机械及生物主动脉瓣机械及生物主动脉瓣

---- 病人选择及手术方式实施病人选择及手术方式实施

第四军医大学西京医院心血管外科第四军医大学西京医院心血管外科易定华，俞世强，刘金成，金振晓等易定华，俞世强，刘金成，金振晓等

2008 年 12 月 上海

cases

1990 － 2007 西京医院心血管外科手术量情况

0

500

1000

1500

2000

2500

3000

3500

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

体外循环例数 非体外例数

例数

年

CHD

VALVE

CABG

AORTA

OTHER52%23%

8%

7%

10%

2007 年西京医院 3225 例心脏手术分布图

人工瓣膜的优缺点

优 点

结构故障少 无须再次手术

缺 点

需终身抗凝 抗凝相关并发症

优异的血流动力学无需抗凝治疗

瓣膜钙化

瓣膜衰败

需再次手术

9143

982

1988 年 5月至 2008 年 5月西京医院

8206 例患者应用 10125 枚人工瓣膜种类分布

总体随访率为 91.2% 累及随访达 49232 病人•年

并发症 机械瓣 ( 病人•年 )

生物瓣 ( 病人•年 )

血栓栓塞 1.8 ％ 0.21 ％ 出血 2.1 ％ 0.48 ％

90.1%

86.4%

69.1%

生物瓣置换 15年随访的 Kaplan-Mier 生存曲线

89.2%

84.5%

68.6%

机械瓣置换 15年随访的 Kaplan-Mier 生存曲线

年龄 < 60 岁

并发房颤

有血栓栓塞的风险

首次感染性心内膜炎的患者

西京医院选择人工瓣膜的原则

选择机械瓣

年龄 > 60 岁

不伴有房颤

无血栓栓塞的风险

进行三尖瓣置换时

具有生育要求的年轻女性患者

西京医院选择人工瓣膜的原则

选择生物瓣

有效开口面积指数（ IEOA ） =0.

85

小于主动脉直径 2 mm

在小主动脉根患者选择≥19mm

的人工瓣膜，必要时根部加宽

应用瓣膜尺寸小于国外报道，与

我国西部身高体重特征有关

人工瓣膜的大小选择

我院 1422 例主动脉瓣置换的型号分布图

主动脉瓣

成人二尖瓣一般置换多为 27

mm 瓣膜

合并左室小或者左心功能不

全，应使用较小型号的瓣膜

45kg 以下小左室患者 22 例

3-12 月婴儿应用 19mm 瓣

膜 3 例

人工瓣膜的大小选择

我院 5321 例二尖瓣置换的型号分布图

二尖瓣

讨 论

推荐选择主动脉瓣小于二尖瓣 4mm ，如二尖瓣 27mm ＋主动脉瓣 23mm ；或二尖瓣 25mm ＋主动脉瓣 21mm 。

主动脉瓣较小时，不宜置换过大二尖瓣，否则左心室负荷过重，易于出现左心功能衰竭。

二尖瓣、主动脉瓣同期置换的瓣膜匹配

讨 论

生物瓣膜钙化和衰坏较快，选择机械瓣 再次手术置换较大瓣膜 小儿基本可以接受华法林抗凝治疗 应当尽量通过成形来修复

婴幼儿瓣膜置换的选择

讨 论

首次手术治疗时选择的标准和非感染性心内膜炎患者相似

对复发的感染性心内膜炎的患者应使用生物瓣膜

在有广泛的瓣环缺损和心室主动脉分离时，采用同种主动脉根部置换

合并感染性心内膜炎的瓣膜置换选择

同期置换多个瓣膜的选择

避免使用不同种类瓣膜进行同期置换

育龄妇女瓣膜置换的选择

对有生育要求的年轻女性力争进行瓣

膜成形术，必要时推荐应用生物瓣膜

进行瓣膜置换。

特殊情况下人工瓣膜的选择

双瓣同期置换术

四瓣膜同期置换 ( 西京医院 )

二尖瓣发育不良并重度关闭不全

婴幼儿换瓣

Yi Dinghua, Liu Jincheng, Yu Shiqiang, Yi Dinghua, Liu Jincheng, Yu Shiqiang, Yang Jian, Jin Zhenxiao, et alYang Jian, Jin Zhenxiao, et al

