本文選題：風(fēng)濕性心臟病 + 主動(dòng)脈瓣置換　； 參考：《廣州醫(yī)科大學(xué)》2017年碩士論文

【摘要】：研究背景和目的在世界范圍內(nèi),風(fēng)濕性心臟病(Rheumatic Heart Disease,RHD)是造成主動(dòng)脈瓣(Aortic Valvet,AV)病變的主要原因之一。長(zhǎng)期以來,手術(shù)是治療主動(dòng)脈瓣病變最有效的方法。主動(dòng)脈瓣置換術(shù)(Aortic valve replacement,AVR)通過使用人工瓣膜替換病變的主動(dòng)脈瓣,主要用于主動(dòng)脈瓣狹窄(Aortic Stenosis,AS)和/或關(guān)閉不全(Aortic insufficiency,AI)的患者,是目前治療風(fēng)濕性主動(dòng)脈瓣病變的有效手段之一。該方法療效肯定,并且隨著我國(guó)心臟外科手術(shù)方式的進(jìn)步和診療操作的規(guī)范化,主動(dòng)脈瓣置換術(shù)現(xiàn)已成為心臟外科的一項(xiàng)常規(guī)手術(shù)。主動(dòng)脈瓣置換時(shí)多采用間斷縫合的方法,目前間斷縫合方式主要包括間斷帶墊片褥式縫合和間斷帶墊片褥式外翻縫合。本研究通過回顧性分析在風(fēng)濕性心臟病患者中行主動(dòng)脈瓣置換時(shí),分別接受帶墊片褥式縫合法和帶墊片褥式外翻縫合法患者的臨床效果進(jìn)行對(duì)比,旨在為臨床行主動(dòng)脈瓣置換術(shù)時(shí)選擇最優(yōu)縫合方法提供理論依據(jù)。研究方法1、研究對(duì)象:病例納入標(biāo)準(zhǔn)(1)術(shù)前根據(jù)病史、癥狀、體征及超聲心動(dòng)圖,胸部X線片和心電圖等檢查確診風(fēng)濕性心臟病的患者。(2)所有手術(shù)由同一手術(shù)組完成。(3)2010年2月-2016年5月在廣州市第一人民醫(yī)院心胸外科行主動(dòng)脈瓣置換術(shù),主動(dòng)脈瓣置換+二尖瓣置換和/或三尖瓣成形的病例。(4)人工主動(dòng)脈瓣膜均采用Sorin Group Italia S.r.i公司生產(chǎn)的Carbomedics Top Hat Supra-Anular Aortic valve prosthesis。人工二尖瓣均采用Sorin Group Italia S.r.i公司生產(chǎn)的Carbomedics Standard Mitral Valve。(5)排除合并冠狀動(dòng)脈粥樣硬化性心臟病、先天性心臟病和二次心臟手術(shù)病例,及主動(dòng)脈內(nèi)徑(Aortic dimension,AoD)過細(xì)需行主動(dòng)脈根部拓寬術(shù)的病例。2、研究對(duì)象分組:選取60例符合入組標(biāo)準(zhǔn)的病例,按照主動(dòng)脈瓣縫合方式不同分為帶墊片褥式縫合組和帶墊片褥式外翻縫合組。其中帶墊片褥式外翻縫合組32例,帶墊片褥式縫合組28例。3、方法:比較兩組術(shù)前的一般情況(年齡、性別、心胸比、體表面積、術(shù)前心功能、主動(dòng)脈內(nèi)徑、主動(dòng)脈瓣跨瓣壓差(pressure gradient,PG)、舒張末期左室內(nèi)徑(Left ventricular end-diastolic diameter,LVDD)和射血分?jǐn)?shù)(ejection fractions,EF)等),術(shù)中觀察兩組手術(shù)方式、主動(dòng)脈瓣阻斷時(shí)間、體外循環(huán)時(shí)間、植入瓣膜大小、自動(dòng)復(fù)跳還是除顫復(fù)跳、臨時(shí)起搏器安裝情況。術(shù)后臨床觀察患者ICU停留時(shí)間、術(shù)后正性肌力藥物使用時(shí)間、術(shù)后住院天數(shù)、主動(dòng)脈瓣跨瓣壓差、射血分?jǐn)?shù)和相關(guān)并發(fā)癥(瓣周漏、低心排、再次開胸止血、腎功能不全)的發(fā)生情況。隨訪觀察患者主動(dòng)脈瓣跨瓣壓差、射血分?jǐn)?shù)、舒張末期左室內(nèi)徑及院外死亡、機(jī)械瓣故障、腦血管意外、瓣周漏、消化道出血等并發(fā)癥。使用SPSS20.0軟件處理分析兩組數(shù)據(jù),計(jì)數(shù)和計(jì)量資料分別采用t檢驗(yàn)和卡方檢驗(yàn),p小于0.05為有統(tǒng)計(jì)學(xué)差異。結(jié)果:兩組在年齡、性別、心胸比、體表面積、術(shù)前心功能、主動(dòng)脈內(nèi)徑、主動(dòng)脈瓣跨瓣壓差、舒張末期左室內(nèi)徑和射血分?jǐn)?shù)等差異無統(tǒng)計(jì)學(xué)意義(P0.05)。兩組早期死亡共3例,其中帶墊片褥式縫合組1例(因術(shù)中打結(jié)時(shí)斷線,墊片落入左室被迫拆除重縫,致使心臟阻斷時(shí)間過長(zhǎng)而終因術(shù)后低心排死亡);而帶墊片褥式外翻縫合組死亡2例(突發(fā)嚴(yán)重心律紊亂室顫1例,多器官功能衰竭1例)。兩組術(shù)后并發(fā)癥(再次開胸止血、腎功能不全、瓣周漏、低心排)發(fā)生率無顯著差異(P0.05)。帶墊片褥式縫合組(23.07±1.49mm)較帶墊片褥式外翻縫合組(21.88±1.34mm)可以植入較大型號(hào)瓣膜(P0.05)。帶墊片褥式縫合組的主動(dòng)脈阻斷時(shí)間(AVR:47.60±13.44min,AVR合并其他手術(shù):82.56±17.68min)、體外循環(huán)時(shí)間(AVR:73.90±15.13min,AVR合并其他手術(shù):116.5±22.3 min)與帶墊片褥式外翻組的主動(dòng)脈阻斷時(shí)間(AVR:56.25±14.55,AVR合并其他手術(shù):86.50±17.10min)、體外循環(huán)時(shí)間(AVR:79.33±18.66min,AVR合并其他手術(shù):119.8±21.7min)無顯著差異(P0.05),而術(shù)后ICU住院時(shí)間(73.93±12.41小時(shí))、術(shù)后正性肌力藥使用天數(shù)(4.26±1.98天)、術(shù)后住院時(shí)間(10.04±1.93天)較帶墊片褥式外翻組術(shù)后ICU住院時(shí)間(81.52±15.03小時(shí))、術(shù)后正性肌力藥使用天數(shù)(5.36±2.36天)、術(shù)后住院時(shí)間(11.74±1.94天)短(P0.05),術(shù)后主動(dòng)脈瓣跨瓣壓差(17.96±6.13mmHg)較帶墊片褥式外翻縫合組(22.97±7.75mmHg)低(P0.05),術(shù)后射血分?jǐn)?shù)(62%±4%)較帶墊片褥式外翻組(53%±5%)高(P0.05),術(shù)后舒張末期左室內(nèi)徑(4.8±0.59cm)較褥式外翻組(5.16±0.42cm)小(P0.05)。