■ Surgical indications for valve diseases
1. Surgical indications for mitral valve disease
(1) Mitral stenosis
Mitral stenosis can be divided into congenital and acquired types. Acquired mitral stenosis is almost always caused by rheumatic fever in China. In rheumatic heart disease, the incidence of mitral valve invasion is 65%-90%, and simple mitral stenosis accounts for about 25%.
1. Surgical indications for congenital mitral stenosis
Congenital mitral stenosis can be divided into three types; Type ⅰ: stenosis is located in the annulus and leaflets; Type ⅱ stenosis is located in the plane of chordae tendineae, which is called parachute mitral valve; Type ⅲ stenosis is located in the papillary muscle plane, and the chordae tendineae are shortened and fused with each other, connecting with the thick papillary muscle.
Congenital valvular heart disease should be treated by internal medicine as far as possible to maintain heart function and control heart failure, and surgery should be performed after the sick child grows up. However, for patients with uncontrollable recurrent heart failure, valve surgery can provide children with a chance to survive. Frequent congestive heart failure is the most common surgical indication of congenital mitral stenosis. In principle, mitral balloon dilatation or direct vision repair can be tried first for type I stenosis, and those with unsatisfactory direct vision repair effect (such as mitral valve bridge) choose valve replacement. Type ⅱ and ⅲ stenosis should be repaired under direct vision as much as possible, and valve replacement should be performed if the repair fails.
2. Surgical indications of acquired mitral stenosis
(1) The symptoms of patients with mitral stenosis are aggravated under mild load, indicating that cardiac function compensation is in a critical state, and surgery should be performed to prevent the disease from developing.
(2) Atrial Fibrillation Mixed mitral valve disease (stenosis with mitral insufficiency) has the highest incidence of atrial fibrillation, followed by patients with mitral stenosis and mitral insufficiency. Atrial fibrillation brings several serious problems to patients: ① Atrial fibrillation makes the left atrial systolic function lose, resulting in a decrease in cardiac output of about 20%-25%; ② The appearance of atrial fibrillation aggravates the clinical symptoms, especially in the early stage of atrial fibrillation, and the acceleration of heart rate can cause pulmonary edema; ③ Atrial fibrillation increases the chance of left atrial thrombosis and embolism, which is about 7 times of sinus heart rate. Clinically, the appearance of multiple atrial premature beats is often a precursor to atrial fibrillation, and timely surgical treatment can avoid atrial fibrillation and related complications.
(3) The incidence of embolic complications in patients with mitral stenosis is 4 times higher than that in patients with mitral insufficiency. Therefore, patients with mitral stenosis with a history of left atrial thrombosis or embolism should undergo surgery even if they are asymptomatic.
(4) Pulmonary Hypertension In most patients with pulmonary hypertension, although they can't return to normal immediately after operation, they can gradually decrease, depending on the pulmonary vascular disease. Surgery must be performed before severe pulmonary vascular disease occurs. There are still some patients with mitral stenosis and severe pulmonary hypertension who have never experienced the symptoms of pulmonary vein hypertension, but have signs of pulmonary hypertension and right ventricular hypertrophy, and their cardiac output is low at rest. Such patients should be operated even if they have no symptoms.
3. Selection of surgical methods
(1) Percutaneous balloon mitral valvuloplasty: Under normal circumstances, patients with simple mitral stenosis have no calcification, no obvious subvalvular lesions, mitral insufficiency and good valve mobility, especially when the first heart sound is loud and the mitral orifice clicks. But this method is not suitable for patients with left atrial thrombosis.
(2) Mitral valve separation: including closed mitral valve separation and direct vision separation. Surgical indications are: simple bicuspid teeth.
Valve stenosis has no calcification, severe subvalvular lesions and obvious mitral insufficiency.
