50至70岁心脏瓣膜置换患者瓣膜选择与长期预后

Valve selection and long-term prognosis in patients aged 50-70 with heart valve replacement

心脏瓣膜置换术是二尖瓣、主动脉瓣病变的主要治疗方式.瓣膜置换术患者选择生物瓣或机械瓣,是心脏外科工作中时常要面对的问题.使用机械瓣的患者需要终生抗凝,出血及栓塞风险增加,使用生物瓣的患者有因瓣膜结构性衰败再次手术的风险.2017美国心脏协会(American Heart Association,AHA)指南推荐年龄50岁以下无抗凝禁忌患者使用机械瓣,70岁以上患者使用生物瓣,但对于50~70岁患者,指南并没有明确优先推荐.国际及国内临床实践,生物瓣的使用比例呈现上升趋势.多项研究结果显示,该年龄段置换生物瓣和置换机械瓣患者的远期生存率无明显差别,机械瓣置换患者远期发生出血、卒中等事件的风险更高,生物瓣置换患者远期再次手术风险更高,但出血、卒中比再次手术导致患者死亡的风险要更高,而且随着外科和介入技术的发展,再次手术导致的风险有进一步下降的趋势.对于50~70岁间患者瓣膜种类的选择,医师和患者仍需要谨慎对待和个体化选择,但是生物瓣使用可以考虑在年龄更小的患者使用.

Heart valve replacement is the main treatment of mitral and aortic valve lesions.The choice of biological valve or mechanical valve is a common problem in cardiac surgery.Mechanical valves require anticoagulation for life,with an increased risk of bleeding and embolism.Bioprosthetic valves are at risk of reoperation due to structural failure of valves.In the 2017 AHA guidelines,mechanical valves are recommended for patients under 50 years of age without anticoagulant contraindications and biological valves are recommended for patients over 70 years of age.However,for the patients between 50 and 70 years of age,the guidelines do not give priority.According to the clinical practice at home and abroad,the proportion of bioprosthetic valves is on the rise.A number of research results show that there is no significant difference in the long-term survival rate between the patients with biological and those with mechanical valve replacement in this age group.The patients with mechanical valve replacement have a higher risk of long-term bleeding,stroke and other events and the patients with biological valve replacement have a higher risk of long-term reoperation.With the development of surgery and interventional technology,the risk of reoperation has a further downward trend.Doctors and patients still need to be cautious and individualized in the selection of valve types for patients aged 50-70.But the use of biological valve can considerd for the younger patients.