Beierlein Wolfram, Becker Vera, Yates Robert, Tsang Victor, Elliott Martin, de Leval Marc, van Doorn Carin
Cardiothoracic Unit, Great Ormond Street Hospital for Children National Health Service Trust, London, United Kingdom.
Eur J Cardiothorac Surg. 2007 May;31(5):860-5. doi: 10.1016/j.ejcts.2007.02.006. Epub 2007 Mar 26.
OBJECTIVE: In children, mechanical mitral valve replacement may be the only option if the failing mitral valve cannot be repaired. Mandatory anticoagulation and the fixed size prosthesis are of concern in the growing child, but long-term follow-up results are lacking. METHODS: Single centre, extended retrospective study of 54 patients who underwent first mitral valve replacement between June 1982 and December 1997. Median age at operation was 3.0 years (range 2 days-18.1 years), 21 patients were<or=2.0-year-old. Mitral valve replacement was performed for congenital (43 patients) or acquired (11 patients) heart disease. Median follow-up for operative survivors was 9.2 years, with follow-up>15 years (maximum 22 years) in nine patients. RESULTS: Thirty-day mortality was 42% in patients<or=2-year-old, and 6% in older patients. There were 10 late deaths. Estimated survival at 10 and 15 years follow-up was 33%+/-19% and 33+/-27% in patients<or=2-year-old, and 81%+/-8% and 75%+/-16% in older patients, respectively. High operative mortality in the younger age group was the most important contributor to poor long-term survival. Fifteen patients underwent redo-mitral valve replacement with one operative death. A larger valve was always implanted. Freedom from redo-mitral valve replacement at 10 and 15 years was 25%+/-22% and 0% in patients with prostheses<23 mm, and 83%+/-13% and 83%+/-27% in patients with larger prostheses. Significant bleeding events occurred in eight patients and were often associated with operative interventions. Estimated freedom from bleeding was 75.7%+/-9% and 70.6%+/-16% at 10 and 15 years, respectively. Thromboembolism and endocarditis were rare. There was no structural valve failure. Estimated freedom from all adverse events at 10 years follow-up was 17%+/-13%. CONCLUSIONS: At 10 years follow-up after mechanical mitral valve replacement, most children had suffered an adverse event. At 15 years, all children with a prosthesis<23 mm had outgrown their valve, but redo-mitral valve replacement with a larger size prosthesis was always possible, and carried low operative risk. Long-term anticoagulation was well tolerated. In children every effort should be made to preserve the native valve.
目的：在儿童中，如果病变的二尖瓣无法修复，机械二尖瓣置换术可能是唯一的选择。对于成长中的儿童而言，强制抗凝和固定尺寸的人工瓣膜是令人担忧的问题，但目前缺乏长期随访结果。 方法：对1982年6月至1997年12月期间首次接受二尖瓣置换术的54例患者进行单中心、扩展性回顾性研究。手术时的中位年龄为3.0岁（范围2天至18.1岁），21例患者年龄≤2.0岁。二尖瓣置换术用于治疗先天性（43例患者）或后天性（11例患者）心脏病。手术存活者的中位随访时间为9.2年，9例患者的随访时间超过15年（最长22年）。 结果：年龄≤2岁的患者30天死亡率为42%，年龄较大患者的死亡率为6%。有10例晚期死亡。在年龄≤2岁的患者中，10年和15年随访时的估计生存率分别为33%±19%和33%±27%，年龄较大患者分别为81%±8%和75%±16%。年龄较小组的高手术死亡率是长期生存率低的最重要原因。15例患者接受了再次二尖瓣置换术，有1例手术死亡。总是植入更大尺寸的瓣膜。人工瓣膜尺寸<23 mm的患者在10年和15年时无需再次二尖瓣置换术的比例分别为25%±22%和0%，人工瓣膜尺寸较大的患者分别为83%±13%和83%±27%。8例患者发生了严重出血事件，且常与手术干预相关。在10年和15年时，估计无出血的比例分别为75.7%±9%和70.6%±16%。血栓栓塞和心内膜炎罕见。未发生人工瓣膜结构性故障。在10年随访时，估计无所有不良事件的比例为17%±13%。 结论：在机械二尖瓣置换术后10年随访时，大多数儿童都经历了不良事件。在15年时，所有人工瓣膜尺寸<23 mm的儿童其瓣膜已不再适用，但总是可以用更大尺寸的人工瓣膜进行再次二尖瓣置换术，且手术风险较低。长期抗凝耐受性良好。对于儿童，应尽一切努力保留自身瓣膜。
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