二尖瓣置換術(shù)幾個(gè)問題的商榷課件

1、二尖瓣置換術(shù)幾個(gè)問題的商榷張寶仁第二軍醫(yī)大學(xué)長(zhǎng)海醫(yī)院胸心外科上海市成人心血管臨床醫(yī)學(xué)中心中國(guó)人民解放軍心胸外科研究所心臟瓣膜手術(shù)409524例主動(dòng)脈瓣手術(shù)216245例，死亡率5.7二尖瓣手術(shù)120641例，死亡率7.7居第二位，死亡率高STS的資料（19942003年）心臟瓣膜手術(shù)主動(dòng)脈瓣手術(shù)1026例，死亡率3.25二尖瓣手術(shù)3416例，死亡率4.30居第一位，死亡率高上海長(zhǎng)海醫(yī)院資料（1978-2006年）風(fēng)濕性瓣膜病80瓣膜置換術(shù)7085病理特點(diǎn)二尖瓣瓣膜與瓣下結(jié)構(gòu)嚴(yán)重受損合并房顫發(fā)生率高（70）合并三尖瓣的病變多（67）上海長(zhǎng)海醫(yī)院二尖瓣病變病因人造瓣膜的選擇與匹配保留瓣下結(jié)構(gòu)的問題

2、合并巨大右心房的處理重視合并房顫的處理合并三尖瓣病變的處理鈣化瓣環(huán)的處理二尖瓣置換術(shù)應(yīng)重視的問題Zam報(bào)告884例術(shù)后Ech，隨訪5.14.1年P(guān)PM定義（有效開口面積指數(shù)）300ml）的處理巨大左房風(fēng)濕性二尖瓣病變合并房顫高達(dá)5079心功能不全進(jìn)一步加重增加血栓栓塞的發(fā)生率影響術(shù)后近、遠(yuǎn)期效果射頻消融法冷凍消融法四、重視合并房顫的處理有效率7080鈣化二尖瓣瓣環(huán)的處理謝謝Controversies and Thoughts in Mitral Valve ReplacementDepartment of Cardiothoracic SurgeryChanghai HospitalSecon

3、d Military Medical University Zhang Bao-renNO.mortalityAV procedure10263.25%MV procedure3416 4.3%Overview from Changhai Hospital China (1986-2006)Profile of MV disease in China The most common cause is chronic rheumatic mitral valve disease (80%) The most common procedure is mitral valve replacement

4、 (70%80%) Pathologic characteristics of rheumatic findingsFibrosis and calcification of mitral valve apparatusCombining chronic atrial fibrillation (70%)Combining tricuspid valve regurgitation (67%)From Shanghai Changhai hospital databaseSpecial problems about MV procedure the impact of patient-pros

5、thesis mismatch preservation of the subvalvular apparatus the management of chronic atrial fibrillation the management of giant left atrium the management of combined tricuspid regurgitation the management of calcified annulus patient-prosthesis mismatch (PPM) PPM in the mitral position an old conce

6、pt and new evidences the threshold value for mitral PPM is high than for aortic PPM mitral PPM is considered moderate when indexed EOA is 1.2 1.3cm2/m222Impact of PPM on cardiac function cardiac insufficiency pulmonary artery hypertensionPreservation of subvalvular apparatus preservation of posterio

7、r leaflets preservation of Chordae to both leaflets artificial tendineae METHODSPreservation of subvalvular apparatusManagement of giant left atriumCriterion: LA 300ml adverse effect: compressing ventricles and lungoptimal plication procedure could improve ventricular and lung functionGiant Left Atr

8、iumManagement of atrial fibrillation The most common complication of MS (5070%) adverse effect: impairing ventricular function methods: modified maze op. and modified ablationManagement of tricuspid regurgitation for more than 25 years to aware of TR complicated in large number of RHD TR is progressive disease after MVR Tricuspid annuloplasty must be done when annulus diameter is 21mm/m2 Make every effort to avoid doing TV replacementManagement of calcified annulus prevalence more than 1/3 posteriomedial annulus involved treatment completely removing the calcificatio