心脏瓣膜病再次手术287例临床分析

Reoperation after valvular heart disease:An analysis of 287 cases

目的探讨心脏瓣膜病再次手术的原因、手术时机、术中注意要点。方法回顾分析2003年6月～2010年6月,该院287例心脏瓣膜病再次手术病例。男性102例,女性185例,年龄(45.89±11.10)岁。两次手术的时间间隔为3个月～38年(14.01±8.74)年,术前心功能(NYHA分级)Ⅱ级14例,Ⅲ级217例,Ⅳ级56例。其中二尖瓣+主动脉瓣+三尖瓣置换2例,二尖瓣+主动脉瓣置换32例,二尖瓣+三尖瓣置换12例,二尖瓣置换201例,三尖瓣置换19例,主动脉瓣置换7例,瓣周漏修补14例。结果全组早期死亡11例,病死率为3.82%,死亡原因包括术后低心排出量综合征5例,恶性心律失常2例,多脏器功能衰竭3例,术中止血困难1例。生存患者术后心功能大都恢复到Ⅰ～Ⅱ级。心脏瓣膜病再次手术原因包括:二尖瓣闭式扩张术后189例,人工瓣膜心内膜(PVE)13例,机械瓣置换术后功能障碍21例,瓣周漏31例,二尖瓣和(或)主动脉瓣置换术后其他瓣膜病变33例。结论合理选择手术时机、加强术中心肌保护是提高手术成功关键。

Objective To investigate the causes of reoperation and the perioperative techniques and operation methods.Methods From June 2003 to June 2010,we performed reoperation on 287 patients（102 males and 185 females,aged 45.89±11.10 years old） who had undergone heart valve surgery.The time interval between two operations was 3 months to 38 years（14.01±8.74 years）.Before reoperation,the cardiac function（NYHA） of the patients was classⅡ in 14 patients,classⅢ in 213 patients,classⅣ in 56 patients.Among the patients,there were 2 cases of mitral valvular replacement＋aortic valvular replacement ＋ tricuspid valvular replacement,32 cases of mitral＋aortic bivalvular replacement,12 cases of mitral＋tricuspid bivalvular replacement,201 cases of mitral valvular replacement,19 cases of tricuspid valvular replacement,7 cases of aortic valvular replacement,14 cases of paravalvular leakage repair.Results There were 11 hospital deaths with a mortality of 3.82%（11/287）.The causes of mortality included 5 case of low cardiac output after operation,2 case of malignant arrhythmia,3 case of multiple organ failure,1 case of difficult surgery to stop bleeding.Mostly recovered to NYHA classⅠ~Ⅱ.The causes for cardiac reoperation after heart valve surgery were 189 cases of after closed mitral commissurotomy,13 cases of PVE,21 cases of prosthetic heart valve dysfunction,31 cases of prosthetic leakage,33 cases of other valvular anomalies.Conclusion The keys to a successful cardiac reoperation include appropriate preoperative preparations,operational timing,and suitable choosing of operational skills.