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1、心脏瓣膜病再次手术的治心脏瓣膜病再次手术的治疗策略疗策略中国瓣膜外科发展史中的几个里程碑1954 1954 第一例闭式扩张术第一例闭式扩张术1958 1958 体外循环的首次应用体外循环的首次应用1958 1958 第一例体外循环下二尖瓣直视分离术第一例体外循环下二尖瓣直视分离术1965 1965 第一例瓣膜置换术第一例瓣膜置换术风险及对策再次瓣膜手术的风险比首次瓣膜手术的风险高 病程长 心功能差 粘连、手术时间长 出血针对不同的原因，其治疗方案及对策有所不同闭式扩张及直视交界切开术后再狭窄风湿性心脏病是导致瓣膜病变的首要原因风湿性心脏病是导致瓣膜病变的首要原因再狭窄是必然结果，闭式扩张术后的
2、症状缓解期再狭窄是必然结果，闭式扩张术后的症状缓解期一般在一般在8-158-15年年特点：病程长，常合并三尖瓣病变特点：病程长，常合并三尖瓣病变策略：策略：再次成形再次成形 换瓣换瓣 ：生物瓣（避免抗凝治疗）：生物瓣（避免抗凝治疗）机械瓣机械瓣 机械瓣功能障碍机械瓣结构原因机械瓣结构原因机械瓣梗阻：机械瓣梗阻：血管翳、纤维组织增生血管翳、纤维组织增生 血栓形成：多发生于血栓形成：多发生于3 3年内年内梗阻原因梗阻原因梗阻原因梗阻原因MVRMVRMVRMVRAVRAVRAVRAVRTVRTVRTVRTVR血栓形成血栓形成血栓形成血栓形成35(71%)35(71%)35(71%)35(71%)8(
3、33%)8(33%)8(33%)8(33%)4(100%)4(100%)4(100%)4(100%)血管翳及纤维组织增生血管翳及纤维组织增生血管翳及纤维组织增生血管翳及纤维组织增生14(29%)14(29%)14(29%)14(29%)16(67%)16(67%)16(67%)16(67%)机械瓣功能障碍机械瓣功能障碍策略血栓：内科溶栓血栓：内科溶栓 外科再次手术治疗外科再次手术治疗血管翳、纤维组织增生：再次手术治疗血管翳、纤维组织增生：再次手术治疗强调早期严格抗凝治疗，不同部位其抗凝标准有强调早期严格抗凝治疗，不同部位其抗凝标准有所不同：所不同：AVRAVR：INR 1.8-2.0INR 1
4、.8-2.0MVRMVR：INR 2.0-2.5INR 2.0-2.5TVRTVR：INR 2.5-3.0INR 2.5-3.0妊娠期机械瓣功能障碍原因：（1）妊娠期高凝状态 （2）担心华法林的副作用 （3）在妊娠早期停用或换用其他抗凝药物我院临床资料2000年2月至2006年12月，妊娠期发生机械瓣功能障碍病人7例，年龄22-32岁，平均26.4 2.6岁风湿性心脏病5例，先天性心脏病2例心功能IV级4例，III级3例妊娠期28周5例，28周2例机械瓣血栓形成，机械瓣梗阻妊娠期机械瓣功能障碍妊娠期机械瓣功能障碍外科治疗方法同期剖腹产和CPB下心脏瓣膜再次置换术；CPB下再换瓣手术，同时对宫内
5、胎儿监测与保护。先行剖腹产，密切监测心功能妊娠期机械瓣功能障碍妊娠期机械瓣功能障碍结果孕妇全部存活，无围手术期及远期死亡.剖腹产婴儿5例，均存活；无畸形，随访生长发育及智力水平正常.孕期体外循环心脏手术：一例胎儿死亡；一例存活.妊娠期机械瓣功能障碍妊娠期机械瓣功能障碍外科决策机械瓣失功能+妊娠期6个月？妊娠期机械瓣功能障碍妊娠期机械瓣功能障碍机械瓣梗阻程度心功能情况妊娠期周数及胎儿的情况患者及家属的意愿心脏外科医生的经验及业务水平涉及的有关专科的技术水平影响外科决策的因素妊娠期机械瓣功能障碍妊娠期机械瓣功能障碍面临的挑战大批育龄妇女在换瓣术后有怀孕的需要孕期的抗凝不规律问题如何预防和处理妊娠期
6、发生瓣膜失功能低温体外循环对母体和胎儿的影响多学科如何协助治疗妊娠期机械瓣功能障碍妊娠期机械瓣功能障碍左心瓣膜置换术后三尖瓣返流是一个易受忽视的问题显著影响长期生存率Nath J,et al,J Am Coll Cardiol,2004;43,405机制 肺动脉高压 三尖瓣环扩张 心房纤颤 风湿性病变的进展 成形技术的局限性 Xuejun X,et al.Heart Lung and Circul,2004;13,65Xuejun X,et al.Heart Lung and Circul,2004;13,65左心瓣膜置换术后三尖瓣返流左心瓣膜置换术后三尖瓣返流处理策略再次成形：Devegas
7、，瓣环成形，如何选择瓣环种类瓣膜置换：金属瓣：血栓风险 生物瓣：近几年多采用左心瓣膜置换术后三尖瓣返流左心瓣膜置换术后三尖瓣返流有待解决的问题l l左心瓣膜置换术后三尖瓣返流的原因l l选择成形术的标准l l选用何种成形方法l l如何选择瓣环的种类和大小l l选择瓣膜置换术的标准l l如何预防三尖瓣返流左心瓣膜置换术后三尖瓣返流左心瓣膜置换术后三尖瓣返流二尖瓣成形失败瓣膜成形术所占的比例不高瓣膜成形术所占的比例不高 在我国瓣膜病以风湿性病变为主，在我国瓣膜病以风湿性病变为主，病人就诊晚病人就诊晚 成形技术未能普遍开展成形技术未能普遍开展 担心成形失败而需再次手术担心成形失败而需再次手术 外科治
8、疗方法再次成形术瓣膜置换术经导管瓣膜植入术 “环中瓣”二尖瓣成形失败二尖瓣成形失败如何预防掌握二尖瓣成形术的指征采用合适的成形方法术中食道B超检查二尖瓣成形失败二尖瓣成形失败实时三维实时三维TEETEE在二尖成形术中的应用在二尖成形术中的应用Post RepairPost RepairPre RepairPre Repair二尖瓣成形失败二尖瓣成形失败展 望随着外科技术及围手术期处理水平的提高，再次手术病人死亡率将下降介入及微创技术的进步可减少再次开胸手术Edwards LifesciencesEdwards Lifesciences经导管主动脉瓣植入术的初步实验经导管主动脉瓣植入术的初步实验
9、经导管主动脉瓣植入术的初步实验经导管主动脉瓣植入术的初步实验THANKYOUTHANKYOUStrategies of Re-operation in Heart Valve DiseaseCong Lu,MDCong Lu,MDGuangdong General HospitalGuangdong General HospitalGuangdong Provincial Cardiovascular InstituteGuangdong Provincial Cardiovascular InstituteGuangzhou,ChinaGuangzhou,ChinaGuangdong Gen
10、eralHospitalGuangdong ProvincialCardiovascular InstituteRelevant Historic Milestones in China1954 1954 Closed mitral commissurotomyClosed mitral commissurotomy1958 The first application of CPB1958 The first application of CPB1958 1958 Open mitral commissurotomy by CPBOpen mitral commissurotomy by CP
