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1、心脏瓣膜病再次手术的治疗策略广东省人民医院广东省心血管病研究所卢聪中国瓣膜外科发展史中的几个里程碑1954 1954 第一例闭式扩张术第一例闭式扩张术1958 1958 体外循环的首次应用体外循环的首次应用1958 1958 第一例体外循环下二尖瓣直视分离术第一例体外循环下二尖瓣直视分离术1965 1965 第一例瓣膜置换术第一例瓣膜置换术瓣膜外科发展史中的领军人物及科研院所蔡用之：长海医院蔡用之：长海医院张宝仁：长海医院张宝仁：长海医院郭加强：阜外心血管病医院郭加强：阜外心血管病医院罗征祥：广东省人民医院罗征祥：广东省人民医院手术数量及再次手术问题uu至1999年，每年瓣膜手术达6000例u
2、u经过近10年的发展，现在每年的瓣膜手术估计在2-3万左右uu随着手术数量的增多，再次手术成为不可避免的问题我院的经验我院我院19971997年至年至20072007年瓣膜手术情况年瓣膜手术情况我院的经验19971997年至年至20072007年总瓣膜手术例数：年总瓣膜手术例数：67036703例例其中再次手术例数：其中再次手术例数：499499例，占例，占 7.4%7.4%再手术病人围手术期死亡率：再手术病人围手术期死亡率：8.8%8.8%再次手术的原因分析占比重最大的为：占比重最大的为：占比重最大的为：占比重最大的为：二尖瓣闭式扩张术后（二尖瓣闭式扩张术后（二尖瓣闭式扩张术后（二尖瓣闭式扩
3、张术后（64.5%64.5%）国内其他医院再次手术的原因分析医院名称医院名称再次手术例数再次手术例数原因原因阜外医院阜外医院333333a,b,c,d,e,fa,b,c,d,e,f新桥医院新桥医院187187f,a,d,gf,a,d,g仁济医院仁济医院203203f,a,g,f,a,g,福建省立医院福建省立医院104104f,e,g,d,a,hf,e,g,d,a,h包头中心医院包头中心医院165165f,a,g,c,d,b,ef,a,g,c,d,b,ea:生物瓣失功能，b:瓣周漏，c:自然瓣膜损坏，d:机械瓣功能障碍，e:感染性心内膜炎，f:二尖瓣闭式扩张，g:二尖瓣直视分离，h:其他,风险及
4、对策再次瓣膜手术的风险比首次瓣膜手术的风险高 病程长 心功能差 粘连、手术时间长 出血针对不同的原因，其治疗方案及对策有所不同闭式扩张及直视交界切开术后再狭窄风湿性心脏病是导致瓣膜病变的首要原因风湿性心脏病是导致瓣膜病变的首要原因再狭窄是必然结果，闭式扩张术后的症状缓解期再狭窄是必然结果，闭式扩张术后的症状缓解期一般在一般在8-158-15年年特点：病程长，常合并三尖瓣病变特点：病程长，常合并三尖瓣病变策略：策略： 再次成形再次成形 换瓣换瓣 ：生物瓣（避免抗凝治疗）：生物瓣（避免抗凝治疗） 机械瓣机械瓣 机械瓣功能障碍机械瓣结构原因机械瓣结构原因机械瓣梗阻：机械瓣梗阻： 血管翳、纤维组织增生
5、血管翳、纤维组织增生 血栓形成：多发生于血栓形成：多发生于3 3年内年内梗阻原因梗阻原因MVRMVRAVRAVRTVRTVR血栓形成血栓形成35(71%)35(71%)8(33%)8(33%)4(100%)4(100%)血管翳及纤维组织增生血管翳及纤维组织增生14(29%)14(29%)16(67%)16(67%) 机械瓣功能障碍机械瓣功能障碍策略血栓：内科溶栓血栓：内科溶栓 外科再次手术治疗外科再次手术治疗血管翳、纤维组织增生：再次手术治疗血管翳、纤维组织增生：再次手术治疗强调早期严格抗凝治疗，不同部位其抗凝标准有强调早期严格抗凝治疗，不同部位其抗凝标准有所不同：所不同：AVRAVR：INR
6、 1.8-2.0INR 1.8-2.0MVRMVR：INR 2.0-2.5INR 2.0-2.5TVRTVR：INR 2.5-3.0INR 2.5-3.0妊娠期机械瓣功能障碍原因： （1）妊娠期高凝状态 （2）担心华法林的副作用 （3）在妊娠早期停用或换用其他抗凝药物我院临床资料2000年2月至2006年12月，妊娠期发生机械瓣功能障碍病人7例，年龄22-32岁，平均26.4 2.6岁风湿性心脏病5例，先天性心脏病2例心功能IV级4例，III级3例妊娠期28周5例，28周2例机械瓣血栓形成，机械瓣梗阻妊娠期机械瓣功能障碍妊娠期机械瓣功能障碍外科治疗方法同期剖腹产和CPB下心脏瓣膜再次置换术；C
7、PB下再换瓣手术，同时对宫内胎儿监测与保护。先行剖腹产，密切监测心功能妊娠期机械瓣功能障碍妊娠期机械瓣功能障碍结果孕妇全部存活，无围手术期及远期死亡.剖腹产婴儿5例，均存活；无畸形，随访生长发育及智力水平正常.孕期体外循环心脏手术：一例胎儿死亡；一例存活.妊娠期机械瓣功能障碍妊娠期机械瓣功能障碍外科决策机械瓣失功能+妊娠期6个月？妊娠期机械瓣功能障碍妊娠期机械瓣功能障碍机械瓣梗阻程度心功能情况妊娠期周数及胎儿的情况患者及家属的意愿心脏外科医生的经验及业务水平涉及的有关专科的技术水平影响外科决策的因素妊娠期机械瓣功能障碍妊娠期机械瓣功能障碍面临的挑战大批育龄妇女在换瓣术后有怀孕的需要孕期的抗凝不
8、规律问题如何预防和处理妊娠期发生瓣膜失功能低温体外循环对母体和胎儿的影响多学科如何协助治疗妊娠期机械瓣功能障碍妊娠期机械瓣功能障碍左心瓣膜置换术后三尖瓣返流是一个易受忽视的问题显著影响长期生存率Nath J,et al, J Am Coll Cardiol,2004;43,405机制 肺动脉高压 三尖瓣环扩张 心房纤颤 风湿性病变的进展 成形技术的局限性 Xuejun X, et al. Heart Lung and Circul, 2004;13,65Xuejun X, et al. Heart Lung and Circul, 2004;13,65左心瓣膜置换术后三尖瓣返流左心瓣膜置换术后
9、三尖瓣返流处理策略再次成形：Devegas， 瓣环成形，如何选择瓣环种类瓣膜置换：金属瓣：血栓风险 生物瓣：近几年多采用左心瓣膜置换术后三尖瓣返流左心瓣膜置换术后三尖瓣返流有待解决的问题l l左心瓣膜置换术后三尖瓣返流的原因l l选择成形术的标准l l选用何种成形方法l l如何选择瓣环的种类和大小l l选择瓣膜置换术的标准l l如何预防三尖瓣返流左心瓣膜置换术后三尖瓣返流左心瓣膜置换术后三尖瓣返流二尖瓣成形失败瓣膜成形术所占的比例不高瓣膜成形术所占的比例不高 在我国瓣膜病以风湿性病变为主，在我国瓣膜病以风湿性病变为主， 病人就诊晚病人就诊晚 成形技术未能普遍开展成形技术未能普遍开展 担心成形失
