心脏瓣膜病再次手术的治疗策略.ppt

心脏瓣膜病再次手术的治疗策略,广东省人民医院广东省心血管病研究所卢聪,中国瓣膜外科发展史中的几个里程碑,1954第一例闭式扩张术1958体外循环的首次应用1958第一例体外循环下二尖瓣直视分离术1965第一例瓣膜置换术,瓣膜外科发展史中的领军人物及科研院所,蔡用之：长海医院张宝仁：长海医院郭加强：阜外心血管病医院罗征祥：广东省人民医院,手术数量及再次手术问题,至2019年，每年瓣膜手术达6000例经过近10年的发展，现在每年的瓣膜手术估计在2-3万左右随着手术数量的增多，再次手术成为不可避免的问题,我院的经验,我院2019年至2019年瓣膜手术情况,我院的经验,2019年至2019年总瓣膜手术例数：6703例其中再次手术例数：499例，占7.4%再手术病人围手术期死亡率：8.8%,再次手术的原因分析,占比重最大的为：二尖瓣闭式扩张术后（64.5%）,国内其他医院再次手术的原因分析,风险及对策,再次瓣膜手术的风险比首次瓣膜手术的风险高病程长心功能差粘连、手术时间长出血针对不同的原因，其治疗方案及对策有所不同,闭式扩张及直视交界切开术后再狭窄,风湿性心脏病是导致瓣膜病变的首要原因再狭窄是必然结果，闭式扩张术后的症状缓解期一般在8-15年特点：病程长，常合并三尖瓣病变策略：再次成形换瓣：生物瓣（避免抗凝治疗）机械瓣,机械瓣功能障碍,机械瓣结构原因机械瓣梗阻：血管翳、纤维组织增生血栓形成：多发生于3年内,机械瓣功能障碍策略,血栓：内科溶栓外科再次手术治疗血管翳、纤维组织增生：再次手术治疗强调早期严格抗凝治疗，不同部位其抗凝标准有所不同：AVR：INR1.8-2.0MVR：INR2.0-2.5TVR：INR2.5-3.0,妊娠期机械瓣功能障碍,原因：（1）妊娠期高凝状态（2）担心华法林的副作用（3）在妊娠早期停用或换用其他抗凝药物,我院临床资料,2000年2月至2019年12月，妊娠期发生机械瓣功能障碍病人7例，年龄22-32岁，平均26.42.6岁风湿性心脏病5例，先天性心脏病2例心功能IV级4例，III级3例妊娠期28周5例，28weeksin4,28in2Thrombogenesisleadingtomechanicalvalveobstructioninallpatients,MechanicalvalvedysfunctioninpregnantwomenMethodsofsurgicalmanagement,Caesareansectionconcomitantwithre-replacementofmechanicalprostheticvalveMechanicalprostheticvalvere-replacementonordinarytemperaturecardiopulmonarybypasswithcontinuefetalheartratemonitoringCaesareansectionfollowedbyre-replacementofmechanicalprostheticvalve,MechanicalvalvedysfunctioninpregnantwomenResults,AllpatientsdischargedfromhospitalinwellconditionTwopatientswithgestationperiod28weekswhounderwentmechanicalprostheticvalvere-replacement,onefetusdiedandtheotheronesurvivedanddeliveredinmaturepregnancyFiveinfantsweredeliveredanddischargedingoodhealth,MechanicalvalvedysfunctioninpregnantwomenStrategiesofsurgicalmanagement,Dysfunctionofmechanicalvalve+gestationperiod6months？,DegreeofobstructionofmechanicalvalveCardiacfunctionGestationperiodandconditionoffetusDesireofpatientsandfamilymembersExperienceofcardiacsurgeonProfessionallevelofrelevantdepartment,MechanicalvalvedysfunctioninpregnantwomenFactorsimpactonmakingdecisionofmanagement,MechanicalvalvedysfunctioninpregnantwomenChallenging,ManyyoungwomenwhounderwentvalvereplacementwanttohavebabyIrregularanticoagulationtherapyduringpregnancyTheadverseimpactsofhypothermiaandCPBonfetusHowtopreventandmanagemechanicalvalvedysfunctioninpregnantpatientsHowtocooperatewithotherdepartment,eg.Neontologydepartment,obstetricsdepartment,LateTricuspidRegurgitationafterLeftCardiacValveReplacement,TricuspidregurgitationisoftenneglectedAdverseimpactonsurvival,NathJ,etal,JAmCollCardiol,2019;43,405,MechanismPersistentpulmonaryhypertensionAnnulardilatationAtrialfibrillationProgressionordevelopmentofrheumaticlesionsLimitationofDeVegasprocedureXuejunX,etal.HeartLungandCircul,2019;13,65,TRafterLeftCardiacValveReplacement,TRafterLeftCardiacValveReplacementStrategiesofmanagement,Re-repairDeVegasprocedureannuloplastyringValvereplacementmechanicalvalve：riskofthrombogenesisbioprostheticvalve：widelyusedinrecentyears,TRafterLeftCardiacValveReplacementRemainingQuestions,WhatisthemechanismoffunctionalTR?Howtoperformtricuspidrepair?Whichsizeandkindofringforwhichpatient?Whenshouldweperformarepair?Whenshouldwethinktovalvereplacement?Whylatedevelopmentoftricuspidregurgitationaftersuccessfulmitralsurgery?Howtopreventit?,FailureandComplicationofValveRepair,ValverepairisfarlessthanvalvereplacementinChinaRheumaticheartdiseaseisstilltheleadingcauseofvalvulardamageleadingtosurgeryinChinaPatientsoftenexperiencedpro-longedhistorybeforetheirfirstvisitsTechniquesofvalverepairarenotappliedwidelyWorryaboutreoperation,MethodsofsurgicaltreatmentRe-repairValvereplacementTranscathetervalveimplantationvalve-in-ring,FailureofValveRepair,FailureofValveRepairHowtoprevent?,IndicationandcontraindicationofmitralrepairApplysuitablemethodsofmitralrepairTEE,FailureofValveRepairLive3DTEEforMitralRepairSurgery,Prospection,Withthedevelopmentofsurgicaltechniques，theincidenceofreoperationandthemortalityofr