Medical Diagnosis
Vol.07 No.01(2017), Article ID:20056,5 pages
10.12677/MD.2017.71003

One Case of Mitral Valve Replacement after Stuck Leaflet of Mitral Valve-in-Valve Implantation

Xiang Yang, Yu Wang, Yuying Duan, Xuejuan Ma, Jiayu Li, Zeran Yu

Department of Cardiology, 1st Affiliated Hospital of the KMU (Kunming Medical University), Kunming Yunnan

Received: Mar. 9th, 2017; accepted: Mar. 27th, 2017; published: Mar. 30th, 2017

ABSTRACT

Although cases of stuck of mitral valve have been reported before, the case of mitral valve replacement after stuck leaflet of mitral valve-in-valve implantation is rare. This article presents such a case and introduces the diagnosis and treatment systematically.

Keywords:Mitral Valve Replacement, Stuck Leaflet, Valve-in-Valve Implantation

二尖瓣置换术后卡瓣行再次换瓣术1例

杨祥,王钰,段玉映,马雪娟,李家宇,俞泽然

昆明医科大学第一附属医院心内科,云南 昆明

收稿日期:2017年3月9日;录用日期:2017年3月27日;发布日期:2017年3月30日

摘 要

既往已有二尖瓣卡瓣的报道,但二尖瓣置换术后卡瓣行再次换瓣术的病例却极其少见,本文介绍了二尖瓣卡瓣后再次换瓣的病例1例,并结合相关文献对其诊治做了系统阐述。

关键词 :二尖瓣置换术,卡瓣,再次换瓣

Copyright © 2017 by authors and Hans Publishers Inc.

This work is licensed under the Creative Commons Attribution International License (CC BY).

http://creativecommons.org/licenses/by/4.0/

1. 病例报告

既往已有二尖瓣卡瓣的报道,但二尖瓣置换术后卡瓣行再次换瓣术的病例却极其少见,本文介绍了二尖瓣卡瓣后再次换瓣的病例1例,并结合相关文献对其诊治做了系统阐述。

患者男性,34岁,因二尖瓣置换术后18年,咯血2天,于2016年2月17日收住昆明医科大学第一附属医院。1998年患者曾因二尖瓣脱垂行二尖瓣金属瓣膜置换术,术后恢复良好,但未长期规律行华法林抗凝治疗。半年前出现乏力,未予诊治,2天前出现咯血,数次,为鲜血,每次量约20~40 ml,伴心悸。既往吸烟史7年,约15支/天。入院查体:体温36.8℃,心率110 bpm,呼吸24 bpm,血压129/84 mmHg;胸部正中可见一长约20 cm手术疤痕。听诊心尖区闻及金属瓣启闭音,胸骨左缘第四肋间闻及全收缩期吹风样杂音,肺动脉瓣区第二心音亢进并分裂。心电图示:窦性心动过速,重度电轴右偏,右心室肥厚。经胸壁超声心动图(TTE)示(见图1图2):1) 二尖瓣前向血流速度明显增高(考虑机械瓣急性卡瓣);2) 主动脉内径增宽,极重度肺动脉高压(115 mmHg);3) 左房径明显增大;4) 冠状静脉窦扩张;5) 三尖瓣中等反流。冠状动脉CTA示:左心房、右心室增大,肺动脉高压征象,二尖瓣区金属致密影,考虑瓣膜置换术后改变。凝血酶原时间:17.7 s,国际标准化比率:1.48,其他检查未见异常。入院诊断为二尖瓣置换术后卡瓣、右心扩大,三尖瓣反流、极重度肺动脉高压、心功能II级(NYHA分级)。美国心胸外科学会评分系统(STS)提示手术病死率为20.91% [1] ,欧洲心脏手术风险评分(logistic Euro SCORE) 65.27% [2] 。

入院后予抗凝、降肺动脉压等对症支持治疗后,心脏外科医师术前讨论分析认为有手术指征,遂于2016年2月25日行二尖瓣再次换瓣术。术中探查原机械瓣人工环表面完全为纤维瘢痕组织覆盖,一瓣叶活动受限,另一个瓣叶无活动,其附近可见大量血栓形成(见图3)。拆除病损瓣膜,彻底清除血栓,见瓣下大量增生的纤维瘢痕组织致左室流入道明显狭窄,充分疏通流入道后,予置换27号St.Jude机械瓣(见图4图5),心脏复跳后探查见三尖瓣,瓣环扩大,后叶瓣尖稍增厚,瓣膜反流明显。以30号爱德华4900环成型后反流消失。术后顺利康复出院。