10、败而需再次手术担心成形失败而需再次手术 外科治疗方法再次成形术瓣膜置换术经导管瓣膜植入术 “环中瓣”二尖瓣成形失败二尖瓣成形失败如何预防掌握二尖瓣成形术的指征采用合适的成形方法术中食道B超检查二尖瓣成形失败二尖瓣成形失败实时三维实时三维TEETEE在二尖成形术中的应用在二尖成形术中的应用Post RepairPost RepairPre RepairPre Repair二尖瓣成形失败二尖瓣成形失败展 望随着外科技术及围手术期处理水平的提高，再次手术病人死亡率将下降介入及微创技术的进步可减少再次开胸手术Edwards LifesciencesEdwards Lifesciences经导管主动脉瓣
11、植入术的初步实验经导管主动脉瓣植入术的初步实验经导管主动脉瓣植入术的初步实验经导管主动脉瓣植入术的初步实验THANK YOUStrategies of Re-operation in Heart Valve DiseaseCong Lu, MDCong Lu, MDGuangdong General HospitalGuangdong General HospitalGuangdong Provincial Cardiovascular InstituteGuangdong Provincial Cardiovascular InstituteGuangzhou, ChinaGuangzhou
12、, ChinaGuangdong GeneralHospitalGuangdong ProvincialCardiovascular InstituteRelevant Historic Milestones in China1954 1954 Closed mitral commissurotomy1958 The first application of CPB1958 The first application of CPB1958 1958 Open mitral commissurotomy by CPB1965 Mitral valve replacement1965 Mitral
13、 valve replacementEminent Pioneers and Institutions of China Cai YongzhiCai Yongzhi Changhai Hospital Changhai Hospital ShanghaiShanghaiZhang BaorenZhang Baoren Changhai Hospital Changhai Hospital ShanghaiShanghaiGuo JiaqiangGuo Jiaqiang Fuwai Cardiovascular Hospital Fuwai Cardiovascular Hospital Be
14、ijingBeijingLuo ZhengxiangLuo Zhengxiang Guangdong General Hospital Guangdong General Hospital GuangzhouGuangzhouOperations and Re-operationsBy the late 1990s, 6000 heart valve operations performed each yearIn recent years, the number of valve In recent years, the number of valve operations per year
15、 is more than 20 000 operations per year is more than 20 000 With the number of heart valve surgeries With the number of heart valve surgeries increasing, re-operation of heart valve increasing, re-operation of heart valve disease becomes an unavoidable problemdisease becomes an unavoidable problem
16、The Experience of Our HospitalHeart valve surgeries in Guangdong Heart valve surgeries in Guangdong General Hospital from 1997 to 2007General Hospital from 1997 to 2007The Experience of Our HospitalThe total operations from 1997 to 2007The total operations from 1997 to 2007： 6703 cases6703 casesRe-o
17、perationsRe-operations：499 cases499 cases ( 7.4%)( 7.4%)Perioperative mortality of re-operations Perioperative mortality of re-operations ：8.8%8.8%Causes of Re-operationThe leading causeThe leading cause：Re-stenosis after closed mitral Re-stenosis after closed mitral commissurotomycommissurotomy（64.
18、5%64.5%）Causes of re-operation of other hospital HospitalHospitalRe-operationRe-operationcausescausesFuwai HospitalFuwai Hospital333333a,b,c,d,e,fa,b,c,d,e,fXinqiao HospitalXinqiao Hospital187187f,a,d,gf,a,d,gRenji HospitalRenji Hospital203203f,a,g,f,a,g,Fujian Provincial HospitalFujian Provincial H
19、ospital104104f,e,g,d,a,hf,e,g,d,a,hBaotou Central HospitalBaotou Central Hospital165165f,a,g,c,d,b,ef,a,g,c,d,b,ea: bioprosthetic failurea: bioprosthetic failure， b: perivalvular leakageb: perivalvular leakage， c: lesion of natural valvec: lesion of natural valve， d: dysfunction of mechanical valved
