机械及生物主动脉瓣-病人选择及手术方式实施

第四军医大学西京医院心血管外科易定华，俞世强，刘金成，金振晓等2008年12月上海cases52%23%8%7%10%人工瓣膜的优缺点优点缺点需终身抗凝抗凝相关并发症优异的血流动力学无需抗凝治疗91439821988年5月至2008年5月西京医院8206例患者应用10125枚人工瓣膜种类分布总体随访率为91.2%累及随访达49232病人•年并发症机械瓣(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%生物瓣置换15年随访的Kaplan-Mier生存曲线89.2%84.5%68.6%机械瓣置换15年随访的Kaplan-Mier生存曲线年龄<60岁

并发房颤

有血栓栓塞的风险首次感染性心内膜炎的患者西京医院选择人工瓣膜的原则选择机械瓣年龄>60岁不伴有房颤无血栓栓塞的风险进行三尖瓣置换时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选择生物瓣有效开口面积指数（IEOA）=0.85小于主动脉直径2mm在小主动脉根患者选择≥19mm的人工瓣膜，必要时根部加宽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

人工瓣膜的大小选择我院1422例主动脉瓣置换的型号分布图主动脉瓣成人二尖瓣一般置换多为27mm瓣膜合并左室小或者左心功能不全，应使用较小型号的瓣膜45kg以下小左室患者22例3-12月婴儿应用19mm瓣膜3例人工瓣膜的大小选择我院5321例二尖瓣置换的型号分布图二尖瓣讨论推荐选择主动脉瓣小于二尖瓣4mm，如二尖瓣27mm＋主动脉瓣23mm；或二尖瓣25mm＋主动脉瓣21mm。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，易于出现左心功能衰竭。二尖瓣、主动脉瓣同期置换的瓣膜匹配讨论婴幼儿瓣膜置换的选择讨论合并感染性心内膜炎的瓣膜置换选择特殊情况下人工瓣膜的选择四瓣膜同期置换(西京医院)二尖瓣发育不良并重度关闭不全婴幼儿换瓣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