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瓣膜外科發(fā)展史中的幾個(gè)里程碑蔡用之：長海醫(yī)院張寶仁：長海醫(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4例，III級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)易受忽視的問題顯著影響長期生存率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