20、: dysfunction of mechanical valve，e: endocarditise: endocarditis， f: closed mitral commissurotomyf: closed mitral commissurotomy，g: open mitral commissurotomyg: open mitral commissurotomy， h: othersh: othersRisks and StrategiesRisks are higher of re-operation than Risks are higher of re-operation th
21、an initial operationinitial operation pro-longed history pro-longed history poor cardiac functionpoor cardiac function adhesionadhesion bleedingbleedingA variety of methods and strategies of A variety of methods and strategies of management should be applied according management should be applied ac
22、cording to different causes leading to re-operationto different causes leading to re-operationRestenosis after Closed or Open Mitral Commissurotomy Was widely done with good results in ChinaRestenosis is unavoidable Restenosis is unavoidable CharactersCharacters：pro-longed historypro-longed history，
23、often often concomitant with tricuspid regurgitationconcomitant with tricuspid regurgitationStrategiesStrategies： re-repair re-repair prosthetic valve replacement prosthetic valve replacement ： bioprosthetic valvebioprosthetic valve mechanical prosthetic valve mechanical prosthetic valveDysfunction
24、of Mechanical Prosthetic ValveProsthetic valve structureProsthetic valve structureObstruction of mechanical prosthetic valveObstruction of mechanical prosthetic valve pannus, fibrous tissue accrementitionpannus, fibrous tissue accrementition thrombogenesis: most within 3 years thrombogenesis: most w
25、ithin 3 years postoperationpostoperationCauses of obstructionMVRMVRAVRAVRTVRTVRthrombogenesis35(71%)35(71%)8(33%)8(33%)4(100%)4(100%)pannus, fibrous tissuepannus, fibrous tissue14(29%)14(29%)16(67%)16(67%) Dysfunction of Mechanical Prosthetic ValveDysfunction of Mechanical Prosthetic Valve Strategie
26、sThrombus：thromblysis reoperationPannus, fibrous tissue ：reoperationDifference of the target value of INR among AVR, MVR and TVRAVR：INR 1.8-2.0MVR：INR 2.0-2.5TVR：INR 2.5-3.0Mechanical valve dysfunction in pregnant womenCauses （1 1）hemostasis changes in pregnancy Pregnancy is associated with a 20-200
27、% increase in levels of fibrinogen and factors II, VII, VIII, X, and XII Lockwood CJ. Obstet Gynecol 2002;99:333. （2 2）worry about the side effect of warfarinworry about the side effect of warfarin （3 3）discontinue anticoagulation therapy in the discontinue anticoagulation therapy in the early stage
28、 of pregnancy or use other early stage of pregnancy or use other anticoagulants anticoagulantsMechanical valve dysfunction in pregnant womenMechanical valve dysfunction in pregnant women Experience of our hospitalSeven patients with mechanical valve dysfunction during pregnancy were retrospectively
29、reviewed NYHA at IV in 3, at III in 3Gestation period 28 weeks in 4, 28 in 2Thrombogenesis leading to mechanical valve obstruction in all patientsMechanical valve dysfunction in pregnant womenMechanical valve dysfunction in pregnant women Methods of surgical managementCaesarean section concomitant w