11、B1965 Mitral valve replacement1965 Mitral valve replacementEminent Pioneers and Institutions of China Cai YongzhiCai Yongzhi Changhai Hospital Changhai Hospital ShanghaiShanghaiZhang BaorenZhang Baoren Changhai Hospital Changhai Hospital ShanghaiShanghaiGuo JiaqiangGuo Jiaqiang Fuwai Cardiovascular
12、Hospital Fuwai Cardiovascular Hospital BeijingBeijingLuo ZhengxiangLuo Zhengxiang Guangdong General Hospital Guangdong General Hospital GuangzhouGuangzhouOperations and Re-operationsBy the late 1990s,6000 heart valve By the late 1990s,6000 heart valve operations performed each yearoperations perform
13、ed each yearIn recent years,the number of valve In recent years,the number of valve operations per year is more than 20 000 operations per year is more than 20 000 With the number of heart valve surgeries With the number of heart valve surgeries increasing,re-operation of heart valve increasing,re-o
14、peration of heart valve disease becomes an unavoidable problemdisease becomes an unavoidable problem The Experience of Our HospitalHeart valve surgeries in Guangdong Heart valve surgeries in Guangdong General Hospital from 1997 to 2007General Hospital from 1997 to 2007The Experience of Our HospitalT
15、he total operations from 1997 to 2007The total operations from 1997 to 2007：6703 cases6703 casesRe-operationsRe-operations：499 cases499 cases (7.4%)(7.4%)Perioperative mortality of re-operations Perioperative mortality of re-operations：8.8%8.8%Causes of Re-operationTheleadingcauseTheleadingcause：Re-
16、stenosisafterclosedmitralRe-stenosisafterclosedmitralcommissurotomycommissurotomy（64.5%64.5%）Causes of re-operation of other hospital HospitalHospitalHospitalHospitalRe-operationRe-operationRe-operationRe-operationcausescausescausescausesFuwai HospitalFuwai HospitalFuwai HospitalFuwai Hospital333333
17、333333a,b,c,d,e,fa,b,c,d,e,fa,b,c,d,e,fa,b,c,d,e,fXinqiao HospitalXinqiao HospitalXinqiao HospitalXinqiao Hospital187187187187f,a,d,gf,a,d,gf,a,d,gf,a,d,gRenji HospitalRenji HospitalRenji HospitalRenji Hospital203203203203f,a,g,f,a,g,f,a,g,f,a,g,Fujian Provincial HospitalFujian Provincial HospitalFu
18、jian Provincial HospitalFujian Provincial Hospital104104104104f,e,g,d,a,hf,e,g,d,a,hf,e,g,d,a,hf,e,g,d,a,hBaotou Central HospitalBaotou Central HospitalBaotou Central HospitalBaotou Central Hospital165165165165f,a,g,c,d,b,ef,a,g,c,d,b,ef,a,g,c,d,b,ef,a,g,c,d,b,ea:bioprosthetic failurea:bioprosthetic
19、 failurea:bioprosthetic failurea:bioprosthetic failure，b:perivalvular leakageb:perivalvular leakageb:perivalvular leakageb:perivalvular leakage，c:lesion of natural valvec:lesion of natural valvec:lesion of natural valvec:lesion of natural valve，d:dysfunction of mechanical valved:dysfunction of mecha
20、nical valved:dysfunction of mechanical valved:dysfunction of mechanical valve，e:endocarditise:endocarditise:endocarditise:endocarditis，f:closed mitral commissurotomyf:closed mitral commissurotomyf:closed mitral commissurotomyf:closed mitral commissurotomy，g:open mitral commissurotomyg:open mitral co