(3) Indications of mitral valve replacement: ① Physical examination showed no opening click, and the first heart sound was loud; ② Mitral valve insufficiency; ③ Echocardiography showed calcification of mitral valve, mottled, fibrosis and thickening of valve leaflet or subvalvular structure; ④ Elderly patients with atrial fibrillation and systemic embolism; ⑤ Restenosis after mitral valve separation.
(2) Mitral valve insufficiency
The most common causes of mitral regurgitation are rheumatic heart disease, mitral valve prolapse, papillary muscle insufficiency and endocarditis. In China, rheumatic heart disease is still the main disease at any age, but the number of patients without rheumatic heart disease is increasing year by year. Congenital mitral insufficiency is more common in patients with atrioventricular canal malformation.
Mitral insufficiency can be divided into organic and functional. Functional mitral regurgitation is mostly mild to moderate, and rarely severe. After the primary disease is corrected, most of them can subside by themselves, but severe mitral regurgitation requires mitral valvuloplasty without valve replacement. Patients with organic mitral regurgitation should choose valvuloplasty or valve replacement according to the etiology and severity of the disease.
General surgical indications are as follows:
1. Patients with asymptomatic moderate mitral insufficiency should undergo surgery if they meet any of the following conditions:
(1) Decreased cardiac function, EF
(2) left ventricle enlargement, LVSD >；; 50 mm, LVEDD & gt70mm
(3) Limited activity, abnormal increase of pulmonary entrapment pressure after exercise;
(4) Pulmonary hypertension at rest;
(5) atrial fibrillation.
2. There are symptoms, no matter whether the heart function is normal or abnormal, surgery should be performed. When ef
3. In asymptomatic patients with moderate severe reflux, the size of the heart cavity.
2. Surgical indications of aortic valve lesions
(1) aortic stenosis
Aortic valve stenosis can be divided into congenital and acquired types. Congenital aortic stenosis accounts for about 2/3 of patients with aortic stenosis, especially bicuspid valve malformation, which accounts for more than 50% of adult aortic stenosis. Acquired rheumatic aortic stenosis is common, accounting for 30%-40% of all patients undergoing aortic valve replacement. Degenerative aortic stenosis is more common in patients over 60 years old.
1. Surgical indications for congenital aortic stenosis
(1) The infant with aortic stenosis has an orifice area of 10kpa(75mmHg), which is called severe stenosis. Emergency operation is needed to cut the valve leaflet interface. Otherwise, it is prone to heart failure and sudden death.
(2) Mild or moderate stenosis should be operated under the following circumstances.
① Recurrent syncope or angina pectoris;
② Exercise palpitation, shortness of breath, left ventricular hypertrophy and strain in electrocardiogram, systolic tremor in the second intercostal region of the right sternum, and aortic valve pressure difference measurement >; 6.7 kPa (50 mm Hg);
③ Valve calcification or bacterial endocarditis with insufficiency.
2. Surgical indications of acquired aortic stenosis
(1); 6.7 kPa (50 mHg), regardless of symptoms and left ventricular dysfunction, surgery should be performed.
(2) Patients with aortic stenosis should be operated within a time limit if the following conditions are met.
① Because of the severe stenosis of the valve orifice, the pressure gradient across the valve is different >:10 kPa (75 mmHg);
② Left heart failure;
③ Syncope, angina pectoris and other symptoms often occur.
Due to the above situation, patients are prone to sudden death.
(3) ECG of moderate valve stenosis showed progressive left ventricular hypertrophy and strain, and ultrasonic examination confirmed that ventricular wall hypertrophy was progressive and should be treated by surgery.
(4) Patients with aortic stenosis complicated with calcification, insufficiency or endocarditis should be operated in time.
(5) Patients with left ventricular hypertrophy and strain, pulmonary vein hypertension and decreased left ventricular systolic function should be operated.
(6) Because of other valve operations, the aortic valve should be operated even if it is slightly narrowed or valvular pathological damage.