30、ith re-Caesarean section concomitant with re-replacement of mechanical prosthetic valve replacement of mechanical prosthetic valve Mechanical prosthetic valve re-replacement on Mechanical prosthetic valve re-replacement on ordinary temperature cardiopulmonary bypass ordinary temperature cardiopulmon
31、ary bypass with continue fetal heart rate monitoring with continue fetal heart rate monitoring Caesarean section followed by re-replacement Caesarean section followed by re-replacement of mechanical prosthetic valve of mechanical prosthetic valve Mechanical valve dysfunction in pregnant womenMechani
32、cal valve dysfunction in pregnant women ResultsAll patients discharged from hospital in well condition Two patients with gestation period 28 weeks who underwent mechanical prosthetic valve re-replacement , one fetus died and the other one survived and delivered in mature pregnancyFive infants were d
33、elivered and discharged in good health Mechanical valve dysfunction in pregnant womenMechanical valve dysfunction in pregnant women Strategies of surgical managementDysfunction of mechanical valve + gestation periodDysfunction of mechanical valve + gestation period 3 months 6 months 6 months？Degree
34、of obstruction of mechanical valveDegree of obstruction of mechanical valveCardiac functionCardiac functionGestation period and condition of fetusGestation period and condition of fetusDesire of patients and family membersDesire of patients and family membersExperience of cardiac surgeonExperience o
35、f cardiac surgeonProfessional level of relevant departmentProfessional level of relevant departmentMechanical valve dysfunction in pregnant womenMechanical valve dysfunction in pregnant women Factors impact on making decision of managementMechanical valve dysfunction in pregnant womenMechanical valv
36、e dysfunction in pregnant women Challenging Many young women who underwent valve Many young women who underwent valve replacement want to have babyreplacement want to have babyIrregular anticoagulation therapy during Irregular anticoagulation therapy during pregnancypregnancyThe adverse impacts of h
37、ypothermia and CPB The adverse impacts of hypothermia and CPB on fetuson fetusHow to prevent and manage mechanical valve How to prevent and manage mechanical valve dysfunction in pregnant patientsdysfunction in pregnant patientsHow to cooperate with other department ,eg. How to cooperate with other
38、department ,eg. Neontology department, obstetrics departmentNeontology department, obstetrics departmentLate Tricuspid Regurgitation after Left Cardiac Valve ReplacementTricuspid regurgitation is often neglectedAdverse impact on survivalNath J,et al, J Am Coll Cardiol,2004;43,405Mechanism Persistent
