二尖瓣置换术几个问题的商榷.ppt

Changhai Hospital长海胸心外科医院二尖瓣置换术几个问题的商榷张宝仁第二军医大学长海医院胸心外科上海市成人心血管临床医学中心中国人民解放军心胸外科研究所Changhai Hospital长海胸心外科医院Ø心脏瓣膜手术 409524例Ø主动脉瓣手术 216245例，死亡率5.7％Ø二尖瓣手术 120641例，死亡率7.7％居第二位，死亡率高STS的资料（1994－2003年）Changhai Hospital长海胸心外科医院Ø心脏瓣膜手术 Ø主动脉瓣手术 1026例，死亡率3.25％Ø二尖瓣手术 3416例，死亡率4.30％居第一位，死亡率高上海长海医院资料（1978-2006年）Changhai Hospital长海胸心外科医院Ø风湿性瓣膜病 80％Ø瓣膜置换术 70～85％Ø病理特点Ø二尖瓣瓣膜与瓣下结构严重受损Ø合并房颤发生率高（70％）Ø合并三尖瓣的病变多（67％）上海长海医院二尖瓣病变病因Changhai Hospital长海胸心外科医院Ø人造瓣膜的选择与匹配Ø保留瓣下结构的问题Ø合并巨大右心房的处理Ø重视合并房颤的处理Ø合并三尖瓣病变的处理Ø钙化瓣环的处理二尖瓣置换术应重视的问题Changhai Hospital长海胸心外科医院ØZam报告884例术后Ech，随访5.1±4.1年ØPPM定义义（有效开口面积积指数）300ml）的处理Changhai Hospital长海胸心外科医院巨大左房巨大左房Changhai Hospital长海胸心外科医院风湿性二尖瓣病变合并房颤高达50～79％Ø心功能不全进一步加重Ø增加血栓栓塞的发生率Ø影响术后近、远期效果Ø射频消融法Ø冷冻消融法四、重视合并房颤的处理有效率70～80％Changhai Hospital长海胸心外科医院Ø风湿性全心炎慢性Ø二尖瓣置换术后，左室腔容积减少，室间隔左移，TV加重Ø常规探查，瓣环直径>21mm/m，TV成形术Ø力争不做三尖瓣置换术五、术中三尖瓣探查与处理 （三尖瓣关闭不全的原因）二尖瓣环扩张，瓣膜受损较重二尖瓣环扩张，瓣膜受损较轻Changhai Hospital长海胸心外科医院Ø钙化瓣环是老年病人少见的病理病变Ø常位于房室的联合部Ø邻近房室沟的冠状血管Ø困难的外科技术问题钙化瓣环的处理Changhai Hospital长海胸心外科医院钙化二尖瓣瓣环的处理钙化二尖瓣瓣环的处理Changhai Hospital长海胸心外科医院钙化二尖瓣瓣环的处理钙化二尖瓣瓣环的处理Changhai Hospital长海胸心外科医院Changhai Hospital长海胸心外科医院Changhai Hospital长海胸心外科医院Controversies and Thoughts in Mitral Valve ReplacementDepartment of Cardiothoracic SurgeryChanghai HospitalSecond Military Medical University Zhang Bao-renChanghai Hospital长海胸心外科医院NO.mortalityTotal409524AV procedure2162455.7%MV procedure132641 7.7%Overview from STS/AHA Database (1994-2003)Changhai Hospital长海胸心外科医院NO.mortalityAV procedure10263.25%MV procedure3416 4.3%Overview from Changhai Hospital China (1986-2006)Changhai Hospital长海胸心外科医院Profile of MV disease in China u The most common cause is chronic rheumaticmitral valve disease (80%)u The most common procedure is mitral valvereplacement (70%~80%)u Pathologic characteristics of rheumatic findingsØ Fibrosis and calcification of mitral valve apparatusØ Combining chronic atrial fibrillation (70%)Ø Combining tricuspid valve regurgitation (67%)From Shanghai Changhai hospital databaseChanghai Hospital长海胸心外科医院Special problems about MV procedure u the impact of patient-prosthesis mismatchu preservation of the subvalvular apparatusu the management of chronic atrial fibrillationu the management of giant left atriumu the management of combined tricuspid regurgitationu the management of calcified annulus Changhai Hospital长海胸心外科医院patient-prosthesis mismatch (PPM)u PPM in the mitral positionan old concept and new evidencesu the threshold value for mitral PPM is high than for aortic PPMu mitral PPM is considered moderate when indexed EOA is 1.2 ~ 1.3cm2/m2★22Changhai Hospital长海胸心外科医院Impact of PPM on cardiac functionu cardiac insufficiency u pulmonary artery hypertensionChanghai Hospital长海胸心外科医院Preservation of subvalvular apparatusu preservation of posterior leaflets u preservation of Chordae to both leafletsu artificial tendineae METHODSChanghai Hospital长海胸心外科医院Preservation of subvalvular apparatusChanghai Hospital长海胸心外科医院Management of giant left atriumuCriterion: LA > 300mlu adverse effect: compressing ventricles and lungoptimal plication procedure could improve ventricular and lung functionChanghai Hospital长海胸心外科医院Giant Left AtriumChanghai Hospital长海胸心外科医院Management of atrial fibrillationu The most common complication of MS (50~70%)u adverse effect: impairing ventricular functionu methods: modified maze op. and modified ablationChanghai Hospital长海胸心外科医院Management of tricuspid regurgitationu for more than 25 years to aware of u TR complicated in large number of RHDu TR is progressive disease after MVRu Tricuspid annuloplasty must be done when annulus diameter is > 21mm/m2u Make every effort to avoid doing TV replacementChanghai Hospital长海胸心外科医院Management of calcified annulusu prevalencemore than 1/3 posteriomedial annulus involvedu treatment completely removing the calcificationu cautionsavoid injuring ventricular myocardium and coronary vessels Changhai Hospital长海胸心外科医院Management of calcified annulusChanghai Hospital长海胸心外科医院Management of calcified annulusChanghai Hospital长海胸心外科医院THANKS !。