兩組出院前的心功能無顯著差異(P0.05)。帶墊片褥式縫合組術(shù)前術(shù)后資料對(duì)比:術(shù)后心功能較術(shù)前明顯改善,具有顯著差異性(P0.05)。術(shù)后射血分?jǐn)?shù)(62%±4%)顯著高于術(shù)前射血分?jǐn)?shù)(51%±6%)(P0.05)。術(shù)后舒張末期左室內(nèi)徑(4.80±0.59cm)顯著小于術(shù)前舒張末期左室內(nèi)徑(5.84±0.49cm)(P0.05);同樣帶墊片褥式外翻縫合組術(shù)前術(shù)后資料對(duì)比:術(shù)后心功能較術(shù)前明顯改善,具有顯著差異性(P0.05)。術(shù)后射血分?jǐn)?shù)(53%±5%)顯著高于術(shù)前射血分?jǐn)?shù)(48%±7%)(P0.05)。術(shù)后舒張末期左室內(nèi)徑(5.16±0.49cm)小于術(shù)前舒張末期左室內(nèi)徑(5.87±0.58cm)(P0.05)。術(shù)后帶墊片褥式縫合組隨訪17.27±7.46月,帶墊片褥式外翻縫合組15.54±9.08月。帶墊片褥式縫合組與帶墊片褥式外翻縫合組出現(xiàn)遠(yuǎn)期隨訪死亡、機(jī)械瓣故障、腦血管意外、瓣周漏、消化道出血等并發(fā)癥無顯著差異(P0.05)。術(shù)后隨訪心彩超結(jié)果(隨訪期間最后一次心彩超結(jié)果)帶墊片褥式縫合組的主動(dòng)脈瓣跨瓣壓差(18.76±5.76mm Hg)較帶墊片褥式外翻縫合組(24.85±7.35mmHg)低(P0.05)。其中帶墊片褥式縫合組1例出現(xiàn)主動(dòng)脈瓣跨瓣壓差大于30mmHg,帶墊片褥式外翻縫合組7例出現(xiàn)主動(dòng)脈瓣跨瓣壓差大于30mmHg,具有顯著差異性(P0.05)。帶墊片褥式縫合組的射血分?jǐn)?shù)(63%±5%)較帶墊片褥式外翻縫合組(54%±7%)高(P0.05),左室內(nèi)徑(4.76±0.43cm)較帶墊片褥式外翻(5.06±0.42cm)小(P0.05)。帶墊片褥式縫合組的心功能好于褥式外翻縫合組心功能,具有顯著差異性(P0.05)。兩組出現(xiàn)遠(yuǎn)期隨訪死亡、機(jī)械瓣故障、腦血管意外、瓣周漏、消化道出血等并發(fā)癥無顯著差異。結(jié)論:1、AVR手術(shù)中用帶墊片褥式縫合法優(yōu)于帶墊片褥式外翻縫合法,因前者人工瓣位于環(huán)上無縮環(huán)作用,故可以植入較大型號(hào)的人工瓣膜、提高術(shù)后射血分?jǐn)?shù)、縮小術(shù)后舒張末期左室內(nèi)徑和降低術(shù)后主動(dòng)脈跨瓣壓差;2、遠(yuǎn)期心功能改善前者更優(yōu)于后者,主要因植入較大型號(hào)人工瓣,跨瓣壓差小,維持通暢的左室流出道有關(guān)。
[Abstract]:Research background and purpose Rheumatic Heart Disease (RHD) is one of the major causes of the aortic valve (Aortic Valvet, AV) disease. For a long time, surgery is the most effective method for the treatment of aortic valve disease. Aortic valve replacement (Aortic valve replacement, AVR) through the use of artificial valve replacement. The changed aortic valve, which is mainly used in patients with Aortic Stenosis (AS) and / or Aortic insufficiency (AI), is one of the effective methods for the treatment of rheumatic aortic valve disease. This method is effective, and with the improvement of the mode of cardiac surgery and the standardization of diagnosis and treatment operation in our country. Arterial valve replacement has now become a routine operation for cardiac surgery. Intermittent suture is used most of the aortic valve replacement. Discontinuous suture mainly includes intermittent belt mattress suture and intermittent belt mattress suture. This study was performed by retrospective analysis of aortic valve replacement in patients with rheumatism heart disease. In order to provide the theoretical basis for selecting the optimal suture