主动脉瓣置换术650例临床分析

Clinical analysis of aortic valve replcement in 650 patients

目的总结主动脉瓣人工瓣膜置换术的临床经验。方法主动脉瓣置换手术650例，年龄11～76岁，平均（43．2±12．6）岁。印岁以上52例。风湿性病变475例，先天性瓣叶畸形58例，退行性变49例，感染性心内膜炎（IE）47例，人工瓣膜感染性心内膜炎4例，外伤性2例。合并升主动脉瘤样扩张或主动脉夹层52例，冠心病36例，陈旧性脑血管意外14例，室间隔缺损10例，房间隔缺损2例，动脉导管未闭7例。心功能Ⅲ级385例，Ⅳ级119例。射血分数（EF）平均0．56±0．11，左室舒张末直径平均（LVED）（58．59±12．55）mm,左室舒张末容积（LVEDV）（191．58±89．88）ml，主动脉瓣跨瓣压差13．00～118．25mmHg（1mmHg=0．133kPa）。生物瓣占8．77％。主动脉瓣二次置换9例，同期行冠状动脉旁路术36例，主动脉大血管手术52例。体外循环110～208min，升主动脉阻断54～129min。结果人工瓣膜直径≤21min者术后跨瓣压差平均为30．00IninHg，直径〉21mm者术后跨瓣压差平均为23．00mmHg，差异有统计学意义。术后30d内死亡40例，1987—1996年死亡29例（9．21％）；199r7—2007年死亡11例（3．28％）。平均随访58个月。结论随着手术技术、心肌保护技术和围术期处理技术的提高，生物瓣的使用和对合并缺血性心脏病病人的再血管化，手术并发症和病死率明显下降。

Objective To summarize the clinical experience of aortic valve replacement （AVR）. methods AVR were performed in 650 patients, the mean age was （43.2 ± 12.6） （11 - 76） years old and 8% of the patients were over 60. The etiology were rhenmatic（73 % ）, cengenital（9% ）, degenerative（8% ）, infective endecarditis（7% ）, and traumatic （1% ）. Comerbidities included ascending aorta aneurysm or dissection, coronary artery disease,chronic cerebral accident, ventricular septal defect, atrial septal defect and patent ductus arteriosus. Three hundren and eighty five patients were in cardiac functien（NYHA） class Ⅲ and 119 were in class Ⅳ,respectively. The average ejection fraction, left ventricular end diastolic diameter,left ventricular end diastolic volume and aortic pressure gradient were （56.16± 11.29）%, （58.59± 12.55） mm, （191.58±89.88）ml and 13.00- 118.25 mm Hg respectively. Biological prosthesis accounted for 8.77 %. Nine patients underwent redo AVR. Concomitant coronary artery bypass grafting （CABG） and concomitaot ascending aorta ancurysm or dissection surgery were in 36 and 52 patients, respectively. The average extracorporeal circulation （ECC） and aortic clamp time were 135.00min and 96.00min, respectively, Results Aortic pressure gradient in patients with prosthesis ≤ 21 mm and 〉 21 mm in diameter after operation were 30.130 mmHg and 23.130 mmHg, respectively （ P 〈 0.001 ）. Forty patients died postoperatively within 30 days （6.15 % ）, 29 patients were in 1987 - 1996 （9.21% ） and 11 patients in 1997- 2007 （3.28 % ）. The average follow-up were 58 months. Conclusion The mortality rate of AVR has significantly decreased with the improvement of surgical techniques, myocardial pretectien, pefioperative management and with using of biopresthetic valves for older patients as well as concomitant CABG.