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1、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
2、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
3、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 1.8-2.0MVR：INR 2.0-2.5TVR：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
4、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
5、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
6、 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
7、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,MDGuangdong General HospitalGuangdong Provincial Cardiovascular InstituteGuangzhou,China,Guangdong GeneralHospital,Guangdong ProvincialCardiovascular Insti
8、tute,Relevant Historic Milestones in China,1954 Closed mitral commissurotomy1958 The first application of CPB1958 Open mitral commissurotomy by CPB1965 Mitral valve replacement,Eminent Pioneers and Institutions of China,Cai Yongzhi Changhai Hospital ShanghaiZhang Baoren Changhai Hospital ShanghaiGuo
9、 Jiaqiang Fuwai Cardiovascular Hospital BeijingLuo Zhengxiang Guangdong General Hospital Guangzhou,Operations and Re-operations,By the late 1990s,6000 heart valve operations performed each yearIn recent years,the number of valve operations per year is more than 20 000 With the number of heart valve
10、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 casesRe-operations：499 cases(7.4%)Pe
11、rioperative 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 ad
12、hesion bleedingA 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 ChinaRestenosis is unavoidable Characters：pro-longed history，often conco
13、mitant with tricuspid regurgitationStrategies：re-repair prosthetic valve replacement：bioprosthetic valve mechanical prosthetic valve,Dysfunction of Mechanical Prosthetic Valve,Prosthetic valve structureObstruction of mechanical prosthetic valve pannus,fibrous tissue accrementition thrombogenesis:mos
14、t within 3 years postoperation,Dysfunction of Mechanical Prosthetic Valve Strategies,Thrombus：thromblysis reoperationPannus,fibrous tissue：reoperationDifference of the target value of INR among AVR,MVR and TVRAVR：INR 1.8-2.0MVR：INR 2.0-2.5TVR：INR 2.5-3.0,Mechanical valve dysfunction in pregnant wome
15、n,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
16、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 3Gestation period 28 weeks in 4,28 in 2Thrombogenesis leading to mechanical
17、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 fet
18、al 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
19、-replacement,one fetus died and the other one survived and delivered in mature pregnancyFive 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 obst
20、ruction of mechanical valveCardiac functionGestation period and condition of fetusDesire of patients and family membersExperience of cardiac surgeonProfessional level of relevant department,Mechanical valve dysfunction in pregnant women Factors impact on making decision of management,Mechanical valv
21、e dysfunction in pregnant women Challenging,Many young women who underwent valve replacement want to have babyIrregular anticoagulation therapy during pregnancyThe adverse impacts of hypothermia and CPB on fetusHow to prevent and manage mechanical valve dysfunction in pregnant patientsHow to coopera
22、te with other department,eg.Neontology department,obstetrics department,Late Tricuspid Regurgitation after Left Cardiac Valve Replacement,Tricuspid regurgitation is often neglectedAdverse impact on survival,Nath J,et al,J Am Coll Cardiol,2004;43,405,Mechanism Persistent pulmonary hypertension Annula
23、r 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 annu
24、loplasty 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?Whe
25、n 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
26、 the leading cause of valvular damage leading to surgery in China Patients often experienced pro-longed history before their first visits Techniques of valve repair are not applied widely Worry about reoperation,Methods of surgical treatment Re-repair Valve replacement Transcatheter valve implantati
27、on valve-in-ring,Failure of Valve Repair,Failure of Valve Repair How to prevent?,Indication and contraindication of mitral repairApply suitable methods of mitral repairTEE,Failure of Valve Repair Live 3D TEE for Mitral Repair Surgery,Prospection,With the development of surgical techniques，the incidence of reoperation and the mortality of reoperation will decreaseWith the improvement of interventional therapy,reopen chest surgery will be avoided in some patients,Edwards Lifesciences,Our preliminary experiment of transcatheter aortic valve implantation,THANK YOU,