method for clinical aortic valve replacement, 1, the study object: the case included standard (1) the medical history, symptoms, signs and echocardiography, chest X Patients with diagnosis of rheumatic heart disease such as wire and electrocardiogram (2) all operations were performed by the same operation group. (3) aortic valve replacement, aortic valve replacement, mitral valve replacement and / or three apical valve forming in the thoracic and thoracic surgery of Guangzhou No.1 People's Hospital in May -2016 February 2010. (4) artificial aortic valve used Sorin Group Italia S.r.i produced Carbomedics Top Hat Supra-Anular Aortic valve prosthesis. artificial mitral valve (5) excluding coronary atherosclerotic heart disease, congenital heart disease and two heart surgery cases, and aorta The Aortic dimension (AoD) was too fine for the case of aortic root widening. The study group: 60 cases were selected in accordance with the standard of the group. According to the aortic valve suture, they were divided into gasket mattress suture group and cushion type ectropion suture group. 32 cases with mattress suture group with gasket and mattress suture group with mattress suture with mattress suture. Group 28 cases of.3, method: compare the general conditions of two groups before operation (age, sex, heart and chest ratio, surface area, preoperative cardiac function, aortic diameter, aortic valve cross valve pressure difference (pressure gradient, PG), end diastolic left ventricular diameter (Left ventricular end-diastolic diameter, LVDD) and ejection fraction (ejection fractions, EF) etc.), the two groups were observed during the operation. Operation mode, aortic valve block time, cardiopulmonary bypass time, valve size implantation, auto jump or defibrillation recovery, temporary pacemaker installation, postoperative clinical observation of patients' ICU stay time, postoperative positive inotropic drug use time, postoperative hospitalization days, active valve cross valve pressure difference, ejection fraction and related complications (perivalvular leakage, The occurrence of low heart drainage, again open chest hemostasis, renal insufficiency. Follow-up observation of aortic valve cross valve pressure difference, ejection fraction, end diastolic left ventricular diameter and out of hospital death, mechanical valve failure, cerebrovascular accident, perivalve leakage, digestive tract bleeding, and other complications. Use SPSS20.0 software to analyze and analyze two groups of data, counting and measurement data, respectively. T test and chi square test showed that there were statistical differences in P less than 0.05. Results: there were no statistically significant differences in age, sex, heart ratio, body surface