【作者】 陈林；

【导师】 肖颖彬；

【作者基本信息】 第三军医大学 ， 外科学， 2005， 博士

【摘要】 研究背景:风湿性心脏瓣膜疾病是常见的心脏疾病,在我国发病率较高,目前,心脏瓣膜置换手术是治疗瓣膜疾病有效、可靠的治疗方法,其中,主动脉和二尖瓣双瓣膜置换术(DVR)占近30%,其手术难度大、危险性高,合并细小主动脉瓣环的处理更困难,争议较多。尽管随着对瓣膜疾病的认识水平、瓣膜置换技术、心肌保护技术、体外循环技术以及瓣膜工艺等的提高,瓣膜置换手术的成功率有较大提高,但仍存在一定的死亡率,约为1-5%,特别是DVR手术的死亡率还要高。死亡原因以低心输出综合征最常见,提示除了基础病变导致的心肌损伤外,还存在手术中心肌保护不完善的情况。目前DVR手术的心肌保护,多采用冠状静脉窦逆行灌注的心肌保护方法,而在主动脉瓣狭窄为主双瓣膜病变的病例中,采用该方法是否妥当,是否还有更完善的方法,目前尚不明确。本研究旨在分析心脏瓣膜置换手术后早期死亡的危险因素,为临床防治提供参考;评估双瓣膜置换术中主动脉瓣位植入小型号机械瓣的疗效,并探讨影响中、远期疗效的因素,为临床应用小口径主动脉机械瓣提供理论依据;研究以主动脉瓣狭窄为主双瓣膜病变的病理特征和能量代谢状况,探寻主动脉瓣狭窄为主双瓣膜置换手术的更佳心肌保护措施。研究方法:第一部分为临床回顾性研究,应用Microsoft Access XP数据库和SPSS10.0统计软件,收集1998年01月至2004年05月我院1092例接受心脏瓣膜置换术患者的临床资料,用logistic回归分析模型,重点分析患者基础病变、手术方式、心肌保护方式、体外循环转流时间、阻断主动脉时间、血清损伤标志物,以及手术并发症等因素对手术早期死亡的影响。第二部分为前瞻性研究,针对重庆地区患者体形小的特点,跟踪记录2002年01月至2005年06月期间,我院232例双瓣膜置换手术(DVR)的临床资料,研究主动脉瓣位植入小型号机械瓣的DVR手术中、后期心功能恢复情况。研究分三组:植入17mm更多还原

【Abstract】 Background:Rheumatic heart valve disease is one of the common heart diseases in China. Valve replacement is the most effective and reliable treatment for this disease at present. However, there is much controversy about combined aortic and mitral replacement, whose proportion is 30% in all the valve replacement surgeries, especially in patients with small aortic valve rings. Various postoperative median and long-term effects have been reported in patients with small aortic valve prothesis. Although outcome of valve replacement has been significantly improved as a result of progress in knowledge about heart valve disease, surgical skills, cardiopulmonary bypass and myocardial protection technologies as well as prothesis engineering, the operation still causes mortality. Combined aortic and mitral valve replacement requires precise surgical skill and usually causes relatively high mortality. Low cardiac output syndrome is the main cause of mortality, which suggests insufficient myocardial protection during operation may result in myocardial injury besides underlying pathological changes of the disease. Retrograde cardioplegia via coronary sinus is frequently used to protect myocardium in combined aortic and mitral replacement, at present few clinical researches have been reported about the effect of this technique in patients with predominant aortic valve stenosis.Objective:1.Analyze risk factors of early death after heart valve replacement.2.Observe effect of combined aortic and mitral valve replacement with small aortic valve mechanical prothesis, explore the possible factors affecting median and long-term outcome.3.Investigate the best myocardial protective strategy in multiple valve disease patients with the main abnormay of aortic valve stenosis.更多还原