregnantwomen

ExperienceofourhospitalSevenpatientswithmechanicalvalvedysfunctionduringpregnancywereretrospectivelyreviewedNYHAatIVin3,atIIIin3Gestationperiod>28weeksin4,<28in2ThrombogenesisleadingtomechanicalvalveobstructioninallpatientsMechanicalvalvedysfunctioninpregnantwomen

MethodsofsurgicalmanagementCaesareansectionconcomitantwithre-replacementofmechanicalprostheticvalveMechanicalprostheticvalvere-replacementonordinarytemperaturecardiopulmonarybypasswithcontinuefetalheartratemonitoringCaesareansectionfollowedbyre-replacementofmechanicalprostheticvalveMechanicalvalvedysfunctioninpregnantwomen

ResultsAllpatientsdischargedfromhospitalinwellconditionTwopatientswithgestationperiod<28weekswhounderwentmechanicalprostheticvalvere-replacement,onefetusdiedandtheotheronesurvivedanddeliveredinmaturepregnancyFiveinfantsweredeliveredanddischargedingoodhealthMechanicalvalvedysfunctioninpregnantwomen

StrategiesofsurgicalmanagementDysfunctionofmechanicalvalve+gestationperiod

<3months？Dysfunctionofmechanicalvalve+gestationperiod

between3and6months？Dysfunctionofmechanicalvalve+gestationperiod

>6months？DegreeofobstructionofmechanicalvalveCardiacfunctionGestationperiodandconditionoffetusDesireofpatientsandfamilymembersExperienceofcardiacsurgeonProfessionallevelofrelevantdepartmentMechanicalvalvedysfunctioninpregnantwomen

FactorsimpactonmakingdecisionofmanagementMechanicalvalvedysfunctioninpregnantwomen

ChallengingManyyoungwomenwhounderwentvalvereplacementwanttohavebabyIrregularanticoagulationtherapyduringpregnancyTheadverseimpactsofhypothermiaandCPBonfetusHowtopreventandmanagemechanicalvalvedysfunctioninpregnantpatientsHowtocooperatewithotherdepartment,eg.Neontologydepartment,obstetricsdepartmentLateTricuspidRegurgitationafterLeftCardiacValveReplacementTricuspidregurgitationisoftenneglectedAdverseimpactonsurvivalNathJ,etal,JAmCollCardiol,2004;43,405Mechanism◆Persistentpulmonaryhypertension◆Annulardilatation◆Atrialfibrillation◆Progressionordevelopmentof rheumaticlesions◆LimitationofDeVega’sprocedure

XuejunX,etal.HeartLungandCircul,2004;13,65TRafterLeftCardiacValveReplacementTRafterLeftCardiacValveReplacement

StrategiesofmanagementRe-repairDeVega’sprocedureannuloplastyringValvereplacementmechanicalvalve：riskofthrombogenesisbioprostheticvalve：widelyusedinrecent yearsTRafterLeftCardiacValveReplacement

RemainingQuestionsWhatisthemechanismoffunctionalTR?Howtoperformtricuspidrepair?Whichsizeandkindofringforwhichpatient?Whenshouldweperformarepair?Whenshouldwethinktovalvereplacement?Whylatedevelopmentoftricuspidregurgitationaftersuccessfulmitralsurgery?Howtopreventit?FailureandComplicationofValveRepairValverepairisfarlessthanvalvereplacementinChina

◆RheumaticheartdiseaseisstilltheleadingcauseofvalvulardamageleadingtosurgeryinChina

◆Patientsoftenexperiencedpro-longedhistorybeforetheirfirst