Greffe G, Henaine R, Metton O, Nloga J, Wautot P, Robin J, Ninet J, Saroul C, Barthelet M, Derumeaux G, Obadia J-F
Département de chirurgie cardiaque et transplantation, Hôpital Cardiothoracique Louis-Pradel, Lyon-Bron.
Arch Cardiovasc Dis. 2008 Apr;101(4):204-12. doi: 10.1016/s1875-2136(08)73694-5.
The French Cardiology Society (SFC) systematically recommends (Class I) transesophageal echocardiography (TEE) after any mitral valve replacement with a mechanical prosthesis (MMVR). Taking into account the increasing workload of echocardiography laboratories, our attitude was to propose that only post-operative transthoracic echocardiography (TTE) is performed. The purpose of this study was to evaluate the possible risks of this simplified procedure.
We performed a precise analysis of one full year of practice of MMVR with exhaustive follow-up for the first 2 years concentrating on thromboembolic complications.
From January to December 2003, 84 MMVRs (46 after rheumatic fever, 22 degenerative disease, 11 infective endocarditis (IE) and 5 ischemia) were conducted in 45 women and 39 men of average age 61 years. Early mortality (<30 days) concerned 5 patients (5.9%). A control TTE to determine normal prosthetic function was performed 7+/-2 days after surgery and this revealed 2 cases of nonobstructive thrombosis which were treated medically, 3 cases of paraprosthetic regurgitation, and 1 vegetation due to underlying IE. Actuarial survival was 90.5% at 1 year and 83.3% at 2 years. After a mean follow-up of 179.3 patient-years, 5 patients were reoperated (5.9%): 1 for IE, 1 for paravalvular regurgitation, 1 for mitral valve insufficiency with haemolysis, and 2 for obstructive prosthetic valve thromboses. In addition there were 2 cases of prosthetic valve thrombosis, 8 ischemic strokes (2 ministrokes, 6 sequelar strokes), and 1 peripheral embolism. The global thromboembolic complication rate was therefore 6.1 per 100 patient-years (n=11). There were 4 hemorrhagic events, i.e. a rate of 2.2 events per 100 patient-years. 63% of the 1193 INR conducted were within the target range (3-4.5), 26% were below 3 and 11% were greater than 4.5. 35% of patients with thromboembolic complications had an INR<3.
Morbidity and mortality during the first 2 years after MMVR were relatively high but equivalent to the values of comparable series in the literature. These complications would not have been reduced by a more precise screening based on early TEE. Despite the increasingly litigious nature of the doctor-patient relationship, it would probably be excessive to oppose that this guideline was not followed in a dispute; in particular as it is difficult to apply this measure as echocardiography departments are overworked.
法国心脏病学会（SFC）系统推荐（I类）在任何机械人工二尖瓣置换术（MMVR）后进行经食管超声心动图（TEE）检查。考虑到超声心动图实验室工作量的增加，我们的态度是建议仅进行术后经胸超声心动图（TTE）检查。本研究的目的是评估这种简化程序可能存在的风险。
我们对MMVR一整年的实践进行了精确分析，并在前两年进行了详尽的随访，重点关注血栓栓塞并发症。
2003年1月至12月，对45名女性和39名男性进行了84例MMVR手术，平均年龄61岁。其中46例因风湿热、22例因退行性疾病、11例因感染性心内膜炎（IE）、5例因缺血。早期死亡率（<30天）涉及5例患者（5.9%）。术后7±2天进行了一次对照TTE以确定人工瓣膜功能是否正常，结果发现2例非梗阻性血栓形成，经药物治疗，3例人工瓣膜旁反流，以及1例因潜在IE导致的赘生物。1年时的精算生存率为90.5%，2年时为83.3%。平均随访179.3患者年之后，5例患者再次手术（5.9%）：1例因IE，1例因人工瓣膜旁反流，1例因二尖瓣关闭不全伴溶血，2例因梗阻性人工瓣膜血栓形成。此外，还有2例人工瓣膜血栓形成、8例缺血性中风（2例小中风、6例后遗症中风）和1例周围栓塞。因此，总体血栓栓塞并发症发生率为每100患者年6.1例（n = 11）。有4例出血事件，即每100患者年发生率为2.2例。1193次国际标准化比值（INR）检测中有63%在目标范围内（3 - 4.5），26%低于3，11%高于4.5。发生血栓栓塞并发症的患者中有35%的INR<3。
MMVR术后头两年的发病率和死亡率相对较高，但与文献中类似系列的值相当。基于早期TEE的更精确筛查并不会降低这些并发症的发生率。尽管医患关系中诉讼性质日益增加，但在纠纷中反对未遵循该指南可能有些过度；特别是因为超声心动图科室工作负担过重，难以实施这一措施。