21、mmissurotomyg:open mitral commissurotomyg:open mitral commissurotomy，h:othersh:othersh:othersh:othersRisks and StrategiesRisks are higher of re-operation than Risks are higher of re-operation than initial operationinitial operation pro-longed history pro-longed history poor cardiac functionpoor card
22、iac function adhesionadhesion bleedingbleedingA variety of methods and strategies of A variety of methods and strategies of management should be applied according management should be applied according to different causes leading to re-operationto different causes leading to re-operationRestenosis a
23、fter Closed or Open Mitral Commissurotomy Was widely done with good results in ChinaWas widely done with good results in ChinaRestenosis is unavoidable Restenosis is unavoidable CharactersCharacters：pro-longed historypro-longed history，often often concomitant with tricuspid regurgitationconcomitant
24、with tricuspid regurgitationStrategiesStrategies：re-repair re-repair prosthetic valve replacement prosthetic valve replacement：bioprosthetic valvebioprosthetic valve mechanical prosthetic valve mechanical prosthetic valveDysfunction of Mechanical Prosthetic ValveProsthetic valve structureProsthetic
25、valve structureObstruction of mechanical prosthetic valveObstruction of mechanical prosthetic valve pannus,fibrous tissue accrementitionpannus,fibrous tissue accrementition thrombogenesis:most within 3 years thrombogenesis:most within 3 years postoperationpostoperationCauses of obstructionCauses of
26、obstructionMVRMVRMVRMVRAVRAVRAVRAVRTVRTVRTVRTVRthrombogenesisthrombogenesis35(71%)35(71%)35(71%)35(71%)8(33%)8(33%)8(33%)8(33%)4(100%)4(100%)4(100%)4(100%)pannus,fibrous tissuepannus,fibrous tissue14(29%)14(29%)14(29%)14(29%)16(67%)16(67%)16(67%)16(67%)Dysfunction of Mechanical Prosthetic ValveDysfu
27、nction of Mechanical Prosthetic Valve StrategiesThrombus：thromblysis reoperationPannus,fibrous tissue：reoperationDifference of the target value of INR among AVR,MVR and TVRAVR：INR 1.8-2.0MVR：INR 2.0-2.5TVR：INR 2.5-3.0Mechanical valve dysfunction in pregnant womenCauses （1 1）hemostasis changes in pre
28、gnancyhemostasis changes in pregnancy Pregnancy is associated with a 20-200%Pregnancy is associated with a 20-200%increase in levels of fibrinogen and factors increase in levels of fibrinogen and factors II,VII,VIII,X,and XII II,VII,VIII,X,and XII Lockwood CJ.Obstet Gynecol 2002;99:333.Lockwood CJ.O
29、bstet Gynecol 2002;99:333.（2 2）worry about the side effect of warfarinworry about the side effect of warfarin （3 3）discontinue anticoagulation therapy in the discontinue anticoagulation therapy in the early stage of pregnancy or use other early stage of pregnancy or use other anticoagulants anticoag
30、ulantsMechanical valve dysfunction in pregnant womenMechanical valve dysfunction in pregnant women Experience of our hospitalSeven patients with mechanical valve dysfunction during pregnancy were retrospectively reviewed NYHA at IV in 3,at III in 3Gestation period 28 weeks in 4,28 in 2Thrombogenesis
