机械及生物主动脉瓣 --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 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

52% 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 缺 点 需终身抗凝 结构故障少 抗凝相关并发症 无须再次手术 瓣膜钙化 瓣膜衰败 优异的血流动力学 需再次手术 无需抗凝治疗

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 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％ 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％

生物瓣置换15年随访的Kaplan-Mier 生存曲线 90.1% 86.4% 69.1% 生物瓣置换15年随访的Kaplan-Mier 生存曲线

机械瓣置换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

西京医院选择人工瓣膜的原则 选择机械瓣 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 选择生物瓣 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

人工瓣膜的大小选择 主动脉瓣 我院1422例主动脉瓣置换的型号分布图 有效开口面积指数（IEOA）=0.85 小于主动脉直径2 mm 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 我院1422例主动脉瓣置换的型号分布图

人工瓣膜的大小选择 二尖瓣 成人二尖瓣一般置换多为27mm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 我院5321例二尖瓣置换的型号分布图

讨 论 二尖瓣、主动脉瓣同期置换的瓣膜匹配 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。

讨 论 婴幼儿瓣膜置换的选择 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 讨 论 婴幼儿瓣膜置换的选择 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

讨 论 合并感染性心内膜炎的瓣膜置换选择 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 讨 论 合并感染性心内膜炎的瓣膜置换选择 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

特殊情况下人工瓣膜的选择 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。

双瓣同期置换术

四瓣膜同期置换(西京医院)

婴幼儿换瓣 二尖瓣发育不良并重度关闭不全

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Patient Selection and Practice Patterns: Mechanical versus Bioprosthetics Aortic Valves Yi Dinghua, Liu Jincheng, Yu Shiqiang, Yang Jian, Jin Zhenxiao, et al Institute of Cardiovascular disease of PLA Department of Cardiovascular Surgery, Xijing Hospital Fourth Military Medical University

cases 1999 2000 2001 2002 2003 2004 2005 2006 2007 Cardiac Operations Performed in the Department of Cardiovascular Surgery in Xijing Hospital from 1990 to 2007

52% 23% 8% 7% 10% Distribution of different types of 3225 cardiac operations in the Department of Cardiovascular Surgery Xijing Hospital in 2007

Advantage and disadvantage of artificial valve Few structural deterioration Free from re-operation Life-long anticoagulation Related complications Calcification Deterioration Re-operation Good haemodynamics Free from anticoagulation

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 Thromboembolisis 1.8％ 0.21％ Bleeding 2.1％ 0.48％

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

Principle for selection of mechanical or bioprosthetic valves in Xijing Hospital Mechanical valve preferred < 60 years old Comorbided with atrial fibrillation Risk factor for thromboembolism Infective endocarditis (For the first time)

Bioprosthetic valve preferred Principle for selection of mechanical or bioprosthetic valves in Xijing Hospital Bioprosthetic valve preferred > 60 years old Comorbided without atrial fibrillation No risk factor for thromboembolism Tricuspid valve replacement Female patients with fertility require

Distribution of the size of 1422 aortic valve replaced in our hospital Selection of the size for artificial valves Aortic valve Indexed effective orifice area（IEOA）=0.85 2 mm smaller than the radius of the aortic annulus >19mm in patients with small aortic root Our sizes were smaller than that of western countries Distribution of the size of 1422 aortic valve replaced in our hospital

Distribution of the size of 5321 mitral valve replaced in our hospital Selection of the size for artificial valves Mitral valve Most selected mitral valve in adults is 27mm Smaller valve preferred in patients with small left ventricle or heart insufficiency 22 cases of valve replacement in patients under 45kg 3 cases of 19mm valve replacement in 3-12 months’ old infants Distribution of the size of 5321 mitral valve replaced in our hospital

Match of concomitant Mitral and Aortic valve replacement Discussion Match of concomitant Mitral and Aortic valve replacement 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 valve should be avoided. Otherwise left ventricle overload will occur, leading to left heart failure.

Choice of valve replacement in infants Discussion Choice of valve replacement in infants Due to the calcification and deterioration of bioprosthesis, mechanical valve is preferred Need for re-operation Valvuloplasty should be the first choice in children Walfarin can usually be well tolerated in children

Choice of valve replacement in patients with endocarditis Discussion Choice of valve replacement in patients with endocarditis 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 special situation Concomitant multi-valve replacement Avoid select valves of different types For young female patients with fertility require Valvuloplasty is the first choice Bioprosthesis can also be used when necessary

Concomitant double-valve replacement

Concomitant four-valve replacement

Valve replacement in infants Congenital mitral valve insufficiency

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