心脏瓣膜病再次手术的治疗策略

心脏瓣膜病再次手术的 治疗策略,广东省人民医院 广东省心血管病研究所 卢聪,中国瓣膜外科发展史中的几个里程碑,1954 第一例闭式扩张术 1958 体外循环的首次应用 1958 第一例体外循环下二尖瓣直视分离术 1965 第一例瓣膜置换术,瓣膜外科发展史中的领军人物 及科研院所,蔡用之：长海医院 张宝仁：长海医院 郭加强：阜外心血管病医院 罗征祥：广东省人民医院,手术数量及再次手术问题,至1999年，每年瓣膜手术达6000例 经过近10年的发展，现在每年的瓣膜手术估计在2-3万左右 随着手术数量的增多，再次手术成为不可避免的问题,我院的经验,我院1997年至2007年瓣膜手术情况,我院的经验,1997年至2007年总瓣膜手术例数：6703例 其中再次手术例数：499例，占 7.4% 再手术病人围手术期死亡率：8.8%,再次手术的原因分析,占比重最大的为： 二尖瓣闭式扩张术后（64.5%）,国内其他医院再次手术的原因分析,风险及对策,再次瓣膜手术的风险比首次瓣膜手术的风险高 病程长 心功能差 粘连、手术时间长 出血 针对不同的原因，其治疗方案及对策有所不同,闭式扩张及直视交界切开术后再狭窄,风湿性心脏病是导致瓣膜病变的首要原因 再狭窄是必然结果，闭式扩张术后的症状缓解期一般在8-15年 特点：病程长，常合并三尖瓣病变 策略： 再次成形 换瓣 ：生物瓣（避免抗凝治疗） 机械瓣,机械瓣功能障碍,机械瓣结构原因 机械瓣梗阻： 血管翳、纤维组织增生 血栓形成：多发生于3年内,机械瓣功能障碍 策略,血栓：内科溶栓 外科再次手术治疗 血管翳、纤维组织增生：再次手术治疗 强调早期严格抗凝治疗，不同部位其抗凝标准有所不同： AVR：INR 1.8-2.0 MVR：INR 2.0-2.5 TVR：INR 2.5-3.0,妊娠期机械瓣功能障碍,原因： （1）妊娠期高凝状态 （2）担心华法林的副作用 （3）在妊娠早期停用或换用其他抗凝药物,我院临床资料,2000年2月至2006年12月，妊娠期发生机械瓣功能障碍病人7例，年龄22-32岁，平均26.4 2.6岁 风湿性心脏病5例，先天性心脏病2例 心功能IV级4例，III级3例 妊娠期28周5例，28周2例 机械瓣血栓形成，机械瓣梗阻,妊娠期机械瓣功能障碍,外科治疗方法,同期剖腹产和CPB下心脏瓣膜再次置换术； CPB下再换瓣手术，同时对宫内胎儿监测与保护。 先行剖腹产，密切监测心功能,妊娠期机械瓣功能障碍,结果,孕妇全部存活，无围手术期及远期死亡. 剖腹产婴儿5例，均存活；无畸形，随访生长发育及智力水平正常. 孕期体外循环心脏手术：一例胎儿死亡；一例存活.,妊娠期机械瓣功能障碍,外科决策,机械瓣失功能+妊娠期6个月？,妊娠期机械瓣功能障碍,机械瓣梗阻程度 心功能情况 妊娠期周数及胎儿的情况 患者及家属的意愿 心脏外科医生的经验及业务水平 涉及的有关专科的技术水平,影响外科决策的因素,妊娠期机械瓣功能障碍,面临的挑战,大批育龄妇女在换瓣术后有怀孕的需要 孕期的抗凝不规律问题 如何预防和处理妊娠期发生瓣膜失功能 低温体外循环对母体和胎儿的影响 多学科如何协助治疗,妊娠期机械瓣功能障碍,左心瓣膜置换术后三尖瓣返流,是一个易受忽视的问题 显著影响长期生存率,Nath J,et al, J Am Coll Cardiol,2004;43,405,机制 肺动脉高压 三尖瓣环扩张 心房纤颤 风湿性病变的进展 成形技术的局限性 Xuejun X, et al. Heart Lung and Circul, 2004;13,65,左心瓣膜置换术后三尖瓣返流,处理策略,再次成形：Devegas， 瓣环成形，如何选择瓣环种类 瓣膜置换：金属瓣：血栓风险 生物瓣：近几年多采用,左心瓣膜置换术后三尖瓣返流,有待解决的问题,左心瓣膜置换术后三尖瓣返流的原因 选择成形术的标准 选用何种成形方法 如何选择瓣环的种类和大小 选择瓣膜置换术的标准 如何预防三尖瓣返流,左心瓣膜置换术后三尖瓣返流,二尖瓣成形失败,瓣膜成形术所占的比例不高 在我国瓣膜病以风湿性病变为主， 病人就诊晚 成形技术未能普遍开展 担心成形失败而需再次手术,外科治疗方法,再次成形术 瓣膜置换术 经导管瓣膜植入术 “环中瓣”,二尖瓣成形失败,如何预防,掌握二尖瓣成形术的指征 采用合适的成形方法 术中食道B超检查,二尖瓣成形失败,实时三维TEE在二尖成形术中的应用,二尖瓣成形失败,展 望,随着外科技术及围手术期处理水平的提高，再次手术病人死亡率将下降 介入及微创技术的进步可减少再次开胸手术,Edwards Lifesciences,经导管主动脉瓣植入术的初步实验,THANK YOU,Strategies of Re-operation in Heart Valve Disease,Cong Lu, MD Guangdong General Hospital Guangdong Provincial Cardiovascular Institute Guangzhou, China,Guangdong General Hospital,Guangdong Provincial Cardiovascular Institute,Relevant Historic Milestones in China,1954 Closed mitral commissurotomy 1958 The first application of CPB 1958 Open mitral commissurotomy by CPB 1965 Mitral valve replacement,Eminent Pioneers and Institutions of China,Cai Yongzhi Changhai Hospital Shanghai Zhang Baoren Changhai Hospital Shanghai Guo Jiaqiang Fuwai Cardiovascular Hospital Beijing Luo Zhengxiang Guangdong General Hospital Guangzhou,Operations and Re-operations,By the late 1990s, 6000 heart valve operations performed each year In recent years, the number of valve operations per year is more than 20 000 With the number of heart valve surgeries increasing, re-operation of heart valve disease becomes an unavoidable problem,The Experience of Our Hospital,Heart valve surgeries in Guangdong General Hospital from 1997 to 2007,The Experience of Our Hospital,The total operations from 1997 to 2007： 6703 cases Re-operations：499 cases ( 7.4%) Perioperative mortality of re-operations ：8.8%,Causes of Re-operation,The leading cause： Re-stenosis after closed mitral commissurotomy（64.5%）,Causes of re-operation of other hospital,Risks and Strategies,Risks are higher of re-operation than initial operation pro-longed history poor cardiac function adhesion bleeding A variety of methods and strategies of management should be applied according to different causes leading to re-operation,Restenosis after Closed or Open Mitral Commissurotomy,Was widely done with good results in China Restenosis is unavoidable Characters：pro-longed history，often concomitant with tricuspid regurgitation Strategies： re-repair prosthetic valve replacement ： bioprosthetic valve mechanical prosthetic