39、 pulmonary hypertension Annular dilatation Atrial fibrillation Progression or development of rheumatic lesions Limitation of De Vegas procedure Xuejun X, et al. Heart Lung and Circul, 2004;13,65 Xuejun X, et al. Heart Lung and Circul, 2004;13,65TR after Left Cardiac Valve ReplacementTR after Left Ca
40、rdiac Valve ReplacementTR after Left Cardiac Valve ReplacementTR after Left Cardiac Valve Replacement Strategies of managementRe-repairRe-repair De Vegas procedure De Vegas procedure annuloplasty ring annuloplasty ring Valve replacementValve replacement mechanical valve mechanical valve：risk of thro
41、mbogenesisrisk of thrombogenesis bioprosthetic valve bioprosthetic valve：widely used in recent widely used in recent years yearsTR after Left Cardiac Valve ReplacementTR after Left Cardiac Valve Replacement Remaining QuestionsWhat is the mechanism of functional TR?What is the mechanism of functional
42、 TR?How to perform tricuspid repair?How to perform tricuspid repair?Which size and kind of ring for which patient?Which size and kind of ring for which patient?When should we perform a repair?When should we perform a repair?When should we think to valve replacement?When should we think to valve repl
43、acement?Why late development of tricuspid regurgitation Why late development of tricuspid regurgitation after successful mitral surgery?after successful mitral surgery?How to prevent it?How to prevent it?Failure and Complication of Valve RepairValve repair is far less than valve replacement Valve re
44、pair is far less than valve replacement in Chinain China R Rheumatic heart disease is still the leading cause of valvular damage leading to surgery in China Patients often experienced pro-longed history before their first visits Techniques of valve repair are not applied widelyTechniques of valve re
45、pair are not applied widely Worry about reoperationWorry about reoperation Methods of surgical treatment Re-repair Valve replacement Transcatheter valve implantation valve-in-ring Failure Failure of Valve of Valve RepairRepairFailure of Valve RepairFailure of Valve Repair How to prevent ?Indication
46、and contraindication of mitral repairApply suitable methods of mitral repairTEEFailure of Valve RepairFailure of Valve Repair Live 3D TEE for Mitral Repair SurgeryPost RepairPost RepairPre RepairPre RepairProspectionWith the development of surgical techniques With the development of surgical techniq
47、ues ，the incidence of reoperation and the mortality of the incidence of reoperation and the mortality of reoperation will decreasereoperation will decreaseWith the improvement of interventional therapy, With the improvement of interventional therapy, reopen chest surgery will be avoided in some reopen chest surgery will be avoided in some patientspatientsEdwards LifesciencesEdwards LifesciencesOur preliminary experiment of transcatheter aortic Our preliminary experiment of transcatheter aortic valve implantationvalve implantationTHANK YOU
