风湿性心脏病人中行主动脉瓣置换时褥式与褥式外翻缝合的效果对比

发布时间：2018-06-18 07:16

本文选题：风湿性心脏病 + 主动脉瓣置换　；参考：《广州医科大学》2017年硕士论文

【摘要】：研究背景和目的在世界范围内,风湿性心脏病(Rheumatic Heart Disease,RHD)是造成主动脉瓣(Aortic Valvet,AV)病变的主要原因之一。长期以来,手术是治疗主动脉瓣病变最有效的方法。主动脉瓣置换术(Aortic valve replacement,AVR)通过使用人工瓣膜替换病变的主动脉瓣,主要用于主动脉瓣狭窄(Aortic Stenosis,AS)和/或关闭不全(Aortic insufficiency,AI)的患者,是目前治疗风湿性主动脉瓣病变的有效手段之一。该方法疗效肯定,并且随着我国心脏外科手术方式的进步和诊疗操作的规范化,主动脉瓣置换术现已成为心脏外科的一项常规手术。主动脉瓣置换时多采用间断缝合的方法,目前间断缝合方式主要包括间断带垫片褥式缝合和间断带垫片褥式外翻缝合。本研究通过回顾性分析在风湿性心脏病患者中行主动脉瓣置换时,分别接受带垫片褥式缝合法和带垫片褥式外翻缝合法患者的临床效果进行对比,旨在为临床行主动脉瓣置换术时选择最优缝合方法提供理论依据。研究方法1、研究对象:病例纳入标准(1)术前根据病史、症状、体征及超声心动图,胸部X线片和心电图等检查确诊风湿性心脏病的患者。(2)所有手术由同一手术组完成。(3)2010年2月-2016年5月在广州市第一人民医院心胸外科行主动脉瓣置换术,主动脉瓣置换+二尖瓣置换和/或三尖瓣成形的病例。(4)人工主动脉瓣膜均采用Sorin Group Italia S.r.i公司生产的Carbomedics Top Hat Supra-Anular Aortic valve prosthesis。人工二尖瓣均采用Sorin Group Italia S.r.i公司生产的Carbomedics Standard Mitral Valve。(5)排除合并冠状动脉粥样硬化性心脏病、先天性心脏病和二次心脏手术病例,及主动脉内径(Aortic dimension,AoD)过细需行主动脉根部拓宽术的病例。2、研究对象分组:选取60例符合入组标准的病例,按照主动脉瓣缝合方式不同分为带垫片褥式缝合组和带垫片褥式外翻缝合组。其中带垫片褥式外翻缝合组32例,带垫片褥式缝合组28例。3、方法:比较两组术前的一般情况(年龄、性别、心胸比、体表面积、术前心功能、主动脉内径、主动脉瓣跨瓣压差(pressure gradient,PG)、舒张末期左室内径(Left ventricular end-diastolic diameter,LVDD)和射血分数(ejection fractions,EF)等),术中观察两组手术方式、主动脉瓣阻断时间、体外循环时间、植入瓣膜大小、自动复跳还是除颤复跳、临时起搏器安装情况。术后临床观察患者ICU停留时间、术后正性肌力药物使用时间、术后住院天数、主动脉瓣跨瓣压差、射血分数和相关并发症(瓣周漏、低心排、再次开胸止血、肾功能不全)的发生情况。随访观察患者主动脉瓣跨瓣压差、射血分数、舒张末期左室内径及院外死亡、机械瓣故障、脑血管意外、瓣周漏、消化道出血等并发症。使用SPSS20.0软件处理分析两组数据,计数和计量资料分别采用t检验和卡方检验,p小于0.05为有统计学差异。结果:两组在年龄、性别、心胸比、体表面积、术前心功能、主动脉内径、主动脉瓣跨瓣压差、舒张末期左室内径和射血分数等差异无统计学意义(P0.05)。两组早期死亡共3例,其中带垫片褥式缝合组1例(因术中打结时断线,垫片落入左室被迫拆除重缝,致使心脏阻断时间过长而终因术后低心排死亡);而带垫片褥式外翻缝合组死亡2例(突发严重心律紊乱室颤1例,多器官功能衰竭1例)。两组术后并发症(再次开胸止血、肾功能不全、瓣周漏、低心排)发生率无显著差异(P0.05)。