再次手术治疗瓣周漏28例临床分析

Clinical analysis of reoperation for paravalvular leakage in 28 patients

目的研究因瓣周漏（PVL）行再次心脏手术的患者的疗效及中远期生存情况。方法回顾性分析1998年10月-2015年10月因人工瓣膜瓣周漏在解放军总医院行手术治疗的28例患者的临床资料,其中男22例,女6例,年龄15~67（55.4±11.6）岁。28例患者中二尖瓣置换术后瓣周漏18例,主动脉瓣置换术后瓣周漏4例,二尖瓣、主动脉瓣置换术后二尖瓣瓣周漏4例,双瓣置换合并左室隧道内隔膜切除术后双瓣瓣周漏1例,法洛三联症根治合并三尖瓣置换术后三尖瓣瓣周漏1例。其中2例起因为感染性心内膜炎。再次手术前心功能分级（NYHA）Ⅱ级11例、Ⅲ级10例、Ⅳ级7例。结果术后早期死亡2例,分别死于感染性休克和多脏器衰竭。术后出现缺血缺氧性脑病1例,再次开胸2例,少量瓣周漏复发1例。26例出院患者中22例获随访,随访率84.6%,随访时间12~219个月,平均76.2个月。1例于术后31个月死于重症胰腺炎;1例术后7个月再次出现瓣周漏复发,目前心功能Ⅲ级;其余患者恢复良好,心功能Ⅱ级。结论对于超声诊断明确的中重度瓣周漏患者积极行外科手术是切实有效的治疗方法。

Objective To observe surgical outcome of reoperation for paravalvular leakage and medium- and long-term survival. Methods The clinical data of 28 patients receiving reoperation for paravalvular leak（PVL） in General Hospital of PLA between October 1998 and October 2015. The patients included 22 males and 6 females, with a mean age of 55.3 years（ranging from 15-67 years）. PVL was reported in 18 cases after mitral valve replacement, in 4 after aortic valve replacement, in 4 after multiple valve replacement（mitral PVL）, in 1 case after multiple valve replacement（multiple PVL） and in 1 after radical surgery for trilogy of Fallot with tricuspid valve replacement（tricuspid PVL）. There were 2 cases diagnosed as infective endocarditis contributing to PVL. The grades of heart function were NYHA Ⅱ in 11 patients, NYHA Ⅲ in 10, NYHA Ⅳ in 7. Results Two patients died in hospital because of septic shock and MODS respectively. One patient developed hypoxic-ischemic encephalopathy after operation. There were 2 patients undergoing second thoracotomy on account of drainage post-operatively. One patient suffered recurrence of PVL. Twenty-two out of 26 patients were followed-up for 12 to 219 months（average 76.21 months） and 4 were lost to follow-up. One patient died of severe pancreatitis 31 months after hospital discharge and 1 had recurrence of PVL with heart function NYHA Ⅲ. Twenty-four survivals are in NYHA class Ⅱ. Conclusion Aggressive operation is effective treatment for moderate-severe PVL diagnosed by cardiac ultrasonography.