Ben Ismail M, Trabelsi S, Kafsi N, Zaouali M
Arch Mal Coeur Vaiss. 1983 Jan;76(1):53-60.
In the period from 1968 to November 1980, 1 023 patients underwent surgery for single or multiple valve replacement. Fifty three patients (6,6% of the follow-up population) had to be reoperated, including 5 patients who had to be reoperated twice, giving a total of 58 reoperations. The average interval before reoperation was 30 months. The incidence was similar in monovalvular (7,5 p. 100 mitral valves, 5 p. 100 aortic valves) and polyvalvular (7 p. 100) cases. On the other hand, the incidence of reoperation of tricuspid prostheses (17 p. 100) was significantly superior to that of mitral valve (5,3 p. 100) or aortic valve (3,8 p. 100) prostheses. In 91 p. 100 of cases, the indication for reoperation was prosthetic valve dysfunction related to endocarditis in over a third of cases (21). In 32 cases, reoperation was required in the absence of any infectious process: 13 spontaneous perivalvular leaks, 10 thromboses, and 9 stenosing prostheses. There were no reoperations for wear of the prosthetic material. Only 9 p. 100 of patients were reoperated for uncorrected valvular disease. The prognosis of these reoperations was poor; hospital mortality being 42,5 p. 100. This high mortality rate is explained by the frequency of reoperation for infective endocarditis (36 p. 100) in our series, the mortality of which was 73,6 p. 100 and even higher when reoperation was an emergency for infectious or hemodynamic reasons. There was also a high mortality rate with reoperation for thrombosis (30 p. 100) because of the severe myocardial dysfunction in thrombosis of tricuspid prostheses and the emergency situation associated with mitral prosthetic valve thrombosis. Excluding these two complications, the average mortality was 21 p. 100. Although the surgical indications are relatively easy for thrombosis, perivalvular leak and stenosing prostheses, they are particularly difficult in infectious endocarditis especially with regards to the timing of reoperation. We believe that, ideally, reoperation should be delayed as long as possible to allow the antibiotic therapy the maximum time to take effect. Surgery can then be performed after controlling the infection and before the installation of severe hemodynamic distress.
在1968年至1980年11月期间，1023例患者接受了单瓣膜或多瓣膜置换手术。53例患者（占随访人群的6.6%）需要再次手术，其中5例患者需要再次手术两次，共进行了58次再次手术。再次手术前的平均间隔时间为30个月。单瓣膜置换（二尖瓣置换为7.5%，主动脉瓣置换为5%）和多瓣膜置换（7%）的发生率相似。另一方面，三尖瓣人工瓣膜再次手术的发生率（17%）明显高于二尖瓣（5.3%）或主动脉瓣（3.8%）人工瓣膜。在91%的病例中，再次手术的指征是人工瓣膜功能障碍，其中超过三分之一的病例（21例）与心内膜炎有关。在32例病例中，在没有任何感染过程的情况下需要再次手术：13例为自发性瓣周漏，10例为血栓形成，9例为人工瓣膜狭窄。没有因人工瓣膜材料磨损而进行的再次手术。只有9%的患者因未纠正的瓣膜疾病而再次手术。这些再次手术的预后很差；医院死亡率为42.5%。如此高的死亡率是由于我们系列中因感染性心内膜炎而再次手术的频率（36%），其死亡率为73.6%，当因感染或血流动力学原因而进行急诊再次手术时甚至更高。因血栓形成而再次手术的死亡率也很高（30%），这是因为三尖瓣人工瓣膜血栓形成时心肌功能严重受损以及二尖瓣人工瓣膜血栓形成相关的紧急情况。排除这两种并发症，平均死亡率为21%。尽管对于血栓形成、瓣周漏和人工瓣膜狭窄，手术指征相对容易确定，但在感染性心内膜炎中，尤其是关于再次手术的时机，手术指征特别难以确定。我们认为，理想情况下，再次手术应尽可能推迟，以便抗生素治疗有最长的起效时间。然后可以在控制感染后且在出现严重血流动力学窘迫之前进行手术。