带垫片褥式缝合组(23.07±1.49mm)较带垫片褥式外翻缝合组(21.88±1.34mm)可以植入较大型号瓣膜(P0.05)。带垫片褥式缝合组的主动脉阻断时间(AVR:47.60±13.44min,AVR合并其他手术:82.56±17.68min)、体外循环时间(AVR:73.90±15.13min,AVR合并其他手术:116.5±22.3 min)与带垫片褥式外翻组的主动脉阻断时间(AVR:56.25±14.55,AVR合并其他手术:86.50±17.10min)、体外循环时间(AVR:79.33±18.66min,AVR合并其他手术:119.8±21.7min)无显著差异(P0.05),而术后ICU住院时间(73.93±12.41小时)、术后正性肌力药使用天数(4.26±1.98天)、术后住院时间(10.04±1.93天)较带垫片褥式外翻组术后ICU住院时间(81.52±15.03小时)、术后正性肌力药使用天数(5.36±2.36天)、术后住院时间(11.74±1.94天)短(P0.05),术后主动脉瓣跨瓣压差(17.96±6.13mmHg)较带垫片褥式外翻缝合组(22.97±7.75mmHg)低(P0.05),术后射血分数(62%±4%)较带垫片褥式外翻组(53%±5%)高(P0.05),术后舒张末期左室内径(4.8±0.59cm)较褥式外翻组(5.16±0.42cm)小(P0.05)。两组出院前的心功能无显著差异(P0.05)。带垫片褥式缝合组术前术后资料对比:术后心功能较术前明显改善,具有显著差异性(P0.05)。术后射血分数(62%±4%)显著高于术前射血分数(51%±6%)(P0.05)。术后舒张末期左室内径(4.80±0.59cm)显著小于术前舒张末期左室内径(5.84±0.49cm)(P0.05);同样带垫片褥式外翻缝合组术前术后资料对比:术后心功能较术前明显改善,具有显著差异性(P0.05)。术后射血分数(53%±5%)显著高于术前射血分数(48%±7%)(P0.05)。术后舒张末期左室内径(5.16±0.49cm)小于术前舒张末期左室内径(5.87±0.58cm)(P0.05)。术后带垫片褥式缝合组随访17.27±7.46月,带垫片褥式外翻缝合组15.54±9.08月。带垫片褥式缝合组与带垫片褥式外翻缝合组出现远期随访死亡、机械瓣故障、脑血管意外、瓣周漏、消化道出血等并发症无显著差异(P0.05)。术后随访心彩超结果(随访期间最后一次心彩超结果)带垫片褥式缝合组的主动脉瓣跨瓣压差(18.76±5.76mm Hg)较带垫片褥式外翻缝合组(24.85±7.35mmHg)低(P0.05)。其中带垫片褥式缝合组1例出现主动脉瓣跨瓣压差大于30mmHg,带垫片褥式外翻缝合组7例出现主动脉瓣跨瓣压差大于30mmHg,具有显著差异性(P0.05)。带垫片褥式缝合组的射血分数(63%±5%)较带垫片褥式外翻缝合组(54%±7%)高(P0.05),左室内径(4.76±0.43cm)较带垫片褥式外翻(5.06±0.42cm)小(P0.05)。带垫片褥式缝合组的心功能好于褥式外翻缝合组心功能,具有显著差异性(P0.05)。两组出现远期随访死亡、机械瓣故障、脑血管意外、瓣周漏、消化道出血等并发症无显著差异。结论:1、AVR手术中用带垫片褥式缝合法优于带垫片褥式外翻缝合法,因前者人工瓣位于环上无缩环作用,故可以植入较大型号的人工瓣膜、提高术后射血分数、缩小术后舒张末期左室内径和降低术后主动脉跨瓣压差;2、远期心功能改善前者更优于后者,主要因植入较大型号人工瓣,跨瓣压差小,维持通畅的左室流出道有关。
[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.
【学位授予单位】：广州医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R654.2

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