再次心脏直视手术治疗人工瓣膜瓣周漏疗效分析

Therapeutic effect of reoperation in patients with prosthetic paravalvular leakage

目的探讨因瓣周漏而再次行心脏直视手术的临床疗效。方法收集该院2004年1月至2010年12月因瓣周漏而再次进行瓣膜手术的27例患者,其中,男16例、女11例;年龄27～62岁,平均年龄(46.11±9.88)岁。其中二尖瓣置换术后瓣周漏11例;主动脉瓣置换术后瓣周漏10例;主动脉瓣、二尖瓣双瓣置换术后,二尖瓣瓣周漏2例;主动脉瓣瓣周漏2例;Wheat术后主动脉瓣瓣周漏1例;右瓦窦瘤修补并主动脉瓣替换术后瓣周漏1例;3例由感染性心内膜炎导致;3例为白塞病患者。结果患者术后左心房及心室较术前明显缩小,左心室射血分数与术前比较差异无统计学意义。术后早期2例发生了低心排综合征,死亡1例,早期病死率3.7%;另外1例经主动脉内球囊反搏(IABP)治疗恢复;术后再次开胸止血1例;少量瓣周漏1例。随访5个月至7年,2例再次发生瓣周漏(为白塞病患者)均接受第3次手术,其中死亡1例。其余患者无瓣周漏再发生,心功能分级提高,生活质量改善,无其他并发症发生。结论人工瓣膜瓣周漏再次手术如恰当掌握手术时机、术中加强心肌保护、保证准确的手术操作、加强围手术期处理,临床近、中期效果满意。但累及主动脉瓣的白塞病患者再次手术时单纯瓣膜置换效果较差。

Objective To review the therapeutic effects of reoperation in 27 patients with prosthetic paravalvular leakage.Methods From January 2004 to December 2010,27 patients underwent valvular reoperations due to paravalvular leakage were collected.In this group,including 16 male and 11 female patients,the average age was 46.11 years（ranged from 27 to 62 years）.11 cases suffered from paravalvular leakage（PVL） after mitral valve replacement（MVR）.10 cases suffered from PVL after aortic valve replacement（AVR）.4 cases suffered from PVL after aortic and mitral valve replacement（2 cases occurred at the mitral position and 2 cases occurred at the aortic position）.1 case suffered from PVL after wheat procedure.1 case suffered from PVL after right valsalva aneurysm repairment and AVR.The paravalvular leakage was caused by infective endocarditis in 3 cases.3 cases were patients with Behcet’s disease.Results The size of left atriums and left ventricles were decreased in all patients after surgery.Low cardiac output syndrome happened in 2 patients.One case died of renal failure（early mortality 3.7%）and the others recovered after using intra-aortic balloon counterpulsation.Other major complications were re-exploration for mediastinal bleeding in 1 case and mild PVL in 1 case.Complete follow-up（5months-7 years） was available for all patients.2 patients suffered from PVL again（both with Behcet’s disease）.One patient died of left heart failure caused by severe PVL after the third operation.Conclusion Satisfactory short-term and middle-term results can be obtained in patients with PVL after reoperation only if appropriate timing of operation control,satisfactory myocardial protection,accurate surgical procedure and suitable perioperative treatment.But the results are poor in patients with Behcet’s disease.