valve,Dysfunction of Mechanical Prosthetic Valve,Prosthetic valve structure Obstruction of mechanical prosthetic valve pannus, fibrous tissue accrementition thrombogenesis: most within 3 years postoperation,Dysfunction of Mechanical Prosthetic Valve Strategies,Thrombus：thromblysis reoperation Pannus, fibrous tissue ：reoperation Difference of the target value of INR among AVR, MVR and TVR AVR：INR 1.8-2.0 MVR：INR 2.0-2.5 TVR：INR 2.5-3.0,Mechanical valve dysfunction in pregnant women,Causes （1）hemostasis changes in pregnancy Pregnancy is associated with a 20-200% increase in levels of fibrinogen and factors II, VII, VIII, X, and XII Lockwood CJ. Obstet Gynecol 2002;99:333. （2）worry about the side effect of warfarin （3）discontinue anticoagulation therapy in the early stage of pregnancy or use other anticoagulants,Mechanical valve dysfunction in pregnant women Experience of our hospital,Seven patients with mechanical valve dysfunction during pregnancy were retrospectively reviewed NYHA at IV in 3, at III in 3 Gestation period 28 weeks in 4, 28 in 2 Thrombogenesis leading to mechanical valve obstruction in all patients,Mechanical valve dysfunction in pregnant women Methods of surgical management,Caesarean section concomitant with re-replacement of mechanical prosthetic valve Mechanical prosthetic valve re-replacement on ordinary temperature cardiopulmonary bypass with continue fetal heart rate monitoring Caesarean section followed by re-replacement of mechanical prosthetic valve,Mechanical valve dysfunction in pregnant women Results,All patients discharged from hospital in well condition Two patients with gestation period 28 weeks who underwent mechanical prosthetic valve re-replacement , one fetus died and the other one survived and delivered in mature pregnancy Five infants were delivered and discharged in good health,Mechanical valve dysfunction in pregnant women Strategies of surgical management,Dysfunction of mechanical valve + gestation period 6 months？,Degree of obstruction of mechanical valve Cardiac function Gestation period and condition of fetus Desire of patients and family members Experience of cardiac surgeon Professional level of relevant department,Mechanical valve dysfunction in pregnant women Factors impact on making decision of management,Mechanical valve dysfunction in pregnant women Challenging,Many young women who underwent valve replacement want to have baby Irregular anticoagulation therapy during pregnancy The adverse impacts of hypothermia and CPB on fetus How to prevent and manage mechanical valve dysfunction in pregnant patients How to cooperate with other department ,eg. Neontology department, obstetrics department,Late Tricuspid Regurgitation after Left Cardiac Valve Replacement,Tricuspid regurgitation is often neglected Adverse impact on survival,Nath J,et al, J Am Coll Cardiol,2004;43,405,Mechanism Persistent pulmonary hypertension Annular dilatation Atrial fibrillation Progression or development of rheumatic lesions Limitation of De Vegas procedure Xuejun X, et al. Heart Lung and Circul, 2004;13,65,TR after Left Cardiac Valve Replacement,TR after Left Cardiac Valve Replacement Strategies of management,Re-repair De Vegas procedure annuloplasty ring Valve replacement mechanical valve：risk of thrombogenesis bioprosthetic valve：widely used in recent years,TR after Left Cardiac Valve Replacement Remaining Questions,What is the mechanism of functional TR? How to perform tricuspid repair? Which size and kind of ring for which patient? When should we perform a repair? When should we think to valve replacement? Why late development of tricuspid regurgitation after successful mitral surgery? How to prevent it?,Failure and Complication of Valve Repair,Valve repair is far less than valve replacement in China Rheumatic heart disease is still the leading cause of