Lindblom D
Department of Thoracic Surgery, Karolinska Hospital, Stockholm, Sweden.
J Thorac Cardiovasc Surg. 1988 Feb;95(2):321-33.
The experience of 810 mitral valve replacements performed during a 15-year period (1969 to June 1983) is reported. All but one patient received a Björk-Shiley disc valve. Five different Björk-Shiley models were used (Delrin, n = 51; standard pyrolytic carbon, n = 307; convexo-concave with an opening angle of 60 degrees, n = 229; convexo-concave with an opening angle of 70 degrees, n = 123; and the Monostrut valve, n = 99). The follow-up was 99.8% complete and covered 4614 patient-years (mean 6.0 years). An autopsy was performed in 77% of all fatalities. Early mortality was 5.7% and decreased during the study period. The 5-, 10-, and 15-year actuarial survival rates (early mortality excluded) were 78%, 62%, and 51%, respectively, and the complication-free survival rates at the same time intervals were 67%, 51%, and 36%. Seven percent of early deaths and 25% of late deaths were valve related, and most of these were due to valve thrombosis. The incidence of valve thrombosis was significantly (p less than 0.0005) reduced after the introduction of the convexo-concave valves, and this reduction was achieved without any increase in bleeding complications. The only patient-related factor found to be related to postoperative thromboembolism was a history of preoperative embolism (p less than 0.05). Most events occurring after implant (death, embolism, valve thrombosis, reoperation, and valve failure) had a peak incidence during the first postoperative year, whereas anticoagulant-related bleedings occurred at a constant rate of 1.2/100 patient-years. The linearized incidence of embolism was 1.6/100 patient-years (actuarial incidence at 5 and 10 years 6.9% and 13.0%, respectively). Seven strut fractures occurred (0.2/100 patient-years, actuarial incidence at 5 and 10 years 1.1%), as did five instances of prosthetic valve endocarditis (0.1/100 patient-years, actuarial incidence at 5 and 10 years, 0.7% and 1.3%). A new concept of valve failure is presented and includes a distinction between events related to the surgical procedure (treatment failure; 1.9/100 patient-years, actuarial incidence at 5 and 10 years 11.0% and 13.5%) and events possibly related to the prosthesis (prosthetic failure; 1.1/100 patient-years, actuarial incidence at 5 and 10 years 7.0% and 8.0%).
本文报告了1969年至1983年6月这15年间进行的810例二尖瓣置换手术的经验。除1例患者外，其余均接受了 Björk-Shiley 碟瓣。使用了5种不同型号的 Björk-Shiley 瓣膜（聚甲醛树脂瓣膜，n = 51；标准热解碳瓣膜，n = 307；开口角度为60度的凸凹型瓣膜，n = 229；开口角度为70度的凸凹型瓣膜，n = 123；以及单支柱瓣膜，n = 99）。随访完成率为99.8%，涵盖4614患者年（平均6.0年）。所有死亡病例中的77%进行了尸检。早期死亡率为5.7%，且在研究期间有所下降。排除早期死亡后，5年、10年和15年的精算生存率分别为78%、62%和51%，同时期无并发症生存率分别为67%、51%和36%。7%的早期死亡和25%的晚期死亡与瓣膜相关，其中大多数是由于瓣膜血栓形成。引入凸凹型瓣膜后，瓣膜血栓形成的发生率显著降低（p < 0.0005），且这种降低并未伴随出血并发症的增加。唯一发现与术后血栓栓塞相关的患者因素是术前有栓塞史（p < 0.05）。植入后发生的大多数事件（死亡、栓塞、瓣膜血栓形成、再次手术和瓣膜功能衰竭）在术后第一年发病率最高，而抗凝相关出血的发生率为1.2/100患者年。栓塞的线性化发病率为1.6/100患者年（5年和10年的精算发病率分别为6.9%和13.0%）。发生了7例支柱骨折（0.2/100患者年，5年和10年的精算发病率分别为1.1%），以及5例人工瓣膜心内膜炎（0.1/100患者年，5年和10年的精算发病率分别为0.7%和1.3%）。提出了瓣膜功能衰竭的新概念，包括区分与手术操作相关的事件（治疗失败；1.9/100患者年，5年和10年的精算发病率分别为11.0%和13.5%）和可能与假体相关的事件（假体功能衰竭；1.1/100患者年，5年和10年的精算发病率分别为7.0%和8.0%）。