Institute of Cardiovascular disease of PLA

Department of Cardiovascular Surgery, Xijing

Hospital

Fourth Military Medical University

Patient Selection and Practice Patterns:Patient Selection and Practice Patterns:Mechanical versus Bioprosthetics Aortic ValvesMechanical versus Bioprosthetics Aortic Valves

cases

Cardiac Operations Performed in the Department of Cardiovascular Surgery in Xijing Hospital from 1990 to 2007

1999 2000 2001 2002 2003 2004 2005 2006 2007

0

500

1000

1500

2000

2500

3000

3500

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

体外循环例数 非体外例数

例数

年

CHD

VALVE

CABG

AORTA

OTHER52%23%

8%

7%

10%

Distribution of different types of 3225 cardiac operations in the Department of Cardiovascular Surgery Xijing Hospital in 2007

Advantage Disadvantage

Advantage and disadvantage of artificial valve

Life-long

anticoagulation

Related complications

Few structural

deterioration

Free from re-

operation

Good haemodynamics Free from anticoagulati

on

Calcification

Deterioration

Re-operation

9143

982

Distribution of 10125 artificial valves used in 8206 patients in Xijing Hospital from May, 1988 to May, 2008

Results

Follow-up rate was 91.2%

Accumulated follow-up time is 49232 patients•year

Complications Mechanical (Patients•year)

Bioprosthetics

(Patients•year) Thromboembolisis 1.8 ％ 0.21 ％ Bleeding 2.1 ％ 0.48 ％

90.1%

86.4%

69.1%

Kaplan-Mier Survival Curve of bioprosthesis during 15 years’ follow-up

89.2%

84.5%

68.6%

Kaplan-Mier Survival Curve of mechanical valve during 15 years’ follow-up

< 60 years old

Comorbided with atrial fibrillation

Risk factor for thromboembolism

Infective endocarditis (For the first time)

Principle for selection of mechanical or bioprosthetic valves in Xijing Hospital

Mechanical valve preferred

> 60 years old

Comorbided without atrial fibrillation

No risk factor for thromboembolism

Tricuspid valve replacement

Female patients with fertility require

Principle for selection of mechanical or bioprosthetic valves in Xijing Hospital

Bioprosthetic valve preferred

Indexed effective orifice area

（ IEOA ） =0.85

2 mm smaller than the radiu

s of the aortic annulus

>19mm in patients with sma

ll aortic root

Our sizes were smaller than t

hat of western countries

Selection of the size for artificial valves

Aortic valve

Distribution of the size of 1422 aortic valve replaced in our hospital

Most selected mitral valve in adu

lts is 27mm

Smaller valve preferred in patien

ts with small left ventricle or hea

rt insufficiency

22 cases of valve replacement in

patients under 45kg

3 cases of 19mm valve replacem

ent in 3-12 months’ old infantsDistribution of the size of 5321 mitral val

ve replaced in our hospital

Mitral valve

Selection of the size for artificial valves

Discussion

Aortic valve 4mm smaller than mitral valve is recommended. I.E.

27mm M ＋ 23mm A ； 25mm M ＋ 23mm A When the aortic valve is small, big mitral v

alve should be avoided. Otherwise left ventricle overload will occur, leading to left heart failure.

Match of concomitant Mitral and Aortic valve replacement

Due to the calcification and deterioration of bioprosthesis, mechanical valve is preferred

Need for re-operation Valvuloplasty should be the first choice in childr

en Walfarin can usually be well tolerated in childre

n

Choice of valve replacement in infants

Discussion

The criteria for first time is same to ordinary patients

For re-occurred patients, bioprosthesis is preferred

For patients with extensive annular defect or the detachment between ventricle and aorta, root replacement would be selected

Choice of valve replacement in patients with endocarditis

Discussion

Concomitant multi-valve replacement

Avoid select valves of different types For young female patients with fertility r

equire Valvuloplasty is the first choice

Bioprosthesis can also be used when nec

essary

Choice of valve replacement in special situation

Concomitant double-valve replacement

Concomitant four-valve replacement

Congenital mitral valve insufficiency

Valve replacement in infants