主动脉瓣替换术188例的病因分析及临床经验

Clinical experience and etiology of 188 cases of aortic valve replacement

目的：分析单纯主动脉瓣替换术（ＡＶＲ）的病因、主要死亡原因及危险因素，并提出合理的围术期处理。方法：回顾性研究分析了本院近１７年１８８例单纯ＡＶＲ的临床资料和结果。结果：单纯ＡＶＲ的病因为风湿性者占３９．４％、先天性２０．２％、退行性１０．６％、原发性心内膜炎１６．５％、先天心脏病继发主动脉瓣病变１２．２％、其他１．１％。术后早期死亡１６例（８．５％），其中急性左心衰６例，低心排综合征并发多器官衰竭６例，急性肾衰和心脏骤停各２例，其他３例；单纯关闭不全（ＡＲ）、心功能Ⅳ级、左室收缩末期内经（ＥＳＤ）≥５．０ｃｍ、左室射血分数（ＥＦ）≤５０％和左室短轴内径缩短率（ＦＳ）≤２５％的患者手术死亡率明显增高。结论：单纯ＡＶＲ的病因以风湿性和先天性居多，手术死亡的主要原因为左心功能不全，影响疗效的主要因素为单纯ＡＲ、心功能Ⅳ级、ＥＳＤ≥５．０ｃｍ、ＥＦ≤５０％和ＦＳ≤２５％；围术期处理应重视手术时机的选择、心肌保护、心肺功能支持及防治室性心律失常。

Objective: To analyse the etiology, predominant causes of death and risk factors in patients undergoing pure aortic valve replacement(AVR), and to propose the appropriate perioperative management. Methods: Clinical materials and results of 188 cases of pure AVR treated in our hospital during recent 17 years were analysed and researched retrospectively. Results: The etiology of pure AVR was rheumatic in 39.4%, congenital 20.2%, degenerative 10.6%, primary endocarditis 16.5%, aortic valve lesion secondary to congenital heart disease 12.2%, others 1.1%;postoperative early death was 16 cases(8.5%), including 6 cases of acute left heart failure, 6 low cardiac output syndrome resulting in multiple organs failure, 2 acute renal failure, 2 cardiac arrest, and 3 others; the operative mortality was significantly higher in pure aortic regurgitation(AR), heart functional class Ⅳ, ESD≥5.0 cm, EF≤50% and FS≤25%. Conclusion: The predominant etiology of pure AVR is rheumatic and congenital; the main cause of operative death is left heart insufficience. Pure AR, heart functional class Ⅳ, ESD≥5.0cm, EF≤50% and FS≤25% are the main factors influencing surgical results. Perioperatively, emphasis must be put on optimal timing of surgery, myocardial protection, heart and lung supporting, and prevention and management of ventricular arrhythmia.