非缺血性心脏瓣膜疾病合并冠心病同期手术治疗的临床分析

Clinical Analysis of Surgical Treatment of Non-Ischemic Heart Valve Disease Combined with Coronary Artery Disease

目的总结非缺血性心脏瓣膜疾病合并冠心病同期手术患者的临床特征和手术效果,以提高手术疗效。方法2000年1月至2007年6月同期手术治疗105例非缺血性心脏瓣膜疾病合并冠心病患者,年龄36～79岁(61.96±7.61岁),其中风湿性心瓣膜疾病59例,退行性二尖瓣病变24例,老年性钙化性主动脉瓣病变13例;其它主动脉瓣病变9例。术前行冠状动脉造影明确诊断98例,术中探查发现冠心病7例。全组均行冠状动脉旁路移植术,共移植血管216支(2.06支/例),同期行二尖瓣置换术36例,二尖瓣成形术15例,主动脉瓣置换术43例,双瓣膜置换术11例。结果术后住院死亡6例(5.7%,6/105)。死于严重低心排血量3例,肾功能衰竭2例,术后心脏骤停并发多器官功能衰竭1例。术后随访93例,随访时间1个月至7年,失访6例。无晚期死亡患者。心功能分级(NYHA)Ⅰ级25例,Ⅱ级53例,Ⅲ级10例,Ⅳ级5例。1例患者活动后仍有心绞痛存在。结论非缺血性心脏瓣膜疾病合并冠心病患者绝大多数无典型的心绞痛症状,50岁以上的患者必须行冠状动脉造影检查,对有冠心病易患因素者,应积极作冠状动脉造影检查;冠心病所致的心肌缺血可明显加重心脏瓣膜疾病所引起的心肌损害,术中心肌保护尤为重要;正确评价术前左心功能低下的患者是选择手术治疗的难点,更是影响手术效果的关键因素。

Objective To summarize the outcomes and clinical features for surgical treatment of non-ischemic heart valve disease （HVD） combined with coronary artery disease （CAD）, so that to get better surgical result. Methods From January 2000 to June 2007, 105 patients with the mean age of 61. 96±7.61 years （range 36--79 years）, underwent the combined procedures. The etiology of HVD included： 59 rheumatic valve disease, 24 degenerative mitral lesion, 13 calcified aortic valve lesion, and 9 other aortic valve disease. CAD was preoperatively diagnosed by coronary arteriongraphy in 98 patients, and intraoperatively identified in 7 patients. Left ventricular ejection fraction was 50% or less in 45 patients. The total number of bypass grafts was 216 with the mean of 2.06 grafts per patient. Valve procedures included： 36 mitral valve valve replacement, 15 mitral repair, 43 aortic valve replacement, 11 mitral valve and aortic valve replacement. Results There were 6 postoperative deaths with the mortality of 5. 7%. The causes of death were 3 low cardiac output syndrome, 2 renal failure, and 1 heart arrest resulting in multiple organs failure. Ninety-three survivals were followed up from 1 month to 7 years, 6 patients were missed on follow-up. There were no late death. New York Heart Association class I was observed in 25 patients, class Ⅱ 53, class Ⅱ 10 and class Ⅳ 5. One patient still had existential chest pain. Conclusion There were no typical angina in majority of patients with non-ischemic HVD combined with CAD, coronary arteriongraphy must be taken in patients with the age of 50 years and more, or with the risk factors for CAD. Intraoperative myocardial protection is very important because CAD further deteriorates myocardial dysfunction caused by HVD. The decreased left ventricular function is the important factor affecting the surgical results and it is hard to evaluate the underlying cause before the operation.