356例风湿性心脏瓣膜替换术的临床探讨

Study of 356 cases of rheumatic valvular disease with valve replacement

１９８０年１月至１９９５年７月，对风湿性心脏瓣膜病施行瓣膜置换３５６例，男１２０例，女２３６例，年龄１４～６３岁（３０．５８±８．４９）。术前心功Ⅱ级２０例，Ⅲ级２００例，Ⅳ级１３６例。施行二尖瓣置换２８６例，主动脉瓣置换１７例，二尖瓣＋主动脉瓣置换５３例，使用猪瓣２７只，机械瓣３８２只。同时施行左房附壁血栓清除１４例，三尖瓣成形３０例。早期手术死亡率为７．６％（２７／３５６），低心排综合征、室颤、呼衰和心包填塞是死亡的主要原因。随访１～１６８个月，晚期死亡２１例（１．８％病人年），晚期死亡主要原因为室性心律失常、细菌性心内膜炎、肺部感染、抗凝出血和生物瓣毁损。本文对其影响疗效因素、２次手术、术后并发症处理及抗凝有关问题进行讨论。

Valve replacement was performed for 356 cases of rheumatic valvular disease in our institute in the period from January 1980 to July l995.The 356 patients consisted of 120 male and 236 female with an age range from 14 to 63 and an average of 30.58±8.49 years.Preperative NYHA classification categorized 20 cases in class Ⅱ(5.6%),200 cases in class Ⅲ(56.2%),and 136 cases in class Ⅳ(38.2%).Mitral valve was replaced in 286 cases,aortic in 17 and both mitral and aortic in 53.27 porcine valves and 382 mechanical ones were employed.Associated procedures were tricuspid annuloplasty in 30 cases and thrombectomy of the left atrium in 14.The early mortality rate(within 30 days after surgery)was 7.6%( 27/356).Low cardiac output,ventricular fibrillation,respiratory failure and cardiac tamponade were the main causes of death.The cases were followed cases of late death(1.8% patient-year).The causes of late death were ventricular arrhythmia,bacterial endocarditis,respiratory infection,severe bleeding due to anticoagulation and failure of porcine valves.The problems concerning the factors affecting the operative results,the second operation,the management of postoperative complications and the efficacy of anticoagulation were discussed.