Grinda J M, Jouan J, Latremouille C H, Couetil J P, Carpentier A, Fabiani J N, Deloche A
Département de chirurgie cardiothoracique et vasculaire, hôpital Broussais, Paris.
Arch Mal Coeur Vaiss. 2000 Oct;93(10):1195-201.
The aim of this study was to assess the immediate and long-term results of human valvular substitutes (homografts and autografts) in the treatment of complex progressive endocarditis in aortic, mitral and tricuspid valves. Since 1992, 80 patients (64 men, 16 women) aged 44 +/- 16 years (range 15 to 76 years), were treated. In 53 patients, the endocarditis involved native valves, 4 on previously plastified valves, or prosthetic valves in 27 patients. The endocarditis was recurrent 6 patients. The lesions were situated on the aortic valve (N = 59), mitral valve (N = 5), aortic and mitral valves (N = 12), aortic and tricuspid valves (N = 3), mitral and tricuspid valves (N = 1). The peroperative findings confirmed the lesions diagnosed at echocardiography: prosthetic valve dehiscence (27 patients), prosthetic cusp tear (N = 7), vegetations (N = 61), perforations (N = 48), periannular abscess (N = 47), aorto-ventricular discontinuity (N = 12), aorto-mitral discontinuity (N = 7), right ventricular aortic fistula (N = 1), aorto-pulmonary fistula (N = 1), pseudo-aneurysm (N = 1), ventricular septal defect (N = 1). Eighty-six human valvular substitutes were used (double homograft in 6 patients): aortic homograft (N = 63), pulmonary in the aortic position (N = 1), the mitral position (N = 12), of which 8 were in the mitral and 4 in the tricuspid position, pulmonary autograft (N = 10). Ten mitral valve repairs were performed on infected lesions. Associated procedures included mitral valve repair (N = 5), tricuspid valve repair (N = 1) for non-infarcted valve lesions, replacement of the ascending aorta (N = 2), the aortic arch (N = 1), coronary bypass surgery (N = 2) and one nephrectomy. The hospital mortality was 5% (4 patients). The causes of death were: infarction (N = 2), myocardial failure (N = 1) and multiorgan failure (N = 1). Four early reoperations were required for technical problems, none for endocarditis. Seventy-three of the 76 survivors were followed up for 43 +/- 24 months (range 1 to 84 months). Eight patients died during follow-up, but only 1 of cardiac causes (operation for recurrent endocarditis in a drug abuser). Seven operations were performed, 3 for technical problems or structural failure, 4 for recurrent endocarditis. At 5 years' follow-up, the survival was 81 +/- 5%; 88 +/- 6% of patients were free of endocarditis, 77 +/- 6% had no reoperation: no patient had thromboembolic complications. These results show that human valvular substitutes are adapted for the treatment of complex, progressive aortic, mitral and tricuspid valve endocarditis when techniques of valvular repair are no longer feasible.
本研究的目的是评估人瓣膜替代物(同种异体移植物和自体移植物)治疗主动脉瓣、二尖瓣和三尖瓣复杂进行性心内膜炎的近期和长期效果。自1992年以来,共治疗了80例患者(64例男性,16例女性),年龄44±16岁(范围15至76岁)。53例患者的心内膜炎累及自身瓣膜,4例累及先前已塑形的瓣膜,27例累及人工瓣膜。6例患者的心内膜炎为复发性。病变位于主动脉瓣(N = 59)、二尖瓣(N = 5)、主动脉瓣和二尖瓣(N = 12)、主动脉瓣和三尖瓣(N = 3)、二尖瓣和三尖瓣(N = 1)。术中发现证实了超声心动图诊断的病变:人工瓣膜裂开(27例患者)、人工瓣膜瓣叶撕裂(N = 7)、赘生物(N = 61)、穿孔(N = 48)、瓣周脓肿(N = 47)、主动脉-心室连续性中断(N = 12)、主动脉-二尖瓣连续性中断(N = 7)、右心室-主动脉瘘(N = 1)、主动脉-肺动脉瘘(N = 1)、假性动脉瘤(N = 1)、室间隔缺损(N = 1)。使用了86个人瓣膜替代物(6例患者使用双同种异体移植物):主动脉同种异体移植物(N = 63)、置于主动脉位置的肺动脉瓣(N = 1)、二尖瓣位置(N = 12),其中8个用于二尖瓣,4个用于三尖瓣位置,肺动脉自体移植物(N = 10)。对感染病变进行了10次二尖瓣修复。相关手术包括二尖瓣修复(N = 5)、非梗死性瓣膜病变的三尖瓣修复(N = 1)、升主动脉置换(N = 2)、主动脉弓置换(N = 1)、冠状动脉搭桥手术(N = 2)和1次肾切除术。医院死亡率为5%(4例患者)。死亡原因是:梗死(N = 2)、心肌衰竭(N = 1)和多器官衰竭(N = 1)。因技术问题需要进行4次早期再次手术,无因心内膜炎进行再次手术的情况。76名幸存者中的73名接受了43±24个月(范围1至84个月)的随访。8例患者在随访期间死亡,但仅1例死于心脏原因(一名药物滥用者因复发性心内膜炎接受手术)。进行了7次手术,3次因技术问题或结构故障,4次因复发性心内膜炎。在5年随访时,生存率为81±5%;88±6%的患者无心内膜炎,77±6%的患者未再次手术:无患者发生血栓栓塞并发症。这些结果表明,当瓣膜修复技术不再可行时,人瓣膜替代物适用于治疗复杂的、进行性的主动脉瓣、二尖瓣和三尖瓣心内膜炎。