CAJ | 학술논문

背景：小主动脉瓣环主动脉瓣置换是心外科手术的难点，治疗不当可能出现瓣膜与患者不匹配现象，使左室流出道狭窄、跨瓣压差增大，引起左室后负荷增加致心肌肥厚甚至充血性心力衰竭。 　　目的：总结预防小主动脉瓣环瓣膜置换后发生人工心脏瓣膜与患者不匹配的治疗策略。 　　方法：小主动脉瓣环均主动脉瓣置换患者85例。瓣口直径>17 mm，≤19 mm的患者，选19 mm SJM Regent瓣；对瓣口直径≤17 mm的患者，用牛心包补片加宽瓣环，再选19 mm SJM Regent 瓣行瓣膜置换；对于瓣口直径>19 mm，≤21 mm，选21 mm Hancock II ultra生物瓣置换。治疗后应用超声心动图测量有效瓣口面积指数、左心室重量指数、室间隔厚度、左心室后壁厚度、跨瓣峰速、跨瓣压差和跨瓣平均压。出院后通过门诊对患者进行随访，定期复查超声心动图。 　　结果与结论：治疗后早期无死亡病例，均治愈出院。随访时间为6个月-3年。主要并发症为低心排综合征2例、二次开胸止血1例、呼吸机依赖2例。所以患者均未出现脑栓塞或脑出血等脑部并发症。无瓣膜功能失调或卡瓣。未发现牛心包补片撕裂、瘤样膨出、钙化、血栓形成、免疫反应和感染等情况。81例获随访，随访率为95%(81/85)。NYHA心功能分级Ⅰ级65例，Ⅱ级16例。各不同瓣环直径患者治疗后跨主动脉瓣峰速和平均压差均明显降低，有效瓣口面积指数明显增加，左心室重量指数、室间隔厚度和左心室后壁厚度均明显降低，均未出现人工心脏瓣膜与患者不匹配。置换21 mm Hancock II ultra 生物瓣和21 mm SJM Regent 瓣组间的比较，前者获得了更好的跨瓣峰速和平均压差，以及更好的左心室重塑指标。19 mm Regent 瓣患者治疗后体质量和体表面积较治疗前明显增加。结果提示对于小主动脉瓣环的患者应采取个体化的治疗策略预防主动脉瓣置换后瓣膜与患者不匹配的发生。揹景：小主動脈瓣環主動脈瓣置換是心外科手術的難點，治療不噹可能齣現瓣膜與患者不匹配現象，使左室流齣道狹窄、跨瓣壓差增大，引起左室後負荷增加緻心肌肥厚甚至充血性心力衰竭。 　　目的：總結預防小主動脈瓣環瓣膜置換後髮生人工心髒瓣膜與患者不匹配的治療策略。 　　方法：小主動脈瓣環均主動脈瓣置換患者85例。瓣口直徑>17 mm，≤19 mm的患者，選19 mm SJM Regent瓣；對瓣口直徑≤17 mm的患者，用牛心包補片加寬瓣環，再選19 mm SJM Regent 瓣行瓣膜置換；對于瓣口直徑>19 mm，≤21 mm，選21 mm Hancock II ultra生物瓣置換。治療後應用超聲心動圖測量有效瓣口麵積指數、左心室重量指數、室間隔厚度、左心室後壁厚度、跨瓣峰速、跨瓣壓差和跨瓣平均壓。齣院後通過門診對患者進行隨訪，定期複查超聲心動圖。 　　結果與結論：治療後早期無死亡病例，均治愈齣院。隨訪時間為6箇月-3年。主要併髮癥為低心排綜閤徵2例、二次開胸止血1例、呼吸機依賴2例。所以患者均未齣現腦栓塞或腦齣血等腦部併髮癥。無瓣膜功能失調或卡瓣。未髮現牛心包補片撕裂、瘤樣膨齣、鈣化、血栓形成、免疫反應和感染等情況。81例穫隨訪，隨訪率為95%(81/85)。NYHA心功能分級Ⅰ級65例，Ⅱ級16例。各不同瓣環直徑患者治療後跨主動脈瓣峰速和平均壓差均明顯降低，有效瓣口麵積指數明顯增加，左心室重量指數、室間隔厚度和左心室後壁厚度均明顯降低，均未齣現人工心髒瓣膜與患者不匹配。置換21 mm Hancock II ultra 生物瓣和21 mm SJM Regent 瓣組間的比較，前者穫得瞭更好的跨瓣峰速和平均壓差，以及更好的左心室重塑指標。19 mm Regent 瓣患者治療後體質量和體錶麵積較治療前明顯增加。結果提示對于小主動脈瓣環的患者應採取箇體化的治療策略預防主動脈瓣置換後瓣膜與患者不匹配的髮生。
배경：소주동맥판배주동맥판치환시심외과수술적난점，치료불당가능출현판막여환자불필배현상，사좌실류출도협착、과판압차증대，인기좌실후부하증가치심기비후심지충혈성심력쇠갈。 　　목적：총결예방소주동맥판배판막치환후발생인공심장판막여환자불필배적치료책략。 　　방법：소주동맥판배균주동맥판치환환자85례。판구직경>17 mm，≤19 mm적환자，선19 mm SJM Regent판；대판구직경≤17 mm적환자，용우심포보편가관판배，재선19 mm SJM Regent 판행판막치환；대우판구직경>19 mm，≤21 mm，선21 mm Hancock II ultra생물판치환。치료후응용초성심동도측량유효판구면적지수、좌심실중량지수、실간격후도、좌심실후벽후도、과판봉속、과판압차화과판평균압。출원후통과문진대환자진행수방，정기복사초성심동도。 　　결과여결론：치료후조기무사망병례，균치유출원。수방시간위6개월-3년。주요병발증위저심배종합정2례、이차개흉지혈1례、호흡궤의뢰2례。소이환자균미출현뇌전새혹뇌출혈등뇌부병발증。무판막공능실조혹잡판。미발현우심포보편시렬、류양팽출、개화、혈전형성、면역반응화감염등정황。81례획수방，수방솔위95%(81/85)。NYHA심공능분급Ⅰ급65례，Ⅱ급16례。각불동판배직경환자치료후과주동맥판봉속화평균압차균명현강저，유효판구면적지수명현증가，좌심실중량지수、실간격후도화좌심실후벽후도균명현강저，균미출현인공심장판막여환자불필배。치환21 mm Hancock II ultra 생물판화21 mm SJM Regent 판조간적비교，전자획득료경호적과판봉속화평균압차，이급경호적좌심실중소지표。19 mm Regent 판환자치료후체질량화체표면적교치료전명현증가。결과제시대우소주동맥판배적환자응채취개체화적치료책략예방주동맥판치환후판막여환자불필배적발생。
