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合并心脏恶病质瓣膜病的外科治疗

目的 为提高合并心脏恶病质瓣膜病患者外科治疗的成功率，探讨其围术期处理的特点。方法 符合心脏恶病质综合征诊断标准的21例心瓣膜病患者接受了手术治疗，其中二尖瓣置换术14例，主动脉瓣及二尖瓣置换术7例，同时三尖瓣成形术16例。结果 发生并发症13例，分别为低心排血量综合征、室性心律失常和多器官功能衰竭等；死亡6例，主要死亡原因为多器官功能衰竭。结论 合并心脏恶病质瓣膜病患者的外科治疗应注意围术期处理；术中应重视三尖瓣功能纠正及左、右心房折叠；术后注意低心排血量的治疗，积极防治多器官功能衰竭，加强营养支持。

Surgical Therapy for Valve Diseases Combined with Coronary Heart Diseases in Patients Over or Below 70 Years Old

Surgical Therapy for Valve Diseases Combined with Coronary Heart Diseases in Patients Over or Below 70 Years Old YU Lei, GU Tianxiang, SHI Enyi, XIU Zongyi, FANG Qin, ZHANG Yuhai. (Department of Cardiac Surgery, The No. 1 Hospital of China Medical University, Shenyang 110001, P.R. China)Corresponding author: GU Tianxiang, Email: cmugtx@sina.comAbstract： Objective To summarize the experiences of valve replacement combined with coronary artery bypass grafting (CABG) in senile patients by comparing clinical outcomes of valve diseases combined with coronary heart diseases in patients over or below 70 years old. Methods We retrospectively analyzed the clinical data of 49 patients who received valve replacement combined with CABG in our department from May 1999 to December 2007. Based on the age, the patients were divided into ≥70 years group (17 cases) with its patients at or above 70 years old and lt;70 years group (32 cases) with its patients younger than 70. The percentage of chronic obstructive pulmonary diseases (COPD) before surgery in ≥70 years group was higher than that in lt;70 years group(Plt;0.05). No significant difference was found in the other relevant factors between the two groups. The clinical index of patients in the two groups were compared and analyzed. Results There were significant differences between the two groups in such factors as the percentage of biovalve use (82.4% vs. 12.5%, χ2=23.311, P=0.000), the time of mechanic ventilation (34.5±29.3 h vs. 18.0±16.1 h, t=-2.542,P=0.014), the time of ICU stay (4.4±1.5 d vs. 3.3±0.7 d, t=-3.522, P=0.001), the time of hospital stay (21.4±7.7 d vs. 18.1±1.8 d, t=-2.319, P=0.025), the percentage of IABP use (29.4% vs. 6.3%, χ2=4.862, P=0.037), the percentage of pulmonary function failure (35.3% vs. 6.3%, χ2=6.859, P=0.009), the percentage of acute renal failure (23.5% vs. 3.1%, χ2=5.051, P=0.025), and the percentage of cerebrovascular accident (11.8% vs. 0.0%, χ2=3.933, P=0.048). There was no significant difference between the two groups in factors like the anastomosis of distal graft (2.5±3.1 vs. 2.4±14, t=0.301, P=0.758), the time of aortic occlusion (89.3±25.4 min vs. 88.5±31.0 min, t=0.108,P=0.913), the time of cardiopulmonary bypass (144.6±44.8 min vs. 138.3±52.9 min, t=0.164, P=0.871) and the mortality (5.9% vs. 6.3%, χ2=0.002,P=0.959). The perioperative myocardial infarction rate was zero in both groups. ≥70 years group patients were followed up for 2 months to 9 years with only 1 case missing. One patient who had undergone mechanic valve replacement died of cerebral hemorrhage 1.5 years after operation. Two died of heart failure and lung cancer 3 months and 6 years after operation respectively. For all the others, the cardiac function was at class Ⅰ to Ⅱ and their life quality was significantly improved. The follow up time of lt;70 years group was 1 month to 6 years and 5 cases were missing. Four patients who had undergone mechanic valve replacement died of complications in relation to anticoagulation treatment. One died of severe low cardiac output. Another died of traffic accident. Conclusion Surgery operation and effective perioperative treatment are key elements in improving surgery successful rate and decreasing mortality in patients with valve and coronary artery diseases. Valve replacement combined with CABG is safe for patients older than 70 years old.

