Search

心血管手术风险预测研究与现状

手术风险预测模型是术前风险评估的重要工具，在外科临床工作中起着十分重要的作用，它对手术适应证的确定、手术相关危险因素的识别、评分标准的确立以及不同中心手术疗效的比较都具有十分重要的意义。而心脏外科手术因受到多方面因素的影响，其围术期的病死率仍较高。因此，在心脏外科临床研究领域很早便开展了有关建立手术风险预测模型的工作。 从国外研究背景来看，至1986年美国胸外科医师协会（The Society of Thoracic Surgeons，STS）公布的第一个心脏术后风险预测模型Parsonnet评分系统起，近20余年间在北美、欧洲及澳洲等地区相继出现了一系列高质量的手术风险预测模型。目前，被广泛应用的预测评分系统包括Parsonnet评分系统、欧洲心脏手术风险评估系统(the European System for Cardiac Operative Risk Evaluation ，EuroSCORE)、STS评分系统及美国心脏病学院/美国心脏协会（American College of Cardiology/American Heart Association，ACC/AHA）评分系统等。  而从国内研究现状来看，由北京阜外心血管病医院牵头联合全国32家心脏中心率先建立了首个国内大型多中心冠状动脉旁路移植术数据库及中国冠状动脉旁路移植术评分系统（SinoSCORE），同时完成了EuroSCORE对我国冠心病患者手术死亡预测能力的评价研究。但目前国内有关其他重要预测评分系统的评价研究以及对我国心脏瓣膜病患者手术风险预测评价研究的报道仍相对缺乏。北京阜外心血管病医院撰写的“不同心脏手术风险预测评分系统对中国冠状动脉旁路移植术后患者早期死亡的预测”论文，收集了该院2006年11月至2007年12月年间1 559例18岁以上施行单纯冠状动脉旁路移植术（CABG）患者的临床资料，参照STS评分系统、EuroSCORE、Parsonnet评分系统和ACC/AHA评分系统的评分及分组方法，采用HosmerLemeshow(HL)卡方检验及受试者工作特征（ROC）曲线下面积的统计学方法，完成了4种预测评分系统对我国行CABG患者早期死亡的预测评价研究，提示除STS评分系统对单纯CABG患者具有潜在的临床应用可能外，其他3种评分系统对单纯CABG术后早期死亡风险预测的准确性均较差。而上海第二军医大学长海医院撰写的“EuroSCORE模型对心瓣膜手术患者死亡风险的预测”论文，收集了该院1998年1月至2008年12月年间4 155例各类心脏瓣膜手术患者的临床资料，参照additive和 logistic EuroSCORE评分及分组方法，采用HL卡方检验及ROC曲线下面积的统计学方法，完成了EuroSCORE模型对心脏瓣膜手术患者在院死亡率的预测评价研究，提示EuroSCORE模型对该中心心脏瓣膜手术患者死亡风险预测的准确性较差。 两篇论文的研究均表明，目前国际上公认的几种重要的手术风险预测评分系统对我国心脏手术患者术后早期死亡的预测效能均存在不同程度的限制，而建立适合我国患者心脏手术的风险预测模型及评分标准具有必要性及重要性。讨论中作者均提出由于地域及人种的差异，我国心脏手术患者的病因学与国外患者存在较大的差异，尤其是心脏瓣膜病的流行病学特点差异，是导致最终结论差异的重要原因。但两篇论文也同样存在一定的研究局限： （1）均为单中心研究，虽样本量较大，但我国地域广大，各心脏中心接诊患者的病种、病情轻重程度及诊疗技术仍存在一定差异，故应用单中心研究对研究结论的正确性可能会造成不同程度的影响，因此仍需扩大样本量以得到更为准确的研究结论。（2）临床资料的收集以回顾性研究为主，且各临床变量的采集标准国内尚未统一，评分系统中变量的定义也存在一定差异，故每例患者评分预测的真实结果存在一定偏倚，对研究结论的准确性也存在影响。随着对手术风险预测模型的临床研究重视程度不断地增加，目前我国各心脏诊疗中心均已开始建立各自的心脏外科临床数据库，故建议加强国内相关临床研究的学术交流，统一数据库建立方法及临床变量的采集标准，建立符合我国国情的大型多中心心脏外科临床数据库，用以进一步规范我国心脏手术术前风险评估工作，这对制定相关临床指南以及进一步降低心脏手术 在院病死率及并发症发生率，必将起到非常积极的作用。综合国内外心脏手术风险预测模型的建立方法和纳入因素，目前均没有考虑到“人”的因素，也就是说同样的手术，由技术水平不同的医师或医院实施，其结果实际上存在很大的差异，而术后处理不恰当也可造成较大的差异。因此，目前在制定手术风险预测模型时，实际上是建立在外科医师手术技术水平相当、正确实施手术和正确处理患者的基础上。就当前而言，要将医师的水平和能力考虑在内，确实非常困难，实际上也无法做到，这也是目前各种风险预测模型所存在的共同限制。　　“不同心脏手术风险预测评分系统对中国冠状动脉旁路移植术后患者早期死亡的预测”和“EuroSCORE模型对心瓣膜手术患者死亡风险的预测”两篇论文均紧紧把握了目前我国心脏外科术前风险预测模型相关临床研究的重要方向，研究目标明确，样本量较大，科研设计合理，统计学方法正确，结论可信，具有较高的学术价值和社会价值，对临床工作具有一定的指导意义，希望在今后的研究工作中能不断完善。

