机械及生物主动脉瓣--病人选择及手术方式实施课件

机械及生物主动脉瓣--病人选择及手术方式实施第四军医大学西京医院心血管外科易定华，俞世强，刘金成，金振晓等2008年12月上海cases1990－2007西京医院心血管外科手术量情况52%23%8%7%10%2007年西京医院3225例心脏手术分布图人工瓣膜的优缺点优点结构故障少无须再次手术缺点需终身抗凝抗凝相关并发症优异的血流动力学无需抗凝治疗瓣膜钙化瓣膜衰败需再次手术91439821988年5月至2008年5月西京医院8206例患者应用10125枚人工瓣膜种类分布89.2%84.5%68.6%机械瓣置换15年随访的Kaplan-Mier生存曲线年龄<60岁并发房颤有血栓栓塞的风险首次感染性心内膜炎的患者西京医院选择人工瓣膜的 原则 组织架构调整原则组织架构设计原则组织架构设置原则财政预算编制原则问卷调查设计原则 选择机械瓣年龄>60岁不伴有房颤无血栓栓塞的风险进行三尖瓣置换时具有生育要求的年轻女性患者西京医院选择人工瓣膜的原则选择生物瓣讨论生物瓣膜钙化和衰坏较快，选择机械瓣再次手术置换较大瓣膜小儿基本可以接受华法林抗凝治疗应当尽量通过成形来修复婴幼儿瓣膜置换的选择讨论首次手术治疗时选择的标准和非感染性心内膜炎患者相似对复发的感染性心内膜炎的患者应使用生物瓣膜在有广泛的瓣环缺损和心室主动脉分离时，采用同种主动脉根部置换合并感染性心内膜炎的瓣膜置换选择同期置换多个瓣膜的选择避免使用不同种类瓣膜进行同期置换育龄妇女瓣膜置换的选择对有生育要求的年轻女性力争进行瓣膜成形术，必要时推荐应用生物瓣膜进行瓣膜置换。特殊情况下人工瓣膜的选择双瓣同期置换术二尖瓣发育不良并重度关闭不全婴幼儿换瓣YiDinghua,LiuJincheng,YuShiqiang,YangJian,JinZhenxiao,etalInstituteofCardiovasculardiseaseofPLADepartmentofCardiovascularSurgery,XijingHospitalFourthMilitaryMedicalUniversityPatientSelectionandPracticePatterns:MechanicalversusBioprostheticsAorticValvescasesCardiacOperationsPerformedintheDepartmentofCardiovascularSurgeryinXijingHospitalfrom1990to200719992000200120022003200420052006200752%23%8%7%10%Distributionofdifferenttypesof3225cardiacoperationsintheDepartmentofCardiovascularSurgeryXijingHospitalin2007AdvantageDisadvantageAdvantageanddisadvantageofartificialvalveLife-longanticoagulationRelatedcomplicationsFewstructuraldeteriorationFreefromre-operationGoodhaemodynamicsFreefromanticoagulationCalcificationDeteriorationRe-operation9143982Distributionof10125artificialvalvesusedin8206patientsinXijingHospitalfromMay,1988toMay,2008ResultsFollow-upratewas91.2%Accumulatedfollow-uptimeis49232patients•yearComplicationsMechanical(Patients•year)Bioprosthetics(Patients•year)Thromboembolisis1.8％0.21％Bleeding2.1％0.48％90.1%86.4%69.1%Kaplan-MierSurvivalCurveofbioprosthesisduring15years’follow-up89.2%84.5%68.6%Kaplan-MierSurvivalCurveofmechanicalvalveduring15years’follow-up<60yearsoldComorbidedwithatrialfibrillationRiskfactorforthromboembolismInfectiveendocarditis(Forthefirsttime)PrincipleforselectionofmechanicalorbioprostheticvalvesinXijingHospitalMechanicalvalvepreferred>60yearsoldComorbidedwithoutatrialfibrillationNoriskfactorforthromboembolismTricuspidvalvereplacementFemalepatientswithfertilityrequirePrincipleforselectionofmechanicalorbioprostheticvalvesinXijingHospitalBioprostheticvalvepreferredIndexedeffectiveorificearea（IEOA）=0.852mmsmallerthantheradiusoftheaorticannulus>19mminpatientswithsmallaorticrootOursizesweresmallerthanthatofwesterncountriesSelectionofthesizeforartificialvalvesAorticvalveDistributionofthesizeof1422aorticvalvereplacedinourhospitalMostselectedmitralvalveinadultsis27mmSmallervalvepreferredinpatientswithsmallleftventricleorheartinsufficiency22casesofvalvereplacementinpatientsunder45kg3casesof19mmvalvereplacementin3-12months’oldinfantsDistributionofthesizeof5321mitralvalvereplacedinourhospitalMitralvalveSelectionofthesizeforartificialvalvesDiscussionAorticvalve4mmsmallerthanmitralvalveisrecommended.I.E.27mmM＋23mmA；25mmM＋23mmAWhentheaorticvalveissmall,bigmitralvalveshouldbeavoided.Otherwiseleftventricleoverloadwilloccur,leadingtoleftheartfailure.MatchofconcomitantMitralandAorticvalvereplacementDuetothecalcificationanddeteriorationofbioprosthesis,mechanicalvalveispreferredNeedforre-operationValvuloplastyshouldbethefirstchoiceinchildrenWalfarincanusuallybewelltoleratedinchildrenChoiceofvalvereplacementininfantsDiscussionThecriteriaforfirsttimeissametoordinarypatientsForre-occurredpatients,bioprosthesisispreferredForpatientswithextensiveannulardefectorthedetachmentbetweenventricleandaorta,rootreplacementwouldbeselectedChoiceofvalvereplacementinpatientswithendocarditisDiscussionConcomitantmulti-valvereplacementAvoidselectvalvesofdifferenttypesForyoungfemalepatientswithfertilityrequireValvuloplastyisthefirstchoiceBioprosthesiscanalsobeusedwhennecessaryChoiceofvalvereplacementinspecialsituationConcomitantdouble-valvereplacementConcomitantfour-valvereplacementCongenitalmitralvalveinsufficiencyValvereplacementininfants