BACKGROUND:It is so difficult to have aortic valve replacement with smal aortic annulus. Improper treatment may lead to patients with valvular mismatch phenomenon, and thus make left ventricular outflow tract obstruction, increase transvalvular pressures, cause cardiac hypertrophy secondary to increased left ventricular afterload and even congestive heart failure. OBJECTIVE:To summarize the treatment strategy for preventing valvular mismatch phenomenon caused by smal aortic annulus after aortic valve replacement. METHODS:Eighty-five patients with smal aortic annulus underwent aortic valve replacement surgery. 19 mm SJM Regent valve was applied to the patients with orifice diameter>17 ≤ 19 mm;to the adult patients with orifice diameter ≤ 17 mm, we performed bovine pericardial patch enlargement of the smal aortic annulus and valve replacement using 19 mm SJM Regent valve. For those with orifice diameter>19 ≤ 21 mm, we selected 21 mm Hancock II ultra biological valve for valve replacement. Effective orifice area index, left ventricular mass index, inter-ventricular septal thickness, left ventricular wal thickness, trans-valvular peak velocity, the pressure difference across the valve and trans-valvular mean pressure were measured through echocardiography. After discharge, patients were fol owed up in out-patient clinic and evaluated regularly by echocardiography. RESULTS AND CONCLUSION:There were no early deaths after operation and al cases were cured and discharged. Fol ow-up time was between 6 months and 3 years. The main complications included low cardiac output syndrome in two cases, reoperation due to bleeding in one case, and ventilator dependence in two cases. No cases occurred in cerebral complications such as cerebral hemorrhage or cerebral thrombosis, and no valvular dysfunction or card flap appeared. There was no bovine pericardium tearing, thrombosis, calcification, tumor-like bulge, infection or immune reactions. A total of 81 cases were fol owed up and the fol ow-up rate was 95%(81/85). There were NYHA class grade I in 65 cases, and grade II in 16 cases. Peak velocity across the aortic valve and the mean pressure were significantly decreased, effective orifice area index increased significantly, left ventricular mass index, left ventricular wal thickness and the thickness of the inter-ventricular septum were significantly reduced compared with pre-operation, and no valvular mismatch phenomenon occurred. Compared 21 mm Hancock II ultra biological valve with 21 mm SJM Regent group, the former got a better peak velocity and mean trans-valvular pressure, and better left ventricular remodeling index. Body weight and body surface area were significantly increased in 19 mm Regent valve group after operation. The results suggest that individualized treatment strategies should be taken to prevent the occurrence of postoperative valvular mismatch phenomenon for patients with smal aortic annulus.