儿童心脏瓣膜置换手术技巧及效果

Prosthetic valve replacement in pediatric patients

目的总结14例儿童心脏瓣膜置换术的经验,探讨儿童瓣膜置换的手术指征、瓣膜选择、手术技术和术后抗凝治疗等问题。方法全组14例中10例为先天性心脏瓣膜病变,3例风湿性病变,1例先天性室间隔缺损致心内膜炎、主动脉瓣膜菌栓。在中低温体外循环下手术,二尖瓣置换7例,主动脉瓣置换6例,二尖瓣置换+主动脉瓣置换1例。均采用机械瓣。若合并其它先天性心脏畸形或三尖瓣关闭不全,同期矫治。术后常规应用华法林抗凝。结果本组手术死亡1例,12例心功能恢复至I级,1例心功能II级。发生1例感染性心内膜炎,治愈。均坚持采用华法林抗凝,无血栓栓塞及抗凝相关并发症发生,瓣膜功能良好。结论儿童心脏瓣膜置换术采用机械瓣效果较好;应用低强度的华法林进行抗凝治疗安全可靠。

Objective To summarize the experience in prosthetic valve replacement in pediatric patients. Methods The clinical data of consecutive 14 children, 8 male and 6 female, aged 10.8 years, with the underlying diseases of congenital heart diseases（ n = 10） ,rheumatic heart diseases（ n = 3 ） ,and infective endocarditis（ n = 1 ）, with the preoperative cardiac function of class Ⅱ （ n = 6） , or class Ⅲ （ n = 5 ） , or Ⅳ （ n = 3 ） , who underwent prosthetic valve replacement, including replacement of mitral valve （ n = 7 ） , aortic valve （ n = 6） , mitral and aortic valves （ n = 1 ） , and tricuspid valvuloplasty （ n = 2） , from September 1999 to September 2006, were respectively analyzed. Mechanical valves were used and took low dose anticoagulant warfarin was administrated to all cases. Postoperatively prothrombin time （PT） and international normal ratio （INR） were observed. Results There was 1 early deaths, owing to serious low cardiac output syndrome. Follow up lasting 5 months to 7 years was performed among 13 discharged patients. The 13 surviving patients showed their cardiac function of class Ⅰ-Ⅱ No serious complications related to anticoagulation and prosthesis dysfunction had been found. Conclusions Prosthetic valve replacement with mechanical valve can be performed in pediatric patients with good outcome. Larger type of mechanical valve should be used as possible. Addi- tional surgical procedures may be required to correct the concomitant malformations during the operation. Postoperative long term low dose nticoagulant treatment is safe.