Preoperative evaluation is crucial for heart valvular surgery. This article discusses some issues that need to be emphasized: the impact of hypertension on the severity of aortic valve lesions, and how to improve the accuracy of clinical assessment; the identification of functional tricuspid regurgitation, in order to choose the appropriate surgical technique; the need for right ventricular function testing, and the use of risk scoring models, to better grasp surgical timing and indications and improve efficacy; and the importance of evaluating atrial mitral and/or tricuspid regurgitation complications in chronic atrial fibrillation, and making rational choices for interventional and surgical treatment.
手術風險預測模型是術前風險評估的重要工具，在外科臨床工作中起著十分重要的作用，它對手術適應證的確定、手術相關危險因素的識別、評分標準的確立以及不同中心手術療效的比較都具有十分重要的意義。而心臟外科手術因受到多方面因素的影響，其圍術期的病死率仍較高。因此，在心臟外科臨床研究領域很早便開展了有關建立手術風險預測模型的工作。 從國外研究背景來看，至1986年美國胸外科醫師協會（The Society of Thoracic Surgeons，STS）公布的第一個心臟術后風險預測模型Parsonnet評分系統起，近20余年間在北美、歐洲及澳洲等地區相繼出現了一系列高質量的手術風險預測模型。目前，被廣泛應用的預測評分系統包括Parsonnet評分系統、歐洲心臟手術風險評估系統(the European System for Cardiac Operative Risk Evaluation ，EuroSCORE)、STS評分系統及美國心臟病學院/美國心臟協會（American College of Cardiology/American Heart Association，ACC/AHA）評分系統等。 而從國內研究現狀來看，由北京阜外心血管病醫院牽頭聯合全國32家心臟中心率先建立了首個國內大型多中心冠狀動脈旁路移植術數據庫及中國冠狀動脈旁路移植術評分系統（SinoSCORE），同時完成了EuroSCORE對我國冠心病患者手術死亡預測能力的評價研究。但目前國內有關其他重要預測評分系統的評價研究以及對我國心臟瓣膜病患者手術風險預測評價研究的報道仍相對缺乏。北京阜外心血管病醫院撰寫的“不同心臟手術風險預測評分系統對中國冠狀動脈旁路移植術后患者早期死亡的預測”論文，收集了該院2006年11月至2007年12月年間1 559例18歲以上施行單純冠狀動脈旁路移植術（CABG）患者的臨床資料，參照STS評分系統、EuroSCORE、Parsonnet評分系統和ACC/AHA評分系統的評分及分組方法，采用HosmerLemeshow(HL)卡方檢驗及受試者工作特征（ROC）曲線下面積的統計學方法，完成了4種預測評分系統對我國行CABG患者早期死亡的預測評價研究，提示除STS評分系統對單純CABG患者具有潛在的臨床應用可能外，其他3種評分系統對單純CABG術后早期死亡風險預測的準確性均較差。而上海第二軍醫大學長海醫院撰寫的“EuroSCORE模型對心瓣膜手術患者死亡風險的預測”論文，收集了該院1998年1月至2008年12月年間4 155例各類心臟瓣膜手術患者的臨床資料，參照additive和 logistic EuroSCORE評分及分組方法，采用HL卡方檢驗及ROC曲線下面積的統計學方法，完成了EuroSCORE模型對心臟瓣膜手術患者在院死亡率的預測評價研究，提示EuroSCORE模型對該中心心臟瓣膜手術患者死亡風險預測的準確性較差。 兩篇論文的研究均表明，目前國際上公認的幾種重要的手術風險預測評分系統對我國心臟手術患者術后早期死亡的預測效能均存在不同程度的限制，而建立適合我國患者心臟手術的風險預測模型及評分標準具有必要性及重要性。討論中作者均提出由于地域及人種的差異，我國心臟手術患者的病因學與國外患者存在較大的差異，尤其是心臟瓣膜病的流行病學特點差異，是導致最終結論差異的重要原因。但兩篇論文也同樣存在一定的研究局限： （1）均為單中心研究，雖樣本量較大，但我國地域廣大，各心臟中心接診患者的病種、病情輕重程度及診療技術仍存在一定差異，故應用單中心研究對研究結論的正確性可能會造成不同程度的影響，因此仍需擴大樣本量以得到更為準確的研究結論。（2）臨床資料的收集以回顧性研究為主，且各臨床變量的采集標準國內尚未統一，評分系統中變量的定義也存在一定差異，故每例患者評分預測的真實結果存在一定偏倚，對研究結論的準確性也存在影響。隨著對手術風險預測模型的臨床研究重視程度不斷地增加，目前我國各心臟診療中心均已開始建立各自的心臟外科臨床數據庫，故建議加強國內相關臨床研究的學術交流，統一數據庫建立方法及臨床變量的采集標準，建立符合我國國情的大型多中心心臟外科臨床數據庫，用以進一步規范我國心臟手術術前風險評估工作，這對制定相關臨床指南以及進一步降低心臟手術 在院病死率及并發癥發生率，必將起到非常積極的作用。綜合國內外心臟手術風險預測模型的建立方法和納入因素，目前均沒有考慮到“人”的因素，也就是說同樣的手術，由技術水平不同的醫師或醫院實施，其結果實際上存在很大的差異，而術后處理不恰當也可造成較大的差異。因此，目前在制定手術風險預測模型時，實際上是建立在外科醫師手術技術水平相當、正確實施手術和正確處理患者的基礎上。就當前而言，要將醫師的水平和能力考慮在內，確實非常困難，實際上也無法做到，這也是目前各種風險預測模型所存在的共同限制。 “不同心臟手術風險預測評分系統對中國冠狀動脈旁路移植術后患者早期死亡的預測”和“EuroSCORE模型對心瓣膜手術患者死亡風險的預測”兩篇論文均緊緊把握了目前我國心臟外科術前風險預測模型相關臨床研究的重要方向，研究目標明確，樣本量較大，科研設計合理，統計學方法正確，結論可信，具有較高的學術價值和社會價值，對臨床工作具有一定的指導意義，希望在今后的研究工作中能不斷完善。
