儿童心脏瓣膜置换术的近远期疗效分析

Early-and Long-term Clinical Efficacy of Heart Valve Replacement in Children

目的探讨儿童心脏瓣膜置换术的病因、手术指征及方法、近远期效果、死亡危险因素及抗凝相关问题。方法回顾性分析1980年1月至2010年12月在华中科技大学同济医学院附属协和医院接受心脏瓣膜置换的53例患儿临床资料。患者年龄2.5~12岁,病因包括先天性心脏病41例（77.3%）,风湿性心脏病8例（15.1%）,单纯感染性心内膜炎2例（3.8%）,心内膜弹力纤维增生症2例（3.8%）。二尖瓣置换29例,主动脉瓣置换18例,双瓣置换2例,三尖瓣置换3例,肺动脉瓣置换1例。机械瓣置换51例,生物瓣置换2例。结果住院死亡6例（11.3%）,主要原因为低心排综合征。存活患者中7例失访,40例随访2.5~20（11.7±3.5）年,大部分患者心功能NYHAⅠ~Ⅱ级。随访期间死亡3例,再次瓣膜置换术3例。结论与成人相比,儿童心脏瓣膜置换手术死亡率高。虽然植入开口较大的人工瓣膜、术后定期监测和调整抗凝强度可在一定程度上提高瓣膜置换的远期疗效,但在初次手术时仍应尽可能保留自体瓣膜。

Objective To explore the etiologies,surgical indications and methods,early-and long-term outcomes,risk factors of mortality and anti-coagulation treatment of heart valve replacement in children.Methods Clinical data of 53 patients who received heart valve replacement in Union Hospital,Tongji Medical College,Huazhong University of Science and Technology,between Jan.1980 and Dec.2010,were retrospectively analyzed.The patients were aged from 2.5to 12 years.The etiologies included congenital heart disease（n=41,77.3%）,rheumatic valve disease（n=8,15.1%）,infective endocarditis（n=2,3.8%）,endocardial fibroelastosis（n=2,3.8%）.Mitral valve replacement was performed in 29 cases,aortic valve replacement in 18,mitral and aortic valve replacement in two,tricuspid valve replacement in three and pulmonary valve replacement in one.Fifty-one patients received mechanical valve implantation and 2patients received bio-prosthetic valve implantation.Results Overall hospital mortality was 11.3%（6/53）.Patients died mainly due to low cardiac output syndrome.Follow-up was completed in 40 out of 47 survivors,with a mean follow-up of（11.7±3.5）years（2.5-20years）.Cardiac function of most patients was at NYHA class Ⅰ or Ⅱ.Three patients died and three patients suffered a second valve replacement during followup.Conclusion The valve replacement is associated with an increased mortality in children relative to adults.Every effort should be made in the first surgery to preserve the native valve,although the long-term outcome can be improved to some extent by using prosthesis with a larger effective orifice area and regularly monitoring and regulating anticoagulation intensity.