双瓣置换围术期处理

Perioperative Management of Combined Aortic and Mitral Valve Replacement

目的总结 1989年 1月～ 1998年 12月双瓣置换围术期处理经验。 方法 10年中 2 0 7例患者施行主动脉瓣、二尖瓣人工机械瓣双瓣置换术。强调对重症患者术前准备充分是围术期成功的关键之一。心肌保护运用仁济医院心肌保护液加山莨菪碱 ,心脏停搏后切开主动脉直接予冠状动脉开口灌注心肌保护液 ;置换二尖瓣时保留二尖瓣后瓣及瓣下结构 ;对中度以上返流的三尖瓣做Kay氏法成形 ;常规切除右侧心包和纵隔胸膜使心包腔与右侧胸腔相通 ,术后加强ICU综合处理。 结果前 5年 118例术死亡 9例 ,死亡率 7.6%。后 5年 89例中死亡 3例 ,死亡率 3 .4 %。 2 0 7例总的围术期死亡率 5 .8%。前 5年 118例术中自动复跳 3 3例 ,占 2 7.9% ;后 5年 89例术中自动复跳 4 7例 ,占 5 2 .8%。随访 185例 ,4～ 12 0个月 ,平均随访 5 8± 2 1个月 ,5年以上生存 92例。 结论对围术期处理的重视 ,术前准备充分 ,合理的手术方法和心肌保护 ,可以减少围术期并发症 ,降低双瓣置换手术围术期的死亡率。

Objective To summarize the experiences of perioperative management for combined aortic and mitral valve replacement from Jan. 1989 to Dec. 1998 In the 10 year 207 cases undergoing combined aortic and mitral valve replacement (DVR) period from 1989 to 1998 were studied. Perioperative management included in fusion of conventional Renji cardioplegia with additional anisodamine, preservation of the posterior mitral leaflet and subvalvular apparatus, Kay's valvuloplasty for moderate and severe tricuspid regurgitation, partial to resection of the right mediastinal pleura and drainage of the right chest, and intensive postoperative care in the ICU. St Jude and Medtronic Hall mechanical valves were used in 199 patients. In the first 5 years, 9 of 118 patients died (mortality 7.6%). During the later 5 years 3 patients died out of 89 cases (mortality 3.4%), the total mortality rate was 5.8%. 33 of 118 cases and 47 of 89 cases had spontaneous resceneption of sinus rhythm. 4 ～ 120 months follow up for 185 patients (average 58±21 months), showed 92 cases survived 5 years and longer. Intensive preoperative prepanration, rational operative methods and myocardial protection could reduce both perioperative mortality and postoperative complications.