Abstract： Quality of life （QOL） refers to an individual’s perception and subjective evaluation of their health and well-being, and has become an important index to evaluate the outcomes of clinical treatment in the last past decades. There are a large number of different instruments to evaluate QOL, and the 36-Item Short Form Health Survey （SF-36） is currently one of the most widely used instruments. In recent years, SF-36 has been used to evaluate QOL of valvular heart disease patients to investigate the risk factors those influence their postoperative QOL, provide more preoperative evaluation tools for clinical physicians, and improve postoperative outcomes of patients with valvular heart disease. However, it is now just the beginning to use SF-36 to examine QOL of valvular heart disease patients. Because of significant differences in sample size, follow-up period, country and culture, current research has some controversial results. This review focuses on the progress in evaluating QOL in postoperative patients with valvular heart disease using SF-36.
Early enteral nutrition after cardiopulmonary bypass (CPB) has been shown to have beneficial effects on intestinal integrity, lower mortality and also on the patient’s immunocompetence. Even in critical patients after CPB, enteral nutrition should be reasonable to start early and also be supplemented by parenteral nutrition in order to meet energy requirement. We conclude that enteral nutrition is preferable in the majority of patients with severe hemodynamic failure, but gastrointestinal complication and hypocaloric feeding should be simultaneously noticed. This paper comprehensively described enteral nutrition’s protective mechanism and effects on digestive system, enteral nutrition’s implementing methods after CPB, and problems or prospects needing attention in execution.
Abstract： Objective To evaluate the early and late results of mitral valve replacement with home made C-L pugesturt tilting disc and analyse the factors which impact on the therapeutic effect，so as to elevate the operative effect. Methods A retrospective study was made on the result of clinical data and longterm followup of 259 patients who had undergone the Chinesemade C-L pugesturt tilting disc mechanical valve replacement from October 1991 to November 2006. Results The data showed that there were 12 patients died in the duration of hospital stay.The hospital mortality was 4.63% (12/259).There were no mechanical valverelated complication in the earlier postoperative period.The mortality fell to 2.59% since 1996.Among the 235 patients,12 patients were lost during the followup,the rate of followup was 95.1%(235/247).The time for followup was 9.77±3.09 years. There were 26 late deaths.During the follow-up,death associated with the deterioration of valve structure were not observed. The 5 years, 10 years and l5 years survival rates were 86.80%±2.30%, 78.20%±3.33% and 55.23%±4.34% respectively; the thromboembolic event free rates for 5 years, 10 years and l5 years were 95.95%±0.74%, 92.52%±4.11% and 80.52%±4.11% respectively; the anticoagulant related bleeding free rates for 5 years, 10 years and l5 years were 94.64%±1.75%, 89.55%±3.28% and 79.39%±4.43% respectively.There were 141 patients(67.46%) in New York Heart Association(NYHA) classⅠ, 56 patients(26.79%) in class Ⅱ, 10 patients(4.78%) in class Ⅲ and 2 patients(0.95%) in class Ⅳ. Conclusion The results of follow-up for 15 years suggest that the Chinesemade C-L pugesturt tilting disc medical mechanical valve is a reliable and safe choice for mitral valve replacement.