Current issues should be emphasized on preoperative evaluation of heart valvular disease

Preoperative evaluation is crucial for heart valvular surgery. This article discusses some issues that need to be emphasized: the impact of hypertension on the severity of aortic valve lesions, and how to improve the accuracy of clinical assessment; the identification of functional tricuspid regurgitation, in order to choose the appropriate surgical technique; the need for right ventricular function testing, and the use of risk scoring models, to better grasp surgical timing and indications and improve efficacy; and the importance of evaluating atrial mitral and/or tricuspid regurgitation complications in chronic atrial fibrillation, and making rational choices for interventional and surgical treatment.

Progress in Evaluating Quality of Life in Postoperative Patients with Valvular Heart Disease Using SF-36 Health Survey

Abstract：　Quality of life （QOL） refers to an individual’s perception and subjective evaluation of their health and well-being, and has become an important index to evaluate the outcomes of clinical treatment in the last past decades. There are a large number of different instruments to evaluate QOL, and the 36-Item Short Form Health Survey （SF-36） is currently one of the most widely used instruments. In recent years, SF-36 has been used to evaluate QOL of valvular heart disease patients to investigate the risk factors those influence their postoperative QOL, provide more preoperative evaluation tools for clinical physicians, and improve postoperative outcomes of patients with valvular heart disease. However, it is now just the beginning to use SF-36 to examine QOL of valvular heart disease patients. Because of significant differences in sample size, follow-up period, country and culture, current research has some controversial results. This review focuses on the progress in evaluating QOL in postoperative patients with valvular heart disease using SF-36.

The Advancement of Early Enteral Nutrition in Critical Patients after Cardiopulmonary Bypass

Early enteral nutrition after cardiopulmonary bypass (CPB) has been shown to have beneficial effects on intestinal integrity, lower mortality and also on the patient’s immunocompetence. Even in critical patients after CPB, enteral nutrition should be reasonable to start early and also be supplemented by parenteral nutrition in order to meet energy requirement. We conclude that enteral nutrition is preferable in the majority of patients with severe hemodynamic failure, but gastrointestinal complication and hypocaloric feeding should be simultaneously noticed. This paper comprehensively described enteral nutrition’s protective mechanism and effects on digestive system, enteral nutrition’s implementing methods after CPB, and problems or prospects needing attention in execution.

心内直视手术后气管切开及其处理方法

胸主动脉夹层的再次手术治疗

目的分析胸主动脉夹层术后复发的原因,总结其外科治疗经验。方法回顾分析4例主动脉夹层术后复发患者行手术治疗的临床资料,其中行Bentall手术2例,胸主动脉置换术2例。结果全组无手术死亡,术后并发呼吸及肾功能不全1例,声音嘶哑1例。结论胸主动脉夹层术后再发与原发病、血压控制不良、第1次手术适应证的选择有关,急性DeBakeyI、II型患者应行急诊手术治疗。

Fifteen Years Follow-up of 259 Patients of Mitral Valve Replacement with Chinesemade C-L Pugesturt Tilting Disc Mechanical Valve Prosthesis