Perioperative Management of Elderly Patients Undergoing Heart Valve Replacement

ObjectiveTo investigate clinical outcomes and summarize perioperative management experience of heart valve replacement (HVR)in elderly patients. MethodsWe retrospectively analyzed clinical data of 47 elderly patients undergoing HVR in Affiliated Hospital of Xuzhou Medical College from January 2011 to May 2014. There were 19 male and 28 female patients with their age of 60-79 years. There were 35 patients with rheumatic heart disease, 10 patients with degenerative valvular disease, and 2 patients with congenital bicuspid aortic valve. Preoperatively, there were 23 patients in NYHA functional class Ⅱ, 19 patients in class Ⅲ, and 5 patients in class Ⅳ. All the patients received HVR under cardiopulmonary bypass (CPB), and some patients received concomitant tricuspid valvuloplasty (TVP), left atrial thrombectomy or coronary artery bypass grafting (CABG). Postoperative mortality, morbidity and heart function improvement were evaluated. ResultsTwenty-seven patients received mitral valve replacement (MVR), 15 patients received aortic valve replacement (AVR), and 5 patients received MVR+AVR. Concomitantly, 4 patients received TVP, 3 patients received left atrial thrombectomy, and 6 patients received CABG. Operation time was 138-412 (196±52)minutes, CPB time was 48-301 (108±33)minutes, aortic cross-clamping time was 34-196 (87±21)minutes, and length of hospital stay was 12-31 (19±5)days. There was no intraoperative death, and 2 patients (4.3%)died postoperatively because of left ventricular failure and multiple organ dysfunction syndrome respectively. Twenty-three patients (51.1%)had postoperative complications including respiratory failure in 6 patients, pulmonary infection in 5 patients, arrhythmias in 5 patients, wound infection in 2 patients, pleural effusion in 2 patients, low cardiac output syndrome in 2 patients, and acute renal failure in 1 patient. Forty-five survival patients were followed up by telephone, online video and at the outpatient department for 1-32 months, and follow-up rate was 100%. There were 11 patients in NYHA functional classⅠ, 32 patients in class Ⅱ, and 2 patients in class Ⅲ. ConclusionAccording to clinical characteristics of elderly patients with valvular heart disease, meticulous surgical techniques and perioperative management can effectively reduce mortality and morbidity after HVR.

Surgical Treatment Experience of Emergency Surgery in Treating Rheumatic Valves Patients with Preoperative Ventricular Electrical Storm

目的探讨成人风湿性心脏瓣膜病术前并发心室电风暴（恶性室性心动过速、心室颤动）行急诊手术的疗效及体会。 方法回顾性分析2004年10月至2014年10月我院成人心脏瓣膜入院后突发恶性室性心动过速、心室颤动的患者6例，其中男2例，女4例，年龄35.0～64.0岁，平均49.8岁。6例患者均为风湿性心脏瓣膜病，二尖瓣中重度狭窄并主动脉瓣及三尖瓣中重度关闭不全2例，二尖瓣中重度关闭不全并三尖瓣中重度关闭不全4例，恶性心律失常发作后立即予艾司洛尔等药物控制，病情基本稳定后急诊手术。其中，行双瓣膜置换+三尖瓣成形术2例，行二尖瓣置换+三尖瓣成形术4例。 结果无围术期患者死亡，术后无心功能显著恶化、无多脏器功能衰竭、无恶性室性心律失常。术后1～2周24 h动态心电图提示室性早搏大于1 000次的2例，室性早搏500～1 000次1例，小于500次的患者3例，短阵室性心动过速2次的患者2例，短阵室性心动过速3次的患者1例。所有6例患者均安全出院，随访6个月至10年，无患者死亡。 结论急诊外科手术联合β受体阻滞剂在治疗成人心脏瓣膜疾病术前突发的反复恶性室性心动过速、心室颤动安全有效。

Progress of transcatheter heart valve intervention

At present, interventional therapy for structural heart disease is in a period of vigorous development. Among them, transcatheter aortic valve replacement, as a representative of the interventional treatment of heart valve disease, has made rapid progress, which is a bright spot in the field of cardiovascular disease. The future development of transcatheter tricuspid valve repair/replacement is also promising. With the availability of important clinical evidence, the indications of transcatheter aortic valve replacement have been extended to the full risk range of severe aortic stenosis. More and more data showed that transcatheter mitral and tricuspid valve interventions could effectively alleviate patients’ symptoms and improve their prognosis. Transcatheter valve interventions have developed rapidly and have made tremendous progress in China. This article will review and interpret the important progress in the field of transcatheter valve interventions.

重症心脏瓣膜病合并巨大左心室患者的外科治疗

风湿性心脏病与非风湿性心脏病患者三尖瓣置换的病例对照研究

目的分析三尖瓣置换患者的流行病学特征、治疗及随访情况，探讨提高三尖瓣置换疗效的策略。方法回顾性分析 2009 年 8 月至 2016 年 10 月 20 例在我院行三尖瓣置换患者的临床资料。男 4 例、女 16 例，年龄 31～73（54.4±2.2）岁。根据病因学分为风湿性心脏病组（14 例）及非风湿性心脏病组（6 例），比较两组患者术前情况、治疗方法、治疗结果及随访情况的差异。结果本组围手术期死亡 3 例，住院病死率 15.0%。死亡原因均为多器官功能衰竭。术后对 17 例出院患者进行了随访，随访率 100.0%，随访时间 1～84 个月，随访期间共有 2 例死亡。风湿性疾病组与非风湿性疾病组术前存在心房颤动/心房扑动心律（P=0.001）、术前有心脏手术史（P=0.017）、手术中是否进行主动脉阻断（P=0.032）差异有统计学意义。结论尽管风险较大，三尖瓣置换仍是针对器质性三尖瓣病变的有效手段，但需严格掌握手术指征及手术时机。风湿性三尖瓣疾病具有更多的危险因素，尤其是既往有左心瓣膜手术史继发三尖瓣关闭不全的患者。

