经胸超声心动图评估人工机械主动脉瓣血管翳清除术及再次置换术的安全性及有效性

The safety and efficacy of pannus removal or aortic valve re-replacement evaluated by transthoracic echocardiogram

目的基于经胸超声心动图(transthoracic echocardiogram,TTE),探讨人工机械主动脉瓣血管翳患者采用血管翳清除术与再次置换术的安全性和有效性。方法回顾性选择2019年9月至2022年3月复旦大学附属中山医院外科手术中证实人工机械主动脉瓣梗阻原因为血管翳患者41例。其中17例采取血管翳清除术,而保留原有的人工机械瓣(血管翳清除组,n=17),24例采取人工机械主动脉瓣再次置换术(再次置换组,n=24),对比2组患者围手术期临床结果及术前、术后经胸超声心动图(transthoracic echocardiogram,TTE)参数。结果2组患者的术前及术后1周TTE检测指标中跨瓣峰值流速(transvalvular peak velocity,V_(max))、跨瓣峰值压差(transvalvular peak pressure gradient,PG_(max))、跨瓣平均压差(transvalvular mean pressure gradient,TMPG)、左心室舒张末期内径(left ventricular end-diastolic diameter,LVEDD)、左心室收缩末期内径(left ventricular end-systolic diameter,LVSDD)及左心室射血分数(left ventricular ejection fraction,LVEF)差异均无统计学意义,2组术前TTE参数均符合手术指征,术后2组TMPG均低于20 mmHg。术中再次置换组较血管翳清除组体外循环时间及主动脉夹闭时间明显延长,差异均有统计学意义(P<0.001),体外循环时间与术后第1天复查血清肌钙蛋白T(cardiac troponin T,cTnT)水平正相关(r=0.543,P<0.001)。再次置换组的术后第1天白细胞(white blood cell,WBC)水平高于血管翳清除组(P<0.05)。术后住院期间,再次置换组发生并发症10例(41.6%),其中2例为严重的多器官功能障碍,住院期间死亡4例(16.7%);而血管翳清除组发生并发症仅4例(23.5%),无围手术期死亡。结论围手术期临床结果及TTE指标显示,血管翳清除术是一种安全有效的手术方式。TTE是人工机械主动脉瓣置换术后人工机械瓣血管翳常规筛查的影像学方法。

Objective To explore the safety and efficacy between the simple pannus removal and the repeat aortic valve replacement accounted of transthoracic echocardiogram(TTE) data. Methods From September 2019 to March 2022, 41 cases of the mechanical aortic valve obstruction from Zhongshan Hospital, Fudan University were conflrmed pannus overgrowth underwent reoperation. Among them, 17 cases received the excision of pannus with preserving the prior implanted prosthesis(pannus removal,n=17) and 24 cases accepted the repeat aortic valve replacement(AVR, valve re-replacement, n=24),compared peroperative clinical outcomes and perioperative TTE data in two groups. Results There was no signiflcant difference between procedures in mechanical aortic in aortic transvalvular peak velocity(Vmax), transvalvular peak velocity(PGmax), transvalvular mean pressure gradient(TMPG),left ventricular end-diastolic diameter(LVEDD), left ventricular end-systolic diameter(LVSDD) and left ventricular ejection fraction(LVEF), tested before and after 1 week of surgery. The preoperative TEE data of two groups had reached the indications for surgery,and both postoperative TMPG was below 20 mmHg. Signiflcant differences were acquired between procedures in cardiopulmonary bypass and aortic cross-clamp time(P<0.01). There was a moderate positive correlation between CPB and serum troponin T(cTnT,r=0.543, P<0.001),on the flrst postoperative day. White blood cells(WBC) of valve re-replacement on the flrst postoperative day was significantly higher than that in Pannus resection group(P<0.05). During postoperative hospitalization, 10 cases emerged complications(41.6%) in valve re-replacement group, including 2 severe multiorgan dysfunction and 4 deaths(16.7%), while only 4cases(16.7%) had complications in the pannus removal group without perioperative death. Conclusion The perioperative clinical outcomes and TTE data show that pannus removal is a safe and effective procedure. TTE is the routine imaging method for screening of the function of mechanical aortic valve.