Abstract： Objective To evaluate the early and late results of mitral valve replacement with home made C-L pugesturt tilting disc and analyse the factors which impact on the therapeutic effect，so as to elevate the operative effect. Methods A retrospective study was made on the result of clinical data and longterm followup of 259 patients who had undergone the Chinesemade C-L pugesturt tilting disc mechanical valve replacement from October 1991 to November 2006. Results The data showed that there were 12 patients died in the duration of hospital stay.The hospital mortality was 4.63% (12/259).There were no mechanical valverelated complication in the earlier postoperative period.The mortality fell to 2.59% since 1996.Among the 235 patients,12 patients were lost during the followup,the rate of followup was 95.1%(235/247).The time for followup was 9.77±3.09 years. There were 26 late deaths.During the follow-up,death associated with the deterioration of valve structure were not observed. The 5 years, 10 years and l5 years survival rates were 86.80%±2.30%, 78.20%±3.33% and 55.23%±4.34% respectively; the thromboembolic event free rates for 5 years, 10 years and l5 years were 95.95%±0.74%, 92.52%±4.11% and 80.52%±4.11% respectively; the anticoagulant related bleeding free rates for 5 years, 10 years and l5 years were 94.64%±1.75%, 89.55%±3.28% and 79.39%±4.43% respectively.There were 141 patients(67.46%) in New York Heart Association(NYHA) classⅠ, 56 patients(26.79%) in class Ⅱ, 10 patients(4.78%) in class Ⅲ and 2 patients(0.95%) in class Ⅳ. Conclusion The results of follow-up for 15 years suggest that the Chinesemade C-L pugesturt tilting disc medical mechanical valve is a reliable and safe choice for mitral valve replacement.

肺动脉瓣球囊扩张术后瓣叶损伤致再狭窄一例

应用自体心包瓣置换术治疗主动脉瓣病变

目的　报告无支架自体心包瓣置换主动脉瓣手术的临床应用效果。　方法　11例单纯主动脉瓣病变患者行自体心包瓣置换主动脉瓣手术，术后定期随访。　结果　11例均存活，顺利出院，随访时间5～30个月，平均随访时间24.2±5.6个月。1例因中等量反流而行二次手术，其余10例心包瓣膜功能良好。　结论　该手术是一种治疗单纯主动脉瓣病变较为理想的方法，术后患者无需长期抗凝，手术近期效果满意，远期效果有待进一步随访。

Mild Functional Tricuspid Regurgitation Approach to Mitral Valve Repair

Abstract: Objective To explore whether clinically mild functional tricuspid regurgitation should be addressed at the time of mitral valve repair (MVP) for moderate or severe mitral regurgitation due to myxomatous degeneration. Methods We retrospectively analyzed the outcomes of 135 patients with moderate or severemitral regurgitation due to myxomatous degeneration with mild functional tricuspid regurgitation. All patients were treated between January 1993 and March 2008 in the Department of Cardiothoracic Surgery of Changhai Hospital, the Second Military Medical University. We divided the patients into a MVP group (n=76) and a MVP+tricuspid valvuloplasty (TVP) group(n=59) according to whether they underwent combined TVP, and observed the perioperative mortality rate, degree of tricuspid regurgitation, and compared survival rate, and freedom from longterm moderate or severe tricuspid regurgitation after operation. Cox regression was used to analyzethe risk factors for longterm moderate or severe tricuspid regurgitation after operations. Results (1) There were no deaths during the perioperative period, and postoperative transthoracic echocardiography of all patients indicated that tricuspid regurgitation was mild or less. (2) Survival rate at 5 years, 10 years after operations in MVP group was 98.4%, 95.0%, respectively, and survival rate at 5 years, 10 years after operations in MVP+TVP group was 100.0%, 93.7%, respectively, and there was no significant difference in the survival rate after operations between the two groups(P=0.311), butthere was a significant difference in the freedom from longterm moderate or severe tricuspid regurgitation after operations between the two groups (P=0.040). Multivariate Cox regression showed that preoperative pulmonary artery pressure gt;30 mm Hg (95%CI 1.127 to 137.487, P=0.040 )and atrial fibrillation (95%CI 1.177 to 23.378, P=0.030) wereindependent risk factors for longterm moderate or severe tricuspid regurgitation afteroperations.Conclusion TVP is necessary for most patients undergoing MVP for moderate or severe mitral regurgitation due to myxomatous degeneration who have coexistent mild functional tricuspid regurgitation, especially those patients with preoperative pulmonary artery pressure gt;30 mm Hg or atrial fibrillation.