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

【摘要】：研究背景和目的在世界范圍內(nèi),風濕性心臟病(Rheumatic Heart Disease,RHD)是造成主動脈瓣(Aortic Valvet,AV)病變的主要原因之一。長期以來,手術是治療主動脈瓣病變最有效的方法。主動脈瓣置換術(Aortic valve replacement,AVR)通過使用人工瓣膜替換病變的主動脈瓣,主要用于主動脈瓣狹窄(Aortic Stenosis,AS)和/或關閉不全(Aortic insufficiency,AI)的患者,是目前治療風濕性主動脈瓣病變的有效手段之一。該方法療效肯定,并且隨著我國心臟外科手術方式的進步和診療操作的規(guī)范化,主動脈瓣置換術現(xiàn)已成為心臟外科的一項常規(guī)手術。主動脈瓣置換時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濕性心臟病患者中行主動脈瓣置換時,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行對比,旨在為臨床行主動脈瓣置換術時選擇最優(yōu)縫合方法提供理論依據(jù)。研究方法1、研究對象:病例納入標準(1)術前根據(jù)病史、癥狀、體征及超聲心動圖,胸部X線片和心電圖等檢查確診風濕性心臟病的患者。(2)所有手術由同一手術組完成。(3)2010年2月-2016年5月在廣州市第一人民醫(yī)院心胸外科行主動脈瓣置換術,主動脈瓣置換+二尖瓣置換和/或三尖瓣成形的病例。(4)人工主動脈瓣膜均采用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)排除合并冠狀動脈粥樣硬化性心臟病、先天性心臟病和二次心臟手術病例,及主動脈內(nèi)徑(Aortic dimension,AoD)過細需行主動脈根部拓寬術的病例。2、研究對象分組:選取60例符合入組標準的病例,按照主動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:比較兩組術前的一般情況(年齡、性別、心胸比、體表面積、術前心功能、主動脈內(nèi)徑、主動脈瓣跨瓣壓差(pressure gradient,PG)、舒張末期左室內(nèi)徑(Left ventricular end-diastolic diameter,LVDD)和射血分數(shù)(ejection fractions,EF)等),術中觀察兩組手術方式、主動脈瓣阻斷時間、體外循環(huán)時間、植入瓣膜大小、自動復跳還是除顫復跳、臨時起搏器安裝情況。術后臨床觀察患者ICU停留時間、術后正性肌力藥物使用時間、術后住院天數(shù)、主動脈瓣跨瓣壓差、射血分數(shù)和相關并發(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。隨訪觀察患者主動脈瓣跨瓣壓差、射血分數(shù)、舒張末期左室內(nèi)徑及院外死亡、機械瓣故障、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),計數(shù)和計量資料分別采用t檢驗和卡方檢驗,p小于0.05為有統(tǒng)計學差異。結果:兩組在年齡、性別、心胸比、體表面積、術前心功能、主動脈內(nèi)徑、主動脈瓣跨瓣壓差、舒張末期左室內(nèi)徑和射血分數(shù)等差異無統(tǒng)計學意義(P0.05)。兩組早期死亡共3例,其中帶墊片褥式縫合組1例(因術中打結時斷線,墊片落入左室被迫拆除重縫,致使心臟阻斷時間過長而終因術后低心排死亡);而帶墊片褥式外翻縫合組死亡2例(突發(fā)嚴重心律紊亂室顫1例,多器官功能衰竭1例)。兩組術后并發(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)可以植入較大型號瓣膜(P0.05)。帶墊片褥式縫合組的主動脈阻斷時間(AVR:47.60±13.44min,AVR合并其他手術:82.56±17.68min)、體外循環(huán)時間(AVR:73.90±15.13min,AVR合并其他手術:116.5±22.3 min)與帶墊片褥式外翻組的主動脈阻斷時間(AVR:56.25±14.55,AVR合并其他手術:86.50±17.10min)、體外循環(huán)時間(AVR:79.33±18.66min,AVR合并其他手術:119.8±21.7min)無顯著差異(P0.05),而術后ICU住院時間(73.93±12.41小時)、術后正性肌力藥使用天數(shù)(4.26±1.98天)、術后住院時間(10.04±1.93天)較帶墊片褥式外翻組術后ICU住院時間(81.52±15.03小時)、術后正性肌力藥使用天數(shù)(5.36±2.36天)、術后住院時間(11.74±1.94天)短(P0.05),術后主動脈瓣跨瓣壓差(17.96±6.13mmHg)較帶墊片褥式外翻縫合組(22.97±7.75mmHg)低(P0.05),術后射血分數(shù)(62%±4%)較帶墊片褥式外翻組(53%±5%)高(P0.05),術后舒張末期左室內(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前術后資料對比:術后心功能較術前明顯改善,具有顯著差異性(P0.05)。術后射血分數(shù)(62%±4%)顯著高于術前射血分數(shù)(51%±6%)(P0.05)。術后舒張末期左室內(nèi)徑(4.80±0.59cm)顯著小于術前舒張末期左室內(nèi)徑(5.84±0.49cm)(P0.05);同樣帶墊片褥式外翻縫合組術前術后資料對比:術后心功能較術前明顯改善,具有顯著差異性(P0.05)。術后射血分數(shù)(53%±5%)顯著高于術前射血分數(shù)(48%±7%)(P0.05)。術后舒張末期左室內(nèi)徑(5.16±0.49cm)小于術前舒張末期左室內(nèi)徑(5.87±0.58cm)(P0.05)。術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)遠期隨訪死亡、機械瓣故障、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)。術后隨訪心彩超結果(隨訪期間最后一次心彩超結果)帶墊片褥式縫合組的主動脈瓣跨瓣壓差(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數(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)遠期隨訪死亡、機械瓣故障、腦血管意外、瓣周漏、消化道出血等并發(fā)癥無顯著差異。結論:1、AVR手術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的人工瓣膜、提高術后射血分數(shù)、縮小術后舒張末期左室內(nèi)徑和降低術后主動脈跨瓣壓差;2、遠期心功能改善前者更優(yōu)于后者,主要因植入較大型號人工瓣,跨瓣壓差小,維持通暢的左室流出道有關。
[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.
【學位授予單位】：廣州醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R654.2

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