(II) Aortic valve insufficiency
Aortic insufficiency has two main causes:
1. The main valve disease is rheumatism, and non-rheumatic diseases include endocarditis, bicuspid valve, VSD with valve prolapse, etc.
2. Aortic lesions: such as Marfan syndrome, syphilis, aortitis, dissecting aneurysm, ruptured aortic sinus aneurysm, etc.
In developing countries, rheumatism is the most common; In developed countries, aortic disease is the main cause, accounting for 50% of AVR operations caused by aortic insufficiency, while rheumatism only accounts for 25%.
3. Surgical indications for aortic insufficiency:
(1) Symptomatic aortic valve insufficiency, patients with dyspnea, fatigue, angina pectoris, chest pain and other symptoms, is an absolute surgical indication. But for lvesd lvesd >: 60mm, EF & lt30%, ESVI & gt；; Patients with 90ml/m2 must make a careful decision.
(2) Asymptomatic aortic insufficiency should be operated with the following indexes:
① LVESD is close to 55mm (ultrasonic examination);
②LVPSWS & lt； 80.0kpa(600mmHg) (ultrasonic inspection);
③LVPSWS & lt； 30. 1kpa(235mmHg) (ultrasonic inspection);
④ FS is close to 25% (ultrasonic examination);
⑤ EF is close to 50% (ultrasonic examination);
⑥ Shortness of breath after activity.
(3) Asymptomatic aortic valve insufficiency, and how to deal with it if the examination fails to reach the above indicators. Generally speaking, LVSD 50-54 mm is followed up once every six months and LVSD 45-49 mm is followed up once a year.
(3) ECG of moderate valve stenosis showed progressive left ventricular hypertrophy and strain, and ultrasonic examination confirmed that ventricular wall hypertrophy was progressive and should be treated by surgery.
(4) Patients with aortic stenosis complicated with calcification, insufficiency or endocarditis should be operated in time.
(5) Patients with left ventricular hypertrophy and strain, pulmonary vein hypertension and decreased left ventricular systolic function should be operated.
(6) Because of other valve operations, the aortic valve should be operated even if it is slightly narrowed or valvular pathological damage.
Three. Indications of tricuspid valve surgery
(a) the indications of tricuspid valvuloplasty are:
1. When the female ring is greater than 33 or the male ring is greater than 35, the nozzle has obvious reflux;
2. Organic valve diseases, including bacterial endocarditis, accompanied by perforation or loss of valve leaflets.
(2) The indications for tricuspid valve replacement are:
1. Severe tricuspid stenosis, mean diastolic pressure difference between right atrium and right ventricle >: 5mmHg or tricuspid orifice area.
2. Severe organic tricuspid insufficiency makes plastic surgery difficult;
3. The tricuspid valve caused by infective endocarditis can't be removed locally, or the valve leaves are missing greatly. The tricuspid valve can be removed, the infected focus can be eliminated, and biological valve replacement can be performed at the same time.
4. Tricuspid valve displacement deformity: If the valve lobe is dysplasia, especially the anterior lobe, valve replacement should be done. If the anterior lobe is enlarged and well developed, it can be treated with annuloplasty.
Four. pulmonary valve disease
Pulmonary valve diseases include pulmonary valve stenosis and pulmonary valve insufficiency.
(1) Pulmonary valve stenosis: Because pulmonary valve stenosis is often a part of congenital heart malformation, pulmonary valve dilatation is often needed while correcting heart malformation. Simple pulmonary valve stenosis can be dilated by balloon through right cardiac catheter. In some severe pulmonary valve stenosis, because the stenosis is very small, it is difficult to dilate the catheter through the balloon, so thoracotomy should be chosen for this kind of patients.
(2) Pulmonary valve insufficiency: Pulmonary valve insufficiency often does not require special treatment. Some scholars believe that pulmonary valve replacement should be performed in patients with severe pulmonary valve insufficiency that cannot be controlled by drugs.