31、 leading to mechanical valve obstruction in all patientsMechanical valve dysfunction in pregnant womenMechanical valve dysfunction in pregnant women Methods of surgical managementCaesarean section concomitant with re-Caesarean section concomitant with re-replacement of mechanical prosthetic valve re
32、placement of mechanical prosthetic valve Mechanical prosthetic valve re-replacement on Mechanical prosthetic valve re-replacement on ordinary temperature cardiopulmonary bypass ordinary temperature cardiopulmonary bypass with continue fetal heart rate monitoring with continue fetal heart rate monito
33、ring Caesarean section followed by re-replacement Caesarean section followed by re-replacement of mechanical prosthetic valve of mechanical prosthetic valve Mechanical valve dysfunction in pregnant womenMechanical valve dysfunction in pregnant women ResultsAll patients discharged from hospital in we
34、ll condition Two patients with gestation period 28 weeks who underwent mechanical prosthetic valve re-replacement,one fetus died and the other one survived and delivered in mature pregnancyFive infants were delivered and discharged in good health Mechanical valve dysfunction in pregnant womenMechani
35、cal valve dysfunction in pregnant women Strategies of surgical managementDysfunction of mechanical valve+gestation periodDysfunction of mechanical valve+gestation period 3 months 6 months 6 months？Degree of obstruction of mechanical valveDegree of obstruction of mechanical valveCardiac functionCardi
36、ac functionGestation period and condition of fetusGestation period and condition of fetusDesire of patients and family membersDesire of patients and family membersExperience of cardiac surgeonExperience of cardiac surgeonProfessional level of relevant departmentProfessional level of relevant departm
37、entMechanical valve dysfunction in pregnant womenMechanical valve dysfunction in pregnant women Factors impact on making decision of managementMechanical valve dysfunction in pregnant womenMechanical valve dysfunction in pregnant women Challenging Many young women who underwent valve Many young wome
38、n who underwent valve replacement want to have babyreplacement want to have babyIrregular anticoagulation therapy during Irregular anticoagulation therapy during pregnancypregnancyThe adverse impacts of hypothermia and CPB The adverse impacts of hypothermia and CPB on fetuson fetusHow to prevent and
39、 manage mechanical valve How to prevent and manage mechanical valve dysfunction in pregnant patientsdysfunction in pregnant patientsHow to cooperate with other department,eg.How to cooperate with other department,eg.Neontology department,obstetrics departmentNeontology department,obstetrics departme
40、ntLate Tricuspid Regurgitation after Left Cardiac Valve ReplacementTricuspid regurgitation is often neglectedAdverse impact on survivalNath J,et al,J Am Coll Cardiol,2004;43,405Mechanism Persistent pulmonary hypertension Annular dilatation Atrial fibrillation Progression or development of rheumatic