area, preoperative cardiac function, aortic diameter, aortic valve cross valve pressure difference, end diastolic left ventricular diameter and ejection fraction (P0.05). The two groups of early death were 3 cases with mattress suture. In group 1, 2 cases (1 cases of severe arrhythmia ventricular fibrillation, 1 cases of severe arrhythmia ventricular fibrillation and 1 cases of multiple organ failure) were killed in the group of 2 cases (1 cases of sudden arrhythmic ventricular fibrillation and 1 cases of multiple organ failure). There was no significant difference in the incidence of circumferential leakage and low cardiac output. (23.07 + 1.49mm) with mattress suture group (23.07 + 1.49mm) with gasket mattress suture group (21.88 + 1.34mm) could be implanted in a larger type of valve (P0.05). The aortic blocking time with a cushion mattress suture group (AVR:47.60 + 13.44min, AVR combined with other surgery: 82.56 + 17.68min), and in extracorporeal circulation (AVR:73.90 + 15.13min, AVR combined with other operations: 116.5 + 22.3 min) and the aortic block time (AVR:56.25 + 14.55, AVR combined with other operations: 86.50 + 17.10min), and no significant difference (P0.05) in the extracorporeal circulation time (AVR:79.33 + 18.66min, AVR combined with other operations: 119.8 + 21.7min), and the postoperative hospitalization time (73.93) 12.41 hours (4.26 + 1.98 days) and postoperative hospitalization time (10.04 + 1.93 days) after operation (81.52 + 15.03 hours) after operation (81.52 + 15.03 hours) after operation (81.52 + 15.03 hours), after operation (5.36 + 2.36 days), postoperative hospitalization time (11.74 + 1.94 days), and postoperative aortic valve cross valve pressure difference (17.96 + 1.98). 6.13mmHg) lower (22.97 + 7.75mmHg) than with mattress suture group (22.97 + 7.75mmHg), after operation, the ejection fraction (62% + 4%) was higher (53% + 5%) than that of the mattress ectropion group (53% + 5%), and the end diastolic left ventricular diameter (4.8 + 0.59cm) was smaller than that of the mattress ectropion group (5.16 + 0.42cm) (P0.05). There was no significant difference between the two groups before discharge (P0.05). Compared with the preoperative and postoperative data, the cardiac function was significantly improved after operation (P0.05). The postoperative ejection fraction (62% + 4%) was significantly higher than that of pre operation (51% + 6%) (P0.05). The end diastolic left ventricular diameter (4.80 + 0.59cm) was significantly lower than that of the left ventricular diastolic diameter (5.84 + 0.49cm) (5.84 + 0.49cm) (P0.05). Comparison of preoperative and postoperative data in the group of valgus suture group: the postoperative cardiac function was significantly better than that before operation (P0.05). The postoperative ejection fraction (53% + 5%) was significantly higher than that of pre operation (48% + 7%) (P0.05). The end diastolic left ventricular diameter (5.16 + 0.49cm) was less than that of the left ventricular diastolic diameter (5.87 + 0.58cm) (P0.05) after operation. The follow-up of the mattress suture group was 17.27 + 7.46 months, with the bedding type ectropion suture group 15.54 + 9.08 months. There was no significant difference between the mechanical flap failure, cerebral vascular accident, perivalve leakage and gastrointestinal bleeding (P0.05). The difference of aortic valve cross valve pressure difference (18.76 5.76mm Hg) in the bedding suture group was lower than that of the group with gasket mattress suture (24.85 + 7.35mmHg) (P0.05). Among them, 1 cases with gasket mattress suture group had aortic valve cross valve pressure difference greater than 30mmHg, and 7 cases of aortic valve cross flap pressure difference with gasket type ectropion suture group. Greater than 30mmHg, with significant difference (P0.05). The ejection fraction of the mattress suture group with gasket (63% + 5%) was higher than that of the bedding type ectropion suture group (54% + 7%) (P0.05), and the inner diameter of the left ventricle (4.76 + 0.43cm) was smaller than that of the mattress type ectropion (5.06 0.42cm) with the cushion (P0.05). The heart function of the group with the cushion type suture group was better than the cardiac function of the mattress suture group. There was significant difference (P0.05). There was no significant difference between two groups of long term follow-up, mechanical valve failure, cerebrovascular accident, perivalve leakage, and digestive tract bleeding. Conclusion: 1, the belt mattress suture method in AVR operation is superior to that with cushion type ectropion suture, because the former is located in the ring without contraction action, so a larger model can be implanted. The artificial valve was used to improve the postoperative ejection fraction, reduce the end diastolic left ventricular diameter and reduce the aortic cross valve pressure difference after operation. 2, the long-term cardiac function improvement was better than the latter, mainly due to the large type of artificial valve implantation, the small difference of cross valve pressure, and the maintenance of the smooth left ventricular outflow tract.
【學(xué)位授予單位】：廣州醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R654.2

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3 劉子罡;個(gè)體化方案治療重度主動(dòng)脈瓣狹窄的療效[D];鄭州大學(xué);2016年

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5 黃凌晨;主動(dòng)脈瓣置換同期行冠脈旁路移植術(shù)臨床分析[D];福建醫(yī)科大學(xué);2016年

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