主动脉瓣置换术后瓣周漏的临床及超声心动图分析

Clinical Analysis and Echocardiographic Evaluation of Paravalvular Leaks After Surgical Aortic Valve Replacement

目的:探讨主动脉瓣人工瓣置换术后瓣周漏的临床特点及超声心动图应用价值。方法:回顾分析2002-03至2017-03在我院住院诊治的外科主动脉瓣置换术后瓣周漏患者123例,年龄12~74岁,平均(45±13)岁。首次换瓣手术包括我院手术及外院手术。所有患者入院行经胸或经食管超声心动图检查确诊瓣周漏。28例(22.8%)予内科保守治疗,95例(77.2%)再次手术治疗。结果:瓣周漏患者超声心动图彩色多普勒可见舒张期源于人工瓣瓣周的反流信号,部分二维超声可见人工瓣缝合环与周围组织之间的裂隙。根据超声心动图等影像学检查、术中所见及病理结果分析瓣周漏产生的原因,包括:感染性心内膜炎45例,白塞病23例,大动脉炎4例,疑诊免疫系统疾病5例,主动脉夹层2例,疑手术技术原因所致3例,余41例原因未能确定。全组患者死亡13例,放弃治疗病重出院5例,随访到的83例患者中,仍有瓣周漏中量以上反流者27例,心功能明显减低1例,55例好转或治愈。结论:有临床意义的瓣周漏是主动脉瓣置换术后的重要并发症,再手术比例高,复发率高,预后较差。主动脉瓣瓣周漏的原因以感染性心内膜炎最常见,其次为非特异性血管炎。

Objectives： To explore the clinical features and the value of echocardiographic examination of paravalvular leaks after surgical aortic valve replacement.Methods： A total of 123 patients（aged from 12-74 [mean age 45 ± 13] years） hospitalized in our hospital from 2002-03 to 2017-03 because of paravalvular leaks after surgical aortic valve replacement were included in this study. The first operation was performed in our hospital or other hospitals. All patients had a confirmed diagnosis of paravalvular leaks by transthoracic or transesophageal echocardiography. Among them, 28 cases received non-surgical treatment and paravalvular leaks were corrected by reoperation in 95 cases.Results： Diastolic paravalvular regurgitation was detected by color doppler echocardiography in most patients, and dehiscence between the artificial valve and adjacent tissue was evidenced by two-dimensional echocardiography in some patients. The causes of paravalvular leaks, defined by imaging modalities including echocardiography, operative findings and pathological results included： infective endocarditis in 45 patients, Bechet＇s syndrome in 23 patients, Takayasu arteritis in 4 patients, suspected diagnosis of immune system diseases in 5 patients, aortic dissection in 2 patients, suspected operative technical reasons in 3 patients, and unknown in 41 patients. There were 13 deaths in this cohort, 5 patients gave up the further treatment and self-discharged due to the serious disease conditions. During follow-up, mild degree or above paravalvular leaks were found in 27 patients, 1 patient suffered from heart failure, improvement or recovery were seen in 55 patients.Conclusions： The paravalvular leaks with significant clinical consequence is an important complication after surgical aortic valve replacement, and most patients need to be treated with reoperation. Despite reoperation, the recurrence rate remains high and the prognosis is poor. Infective endocarditis is the most common cause of paravalvular leaks in prosthetic aortic valves, followed by non-specific vasculitis. Echocardiography plays an important role on diagnosis and monitoring in these patients.