41、lesions Limitation of De Vegas procedure Xuejun X,et al.Heart Lung and Circul,2004;13,65 Xuejun X,et al.Heart Lung and Circul,2004;13,65TR after Left Cardiac Valve ReplacementTR after Left Cardiac Valve ReplacementTR after Left Cardiac Valve ReplacementTR after Left Cardiac Valve Replacement Strateg
42、ies of managementRe-repairRe-repair De Vegas procedure De Vegas procedure annuloplasty ring annuloplasty ring Valve replacementValve replacement mechanical valve mechanical valve：risk of thrombogenesisrisk of thrombogenesis bioprosthetic valve bioprosthetic valve：widely used in recent widely used in
43、 recent years yearsTR after Left Cardiac Valve ReplacementTR after Left Cardiac Valve Replacement Remaining QuestionsWhat is the mechanism of functional TR?What is the mechanism of functional TR?How to perform tricuspid repair?How to perform tricuspid repair?Which size and kind of ring for which pat
44、ient?Which size and kind of ring for which patient?When should we perform a repair?When should we perform a repair?When should we think to valve replacement?When should we think to valve replacement?Why late development of tricuspid regurgitation Why late development of tricuspid regurgitation after
45、 successful mitral surgery?after successful mitral surgery?How to prevent it?How to prevent it?Failure and Complication of Valve RepairValve repair is far less than valve replacement Valve repair is far less than valve replacement in Chinain China R Rheumatic heart disease is still the leading heuma
46、tic heart disease is still the leading cause of valvular damage leading to surgery in cause of valvular damage leading to surgery in ChinaChina Patients often experienced pro-longed history Patients often experienced pro-longed history before their first visitsbefore their first visits Techniques of
47、 valve repair are not applied widelyTechniques of valve repair are not applied widely Worry about reoperationWorry about reoperation Methods of surgical treatment Re-repair Valve replacement Transcatheter valve implantation valve-in-ring Failure of Valve RepairFailure of Valve RepairFailure of Valve
48、 RepairFailure of Valve Repair How to prevent?Indication and contraindication of mitral repairApply suitable methods of mitral repairTEEFailure of Valve RepairFailure of Valve Repair Live 3D TEE for Mitral Repair SurgeryPost RepairPost RepairPre RepairPre RepairProspectionWith the development of sur
49、gical techniques With the development of surgical techniques，the incidence of reoperation and the mortality of the incidence of reoperation and the mortality of reoperation will decreasereoperation will decreaseWith the improvement of interventional therapy,With the improvement of interventional the
50、rapy,reopen chest surgery will be avoided in some reopen chest surgery will be avoided in some patientspatientsEdwards LifesciencesEdwards LifesciencesOur preliminary experiment of transcatheter aortic Our preliminary experiment of transcatheter aortic valve implantationvalve implantationTHANKYOU结束语