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1、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,心脏瓣膜手术 409524例 主动脉瓣手术 216245例，死亡率5.7 二尖瓣手术 120641例，死亡率7.7 居第二位，死亡率高,STS的资料（19942003年）,心脏瓣膜手术 主动脉瓣手术 1026例，死亡率3.25 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）,风湿性瓣膜病 80 瓣膜置换术 7085 病理特点 二尖瓣瓣膜与瓣下结构严重受损 合并房颤发生率高（70） 合并三尖瓣的病变多（67）,上海长海
2、医院二尖瓣病变病因,人造瓣膜的选择与匹配 保留瓣下结构的问题 合并巨大右心房的处理 重视合并房颤的处理 合并三尖瓣病变的处理 钙化瓣环的处理,二尖瓣置换术应重视的问题,Zam报告884例术后Ech，随访5.14.1年 PPM定义（有效开口面积指数）0.25cm/m EOA=,关于MVR人造瓣膜与病人不匹配（PPM）,EOA（cm） BSA（m）,心功能不全 跨瓣压差高 肺动脉高压 右室压升高,PPA对心功能的影响,有效的维护左心功能 保留二尖瓣后瓣下结构 保留二尖瓣全瓣下结构 人工腱索或瓣中瓣,二、关于保留瓣下结构问题,保留瓣环手术,型：向下压迫左心室的基底部 型：向上向左压迫总支气管 型：向
3、右压迫左肺中下叶， 施行不同部位折叠术,三、巨大左房（300ml）的处理,巨大左房,风湿性二尖瓣病变合并房颤高达5079 心功能不全进一步加重 增加血栓栓塞的发生率 影响术后近、远期效果 射频消融法 冷冻消融法,四、重视合并房颤的处理,风湿性全心炎慢性 二尖瓣置换术后，左室腔容积减少，室间隔左移，TV加重 常规探查，瓣环直径21mm/m，TV成形术 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）,钙化瓣环是老年病人少见的病理病变 常位于房室的联合部 邻近房室沟的冠状血管 困难的外科技术问题,钙化瓣环的处理,钙化二尖瓣瓣环的处理,钙化二尖瓣瓣环的处理,谢谢,Contro
4、versies and Thoughts in Mitral Valve Replacement,Department of Cardiothoracic Surgery Changhai Hospital Second Military Medical University,Zhang Bao-ren,Overview,from STS/AHA Database (1994-2003),Overview,from Changhai Hospital China (1986-2006),Profile of MV disease in China,The most common cause i
5、s chronic rheumatic mitral valve disease (80%) The most common procedure is mitral valve replacement (70%80%) Pathologic characteristics of rheumatic findings Fibrosis and calcification of mitral valve apparatus Combining chronic atrial fibrillation (70%) Combining tricuspid valve regurgitation (67%
6、),From Shanghai Changhai hospital database,Special problems about MV procedure,the impact of patient-prosthesis mismatch preservation of the subvalvular apparatus the management of chronic atrial fibrillation the management of giant left atrium the management of combined tricuspid regurgitation the
7、management of calcified annulus,patient-prosthesis mismatch (PPM),PPM in the mitral position an old concept and new evidences the threshold value for mitral PPM is high than for aortic PPM mitral PPM is considered moderate when indexed EOA is 1.2 1.3cm2/m2,2,2,Impact of PPM on cardiac function,cardi
8、ac insufficiency pulmonary artery hypertension,Preservation of subvalvular apparatus,preservation of posterior leaflets preservation of Chordae to both leaflets artificial tendineae,METHODS,Preservation of subvalvular apparatus,Management of giant left atrium,Criterion: LA 300ml adverse effect: comp
9、ressing ventricles and lung,optimal plication procedure could improve ventricular and lung function,Giant Left Atrium,Management of atrial fibrillation,The most common complication of MS (5070%) adverse effect: impairing ventricular function methods: modified maze op. and modified ablation,Managemen
10、t of tricuspid regurgitation,for more than 25 years to aware of TR complicated in large number of RHD TR is progressive disease after MVR Tricuspid annuloplasty must be done when annulus diameter is 21mm/m2 Make every effort to avoid doing TV replacement,Management of calcified annulus,prevalence more than 1/3 posteriomedial annulus involved treatment completely removing the calcification cautions avoid injuring ventricular myocardium and coronary vessels,Management of calcified annulus,Management of calcified annulus,THANKS !,