Objective To elucidate the protective effect of leukocyte depletion on the myocardium during the settings of myocardial reperfusion injury. Methods Twenty patients undergoing cardiopulmonary bypass with continuous infusion of blood cardioplegia were randomized into two groups:the control group (n=10) with no leukocyte depletion filter used, and the experimental group (n=10) with the use of leukocyte depletion filter on the bypass circuit. The blood cells count before and after the filtration were measure...
Objective To investigate the clinical effects and the brain protection effect of different cardiopulmonary bypass in treating descending aortic aneurysms. Methods From January 2001 to December 2008, 65 patients were diagnosed to have descending aortic aneurysm with magnetic resonance imaging (MRI) in our hospital. Among them, there were 56 males and 9 females whose age was between 15 and 71 years old with an average of 48.1 years. The disease process ranged from 6 days to 4 months (19.0±6.5 d ). Preoperative diagnosis showed that there were 41 cases of DeBakey type Ⅲinterlayer, 9 cases of Marfan syndrome with postoperative complications of type Ⅲ interlayer, 7 cases of pseudoaneurysm and 8 cases of true aneurysm. We adopted artificial blood vessel repair patch to repair the damaged point of the descending aorta in 2 cases, performed vascular aneurysm resection and artificial vessel replacement on 63 patients, and carried out descending aorta replacement and intercostal artery grafting in 18 cases. Results Among the 65 cases of cardiopulmonary bypass patients, there were 13 cases of left heart bypass, 12 cases of heart bypass, 30 cases of deep hypothermic circulatory arrest (DHCA) with total body retrograde perfusion (TBRP) and 10 cases of modified separate perfusion of upper and low body. Cardiopulmonary bypass time, DHCA time, retrograde perfusion time, upper body circulatory arrest time and low body circulatory arrest time were respectively 51-212 min, 18-75min, 18-73 min, 21-31 min, and 39-67 min. No death occurred during the operation, and there were no brain complications or complications of paralysis among all the patients. Two patients died after operation because of renal failure. Conclusion Good results can be achieved by selecting different method of cardiopulmonary bypass based on the anatomical location and range of the thoracic descending aortic aneurysms. The selection criteria should be favorable to the surgical operation and organ protection.
Abstract:Objective To summarize the experiences in surgical treatment of ascending aortic root aneurysms. Methods One hundred and one patients （age ranging from 14 to 72 years, mean 42.7 years） with ascending aortic root aneurysms were diagnosed as having Marfan syndrome （58 cases）, annuloaortic ectasia （34 cases）, bicuspid aortic valve （5 cases）, aorto arteritis （4 cases） combined with aortic valve incompetence （96 cases） and aortic valve stenosis （4 cases） , preoperatively with type A dissection （26 cases） and acute left heart failure （5 cases）. Our operations consisted of 4 Wheat procedures, 13 Cabrol or modified Cabrol procedures, 1 David and 83 Bentall procedures. Concomitant operations included hemi-arch replacement or descending aorta intraluminal stent grafting （16 cases）, total arch replacement or descending aorta intraluminal stent grafting （4 cases）, mitral valve replacement or anuloplasty （14 cases） and coronary artery bypass grafting （CABG, 8 cases）. Results The overall mortality was 6.9%（7/101）, and decreased to 3. 6%（3/83） after the year 2000. Main postoperative complications were low cardiac output （10 cases）, respiratory insufficiency （9 cases）, and renal inadequacy （9 cases）. Follow-up was completed in 94 patients. During the period of follow-up, one patient died and 5 patients with Marfan syndrome suffered with type B dissection. Conclusion Bentall procedure is the method of choice for ascending aortic root aneurysms. Preoperative left heart function and surgical techniques give the crucial impact on the outcome of surgery.
