单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,C,hanghai,H,ospital,长海胸心外科医院,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,上海长海医院二尖瓣病变病因,人造瓣膜的选择与匹配,保存瓣下结构的问题,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,有效率7080,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,二尖瓣环扩张，瓣膜受损较重,二尖瓣环扩张，瓣膜受损较轻,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,Controversies and Thoughts,in Mitral Valve Replacement,Department of Cardiothoracic Surgery,Changhai Hospital,Second Military Medical University,Zhang Bao-ren,NO.,mortality,Total,409524,AV procedure,216245,5.7%,MV procedure,132641,7.7%,Overview,from STS/AHA Database(1994-2003),NO.,mortality,AV procedure,1026,3.25%,MV procedure,3416,4.3%,Overview,from Changhai Hospital China(1986-2006),Profile of MV disease in China,The most common cause is 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%),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 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 1.2,1.3cm,2,/m,2,2,2,Impact of PPM on cardiac function,cardiac 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,C,riterion:,LA 300ml,adverse effect:,compressing 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(50,70%,),adverse effect:impairing ventricular function,methods:modified maze op.and modified ablation,Management 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/m,2,Make every effort to avoid doing TV replacement,Management of calcified annulus,prevalence,more than 1/3,posteriomedial,annulus involved,treatment,complet,e,ly removing the calcification,cautions,avoid injuring ventricular myocardium and coronary vessels,Management of calcified annulus,Management of calcified annulus,THANKS!,