50岁以上的主动脉瓣病变患者的外科治疗:附73例报告

摘要

目的 对73名50岁以上的中老年患者进行回顾性分析,探讨该人群先天性二叶主动脉瓣畸形发病特点、外科治疗策略及术后并发症情况.方法 2009年1月～2011年9月收治73名50岁以上的中老年主动脉瓣病变患者,其中男性45人,女性28人,年龄51～75岁,平均年龄为(61.8±0.7)岁.患者中1例行Bcntall术,1例行Wheat术,其余全部接受了主动脉瓣置换手术,同时行主动脉瓣,二尖瓣双瓣置换术7例,合并行二尖瓣成形术6例,三尖瓣Devega环缩术11例,冠状动脉搭桥术8例,主动脉-左室隧道修补术1例,左房血栓取出术1例,射频消融术1例.结果 患者围手术期死亡2例.手术体外循环时间为78～217min,平均(131.9±6.0) min;阻断时间56～158 min,平均(88.2±4.8) min.ICU时间为(23.0～647.4)h,平均(97.9±10.5)h.术后并发症包括5例低心排综合征；4例术后出血行再次开胸止血术；术后伤口清创4例；1例术后急性肾功能衰竭需行血液透析.术后左心室舒张末期内径较术前有明显减小[(52.6±1.7) mmvs(43.2±1.0) mm,P=0.001],手术前后左室射血分数无明显变化[(62.2±2.5)vs(65.5±1.3),P=0.257].结论 完善的术前检查、充分的术前风险因素评估、围术期的早期干预、手术策略制定上考虑患者耐受程度、预防手术并发症对降低手术死亡率是非常必要的.通过以上处理,可以将中老年二叶主动脉瓣膜置换术的手术风险降低到与同期瓣膜置换手术相似或者更低的水平.%Objective To summarize the clinical characteristics, surgical management and postoperative complications in patients with congenital bicuspid aortic valve (CBAV) over 50 years of age. Methods From January 2009 to September 2011, 73 CBAV patients aged 51-76 years (mean 61.8±0.73 years) were treated in our center. Except for 1 patient who underwent Bentall surgery and another having Wheat surgery, all the patients received aortic valve replacement (AVR), including 7 with double (mitral and aortic) valve replacement (DVR), 6 with mitral valvular plasty, 11 with tricuspid valvular plasty, 8 with coronary artery bypass graft implantation, 1 with aortic-left ventricular tunnel repair, 1 with atrial maze ablation, and 1 with left atrial thrombosis removal. Results Two patients died after the surgery, with a perioperative mortality rate of 2.7% . The cardiopulmonary bypass time was 78-217 min (mean 131.9 ±6.0 min) with an aortic blocking time of 56-158 min (mean 88.2 ±4.8 min) and total postoperative ICU time of 23.0-647.4 h (mean 97.9±10.5 h). The postoperative complications included low heart output syndrome in 5 cases, bleeding in 4 cases, wound debridement in 4 cases, and hemodialysis due to acute renal failure in 1 case. The left ventricular end diastolic diameter reduced significantly after the surgery (52.6±1.7 vs 43.2±1.0, P=0.001). No significant changes were detected in the left ventricular ejection fraction (62.3±2.5 vs 65.5±1.3, P=0.257). Conclusions Thorough preoperative examination, preoperative risk factor assessment, timely perioperative interventions, careful evaluation of patients' tolerance of surgery, and prevention of surgical complications are essential to decrease the perioperative mortality in elderly patients with CBAV.