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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. cases. 1990 - 2007 西京医院心血管外科手术量情况. 7%. 8%. 10%. 52%. 23%. 2007 年西京医院 3225 例心脏手术分布图. 人工瓣膜的优缺点. 优 点. 缺 点. 需终身抗凝 抗凝相关并发症. 结构故障少 无须再次手术. 瓣膜钙化 瓣膜衰败 需再次手术. 优异的血流动力学 无需抗凝治疗. 982. 9143. - PowerPoint PPT Presentation
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机械及生物主动脉瓣机械及生物主动脉瓣
---- 病人选择及手术方式实施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,金振晓等易定华,俞世强,刘金成,金振晓等
2008 年 12 月 上海
cases
1990 - 2007 西京医院心血管外科手术量情况
0
500
1000
1500
2000
2500
3000
3500
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
体外循环例数 非体外例数
例数
年
CHD
VALVE
CABG
AORTA
OTHER52%23%
8%
7%
10%
2007 年西京医院 3225 例心脏手术分布图
人工瓣膜的优缺点
优 点
结构故障少 无须再次手术
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
瓣膜钙化
瓣膜衰败
需再次手术
9143
982
1988 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 2 mm
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 27
mm 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
生物瓣膜钙化和衰坏较快,选择机械瓣 再次手术置换较大瓣膜 小儿基本可以接受华法林抗凝治疗 应当尽量通过成形来修复
婴幼儿瓣膜置换的选择
讨 论
首次手术治疗时选择的标准和非感染性心内膜炎患者相似
对复发的感染性心内膜炎的患者应使用生物瓣膜
在有广泛的瓣环缺损和心室主动脉分离时,采用同种主动脉根部置换
合并感染性心内膜炎的瓣膜置换选择
同期置换多个瓣膜的选择
避免使用不同种类瓣膜进行同期置换
育龄妇女瓣膜置换的选择
对有生育要求的年轻女性力争进行瓣
膜成形术,必要时推荐应用生物瓣膜
进行瓣膜置换。
特殊情况下人工瓣膜的选择
双瓣同期置换术
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
Yi Dinghua, Liu Jincheng, Yu Shiqiang, Yi Dinghua, Liu Jincheng, Yu Shiqiang, Yang Jian, Jin Zhenxiao, et alYang Jian, Jin Zhenxiao, et al
Institute of Cardiovascular disease of PLA
Department of Cardiovascular Surgery, Xijing
Hospital
Fourth Military Medical University
Patient Selection and Practice Patterns:Patient Selection and Practice Patterns:Mechanical versus Bioprosthetics Aortic ValvesMechanical versus Bioprosthetics Aortic Valves
cases
Cardiac Operations Performed in the Department of Cardiovascular Surgery in Xijing Hospital from 1990 to 2007
1999 2000 2001 2002 2003 2004 2005 2006 2007
0
500
1000
1500
2000
2500
3000
3500
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
体外循环例数 非体外例数
例数
年
CHD
VALVE
CABG
AORTA
OTHER52%23%
8%
7%
10%
Distribution of different types of 3225 cardiac operations in the Department of Cardiovascular Surgery Xijing Hospital in 2007
Advantage Disadvantage
Advantage and disadvantage of artificial valve
Life-long
anticoagulation
Related complications
Few structural
deterioration
Free from re-
operation
Good haemodynamics Free from anticoagulati
on
Calcification
Deterioration
Re-operation
9143
982
Distribution of 10125 artificial valves used in 8206 patients in Xijing Hospital from May, 1988 to May, 2008
Results
Follow-up rate was 91.2%
Accumulated follow-up time is 49232 patients•year
Complications Mechanical (Patients•year)
Bioprosthetics
(Patients•year) Thromboembolisis 1.8 % 0.21 % Bleeding 2.1 % 0.48 %
90.1%
86.4%
69.1%
Kaplan-Mier Survival Curve of bioprosthesis during 15 years’ follow-up
89.2%
84.5%
68.6%
Kaplan-Mier Survival Curve of mechanical valve during 15 years’ follow-up
< 60 years old
Comorbided with atrial fibrillation
Risk factor for thromboembolism
Infective endocarditis (For the first time)
Principle for selection of mechanical or bioprosthetic valves in Xijing Hospital
Mechanical valve preferred
> 60 years old
Comorbided without atrial fibrillation
No risk factor for thromboembolism
Tricuspid valve replacement
Female patients with fertility require
Principle for selection of mechanical or bioprosthetic valves in Xijing Hospital
Bioprosthetic valve preferred
Indexed effective orifice area
( IEOA ) =0.85
2 mm smaller than the radiu
s of the aortic annulus
>19mm in patients with sma
ll aortic root
Our sizes were smaller than t
hat of western countries
Selection of the size for artificial valves
Aortic valve
Distribution of the size of 1422 aortic valve replaced in our hospital
Most selected mitral valve in adu
lts is 27mm
Smaller valve preferred in patien
ts with small left ventricle or hea
rt insufficiency
22 cases of valve replacement in
patients under 45kg
3 cases of 19mm valve replacem
ent in 3-12 months’ old infantsDistribution of the size of 5321 mitral val
ve replaced in our hospital
Mitral valve
Selection of the size for artificial valves
Discussion
Aortic valve 4mm smaller than mitral valve is recommended. I.E.
27mm M + 23mm A ; 25mm M + 23mm A When the aortic valve is small, big mitral v
alve should be avoided. Otherwise left ventricle overload will occur, leading to left heart failure.
Match of concomitant Mitral and Aortic valve replacement
Due to the calcification and deterioration of bioprosthesis, mechanical valve is preferred
Need for re-operation Valvuloplasty should be the first choice in childr
en Walfarin can usually be well tolerated in childre
n
Choice of valve replacement in infants
Discussion
The criteria for first time is same to ordinary patients
For re-occurred patients, bioprosthesis is preferred
For patients with extensive annular defect or the detachment between ventricle and aorta, root replacement would be selected
Choice of valve replacement in patients with endocarditis
Discussion
Concomitant multi-valve replacement
Avoid select valves of different types For young female patients with fertility r
equire Valvuloplasty is the first choice
Bioprosthesis can also be used when nec
essary
Choice of valve replacement in special situation
Concomitant double-valve replacement
Concomitant four-valve replacement
Congenital mitral valve insufficiency
Valve replacement in infants