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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.

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。

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.

The analysis of mitral valve replacement on the old

Objective To study effects of mitral valve replacement(MVR) on the old with mitral valve diseases(MVD). Methods The documents of 265 cases undergoing MVR were reviewed, who aged 60 years old or over between June 1991 and June 2003. Demographices, clinical preoperative conditions, indications to surgery, early postoperative course and long-term outcome were collected via hospital documents and outpatient follow-up. Many risk factors were analysed. Results Follow-up rate amounted to 93.7%(236/252). The mortality was 4.9% (13/265) within 30 days. Heart failure and renal failure were the main cause of death. Compared with younger patients(lt;60 years old), long-term survival rate was lower in the old, 5-year 87.52% vs 96.84%, 10-year 81.23% vs 94.87%. There were 15 late deaths(0.17% case/M), most of whom died of heart failure, cancers and lung infections. Risk factors for MVR in the old included New York Heart Association class Ⅳ, diabetes, and lung incompetence. Conclusions The patients with MVD over 60 years old tended to present high postoperatively mortality and morbidity.

Protective Effect of Blood Cardioplegia with Leukocyte Depletion on Myocardial Reperfusion Injury

Objective To elucidate the protective effect of leukocyte depletion on the myocardium during the settings of myocardial reperfusion injury. Methods Twenty patients undergoing cardiopulmonary bypass with continuous infusion of blood cardioplegia were randomized into two groups:the control group (n=10) with no leukocyte depletion filter used, and the experimental group (n=10) with the use of leukocyte depletion filter on the bypass circuit. The blood cells count before and after the filtration were measure...

二尖瓣脱垂合并感染性心内膜炎的临床分析

目的 总结二尖瓣脱垂(mitral valve prolapse，MVP)合并感染性心内膜炎(infectous endocarditis,IE)的临床特点、手术时机和手术前后超声心动图的特点。 方法 2000年6月至2007年12月我科共收治原发性MVP合并IE患者45例，术前心功能分级(NYHA)Ⅱ级15例，Ⅲ级21例，Ⅳ级9例。术前血培养阳性率为40％，最常见的为草绿色链球菌(38.9％)。术前超声心动图检查发现腱索断裂3例，急性左心功能衰竭9例，有脑血管意外6例。术中根据瓣膜质量和损伤情况，行二尖瓣成形术5例，二尖瓣置换术35例；同期行主动脉瓣置换术6例，三尖瓣成形术19例，冠状动脉旁路移植术1例。 结果 术前死亡5例，3例死于脑血管意外，2例死于多器官功能衰竭；术后早期死亡1例，死于肾功能衰竭；长期生存39例，术后随访6个月～8年(平均2.7年)，无晚期死亡，超声心动图复查未见心内膜炎复发及瓣周漏。 结论 MVP合并IE的临床特点为起病隐匿，心力衰竭、体循环栓塞(尤其脑栓塞)等并发症的发生率较高。对中至重度关闭不全的MVP合并IE患者应早期治疗。

Surgery Treatment of Chronic Moderate Ischemic Mitral Regurgitation in Coronary Artery Disease

Objective To investigate the treatment and prognosis of moderate ischemic mitral regurgitation (IMR) in coronary artery disease(CAD). Methods From January 1998 to May 2006, 28 patients of CAD with moderate IMR underwent coronary artery bypass grafting (CABG) and mitral valve plasty(MVP, 24) or mitral valve replacement (MVR,4). The Reed method were used in 9 cases, the annuloplasty ring were used in 15 cases. Mechanical valve were implanted in 1 case and biological valve in 3 cases. Results There was no operative or hospital death. Twentysix patients were followed up to a mean period of 41 months. There were two late death(one was MVP, the other was MVR). In MVP cases, nineteen patients were in New York Heart Association (NYHA) functional class Ⅰ and Ⅱ, 3 in class Ⅲ, which was better than that of preoperative one. Ultrasonic cardiography (UCG) examination showed no mitral regurgitation in 5 cases, mild in 7, light in 6, moderate in 3, severe in 1. Left atrial volume (LAV) and left ventricular enddiastolic volume (LVEDV) were 54.1±12.7ml and 60.9±14.8 ml, decreased more significantly than that preoperatively (Plt;0.05). In MVR cases, 2 cases were survival and followed. One patient was in NYHA functional class Ⅰ, 1 in class Ⅱ, which was better than that of preoperative one. Conclusion Moderate IMR with CAD should be treated carefully. MVP with annuloplasty ring have better early results. For patients with bad heart function and abnormal left ventricular wall motion, the late results need more studies.

心内直视手术后气管切开及其处理方法

Longterm Results of Tetralogy of Fallot in Adults

Abstract: Objective To evaluate the longterm results of surgical treatment of tetralogy of Fallot (TOF) in adults and discuss the perioperative treatment skills. Methods From January 2000 to March 2008, 149 patients older than 14 years with tetralogy of Fallot received surgical treatment in Changhai Hospital. Among the patients, there were 78 males and 71 females with ages ranged from 14 years to 53 years and the average age was 26.3 years. Twenty patients had previous pulmonary arterial shunts before radical treatment. A total of 129 patients underwent primary radical treatment. Thirtyeight patients received a right ventricular outflow tract patch, 107 patients had transannular patch, and 4 patients had homograft aorta with valves. Results Hospital mortality was 4.0%(6/149). Four patients died of low cardiac output syndrome (LCOS), and multiple organ failure, and 2 patients died of acute renal failure. The postoperative complications included pleural effusion in 11 patients, pulmonary edema in 10 patients, severe LCOS in 9 patients, severe cardiac arrhythmia in 7 patients, reoperation for excessive bleeding in 7 patients, reintubation in 6 patients, and residual ventricular septal defect (VSD) in 5 patients (two of them had reoperation for residual VSD repair and 2 received transcatheter closure of VSD). One hundred and thirtyfour patients were followed up for 3 to 102 months (47.2±28.6 months) with a followup rate of 93.7%(134/143). Late death occurred in 2 patients, one of whom died of secondary infective endocarditis and the other had a sudden death 29 months after operation. During the followup, one patient had residual VSD (2 mm), but had a normal life. The peak systolic right ventricletopulmonary artery pressure gradient exceeded 40 mmHg in 4 patients. Two patients had severe pulmonary regurgitation. A total of 132 patients survived and had an improved life. One hundred and twentyone patients had class Ⅰ heart function (NYHA), and 11 patients in class Ⅱ. Conclusion The pathophysiologic conditions of the patients with tetralogy of Fallot in adults are very complicated due to longterm right ventricle outlet stricture and chronic hypoxia. Preoperative evaluations and postoperative treatment of complications are necessary. The systemicpulmonary arterial shunts should be performed when hypotrophy of the pulmonary arteries or left ventricles exists. Repair of tetralogy of Fallot in adults has acceptable morbidity and mortality rates with goodlongterm outcomes.