The surgical treatment strategy and perioperative management of patients with heart valve disease complicated with severe chronic heart failure

ObjectiveTo summarize the individualized selection of surgical treatment strategies and the key points of perioperative management for patients with heart valve disease complicated with severe chronic heart failure.MethodsThe clinical characteristics of 5 male patients with valvular heart disease complicated with severe chronic heart failure (CHF) were analyzed retrospectively from June 2017 to October 2018 in Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, with an average age of 60.21 years.ResultsFive patients were given angiotensin receptor and neprilysin inhibitor (ARNI)-based anti-heart failure treatment after admission. The operation mode of these patients was decided to be valve replacement under cardiopulmonary bypass after individualized evaluation of patients’ improving symptoms. Three patients were treated with intra-aortic balloon pump (IABP) and continuous renal replacement therapy (CRRT) early after operation to assist patients in improving cardiac function. Five patients recovered oral anti-heart failure after awakening. All patients were discharged smoothly 2 weeks after operation.ConclusionIndividualized evaluation is needed for the choice of operation timing and mode, standardized preoperative treatment for heart failure, shortening the aortic blocking time during cardiopulmonary bypass, and early application of left ventricular adjuvant drugs or instruments are all important measures to help patients recover smoothly.

Current status of valvular heart disease in China

Valvular heart disease (VHD) is a common cardiac disease. Patients with severe VHD have a poor prognosis. With the development of minimal invasive treatments in VHD, especially with the wide application of transcatheter aortic valve replacement in aortic stenosis, these diseases have been regained attention. The disease spectrum and modes of treatment have also changed. However, we currently lack a large population-based VHD-related epidemiologic study in China. In this article, we will summarize the current status of VHD in China using available epidemiologic data.

Concomitant Tricuspid Annuloplasty for Patients with Tricuspid Valve Annulus Dilation and Mild Tricuspid Regurgitation Underwent Mitral Valve Replacement: A Randomized Controlled Trial

ObjectiveTo investigate effect of cardiac function and tricuspid regurgitation (TR) degree of concomitant tricuspid annuloplasty for patients with tricuspid valve annulus dilation and mild TR underwent mitral valve replacement (MVR), and provide an objective basis for clinical decision about concomitant tricuspid annuloplasty for patients with tricuspid valve annulus dilation and mild TR underwent MVR. MethodsA total of 36 patients who underwent MVR from April to October 2013 in Department of Cardiovascular Surgery, West China Hospital, Sichuan University were enrolled in this study. Preoperative echocardiography showed mild TR and tricuspid valve annular end-diastolic dimension (TVAEDD)/body surface area (BSA)>21 mm/m2. All the 36 patients were randomly divided into a tricuspid annuloplasty group (TAPG group, n=18, including 7 males and 11 females) and a no tricuspid annuloplasty group (NTAPG group, n=18, including 6 males and 12 females). One week and 6 months postoperative echocardiography were recorded. ResultsThere were no statistical differences in age, gender, heart rate, body surface area, preoperative cardiac function (NYHA), left atrium dimension (LAD), left ventricular dimension (LVD), maximal long-axis of RA (RAmla), mid-RA minor distance (RAmmd), right ventricle dimension (RVD2), left ventricular ejection fraction (LVEF), left ventricular fractional shortening (LVFS) between the two groups (P>0.05). Six-months postoperative left atrial-ventricular diameter significantly reduced than that before surgery in the two groups (P<0.05). In the TAPG group, six-months postoperative right ventricle dimension (RVD1), right ventricular wall thickness (RVWT), tricuspid valve annular end-diastolic dimension (TVAEDD), tricuspid valve annular end-systolic dimension (TVAESD) significantly decreased, while percent shorting of tricuspid valve annulus (PSTVA) did not change significantly (P>0.05), TR degree improved significantly (P<0.05), right ventricular fractional area change (RVFAC) and right ventricular ejection fraction (RVEF) significantly increased (P<0.05). In the NTAPG group, compared with preoperative data, six-months postoperative RVD1, RVWT significantly increased, TVAEDD, TVAESD, PSTVA did not change significantly (P>0.05), RVEF reduced significantly (P<0.05), RVFAC increased significantly but less than that in the TAPG group at the same period, constituent ratio of TR changed significantly (P<0.05), but postoperative moderate or more TR were recorded in 6 patients. ConclusionConcomitant tricuspid annuloplasty for patients with tricuspid valve annulus dilation and mild TR underwent mitral valve replacement (MVR) can help to decrease RVD1, RVWT, TVAEDD and TVAESD, improve the constituent ratio of TR, and increase RVFAC and RVEF.