Figure 1. Metal mitral valve opening is limited, the blood flow of orifice was accelerated

图1. 二尖瓣金属瓣开放受限,瓣口血流

Figure 2. The Doppler show a markedly faster diastolic flow

图2. 多普勒频谱提示舒张期流速明显增快

Figure 3. Endothelialization of prothetic mitral annulus, around the valve leaflets has thrombus formation

图3. 人工瓣环内膜化,瓣叶周围有血栓

Figure 4. The mechanical prosthetic valve has circular annulus formation, fibrous tissue proliferation among the surface, like a another annulus

图4. 人工机械瓣瓣中环形成,纤维结蹄组织沿机械瓣瓣环内侧增生,呈环状,似又一瓣环

2. 讨论

中国是一个瓣膜病多发国 [3] ,二尖瓣置换术作为瓣膜病的治疗方法之一 [4] ,术后极少出现瓣膜功能障碍,机械瓣急性卡瓣是二尖瓣置换术后的严重并发症,发生原因有 [5] [6] [7] ① 血管翳增生:周围心内膜组织、肉芽或纤维组织的增生;② 血栓形成:陈旧性及新鲜血栓;③ 赘生物形成;④ 自体瓣膜残余组织干扰。目前经食道超声心动图(TEE)辅以三维成像是确诊急性卡瓣最敏感及特异的手段,但在某些危重情况下,如本例患者已无法耐受TEE 检查,可根据TTE的典型瓣膜形态特征和血流动力学改变进行诊断,为进一步治疗争取时间。本例患者发生二尖瓣置换术后卡瓣多考虑为术后未行长期规律华法林抗凝治疗,INR未达标,致瓣周大量血栓形成并保留的后瓣瓣下结缔组织增生,使瓣膜活动失灵,左室流入道梗阻(如图6)。

患者一旦确诊二尖瓣卡瓣,若无相应临床症状,且心功能尚可,Hurrel D,Shapira Y和Montorsi P等人 [8] [9] [10] 建议将成功率高及并发症少的抗凝治疗作为首选,并且每半年行1次TEE和TTE,进行密切随访,但具体随访时间尚未见详细报道。而对于上述危急重症患者,二尖瓣开瓣音不清脆或消失,存在心源性休克、急性左心衰、,预示其病理生理基础为左房压过高,严重肺淤血,肺动脉高压,需立即行急诊手术,术中少数患者可行卡顿瓣膜旋转,而绝大多数患者需行二尖瓣再次置换手术 [11] [12] [13] 。

Figure 5. Remove the hyperplastic “annulus fibrosus” and reserved posterior leaflets in first operation

图5. 切除增生的“纤维环”,切除首次手术保留的后瓣叶

Figure 6. A new mechanical valve was inserted

图6. 置入新的机械瓣

此外,Jorge Almeida指出有极少数患者甚至不出现卡瓣相关症状及心脏事件,他们是在术中行食道超声才得以发现卡瓣,值得我们注意 [5] 。

我们对急性二尖瓣置换术及卡瓣后行再次瓣膜置换术的体会如下:1) 虽然二尖瓣瓣膜置换术后极少出现功能障碍,但仍应警惕卡瓣发生,应该每3~6月行一次TTE随访;2) 若无相关禁忌,换瓣患者应在术后规律服用华法林抗凝治疗,并定期监测INR维持于2~3;3) 对于超声表现为金属瓣启闭不良伴团块样物质回声,舒张期前向血流增快,左房显著增大,右心扩张并重度肺高压的患者,需立即给予相关干预,加强抗凝治疗,若还合并心源性休克、急性左心衰等则再次换瓣术刻不容缓。总之,临床上患者病情千变万化,我们应综合考虑作出最佳决策。

文章引用

杨祥,王钰,段玉映,马雪娟,李家宇,俞泽然. 二尖瓣置换术后卡瓣行再次换瓣术1例
One Case of Mitral Valve Replacement after Stuck Leaflet of Mitral Valve-in-Valve Implantation[J]. 医学诊断, 2017, 07(01): 11-15. http://dx.doi.org/10.12677/MD.2017.71003

参考文献 (References)

  1. 1. Nashef, S.A., Roques, F., Gauducheau, E., et al. (1999) European System for Cardiac Operative Risk Evaluation (EuroSCORE). European Journal of Cardio-Thoracic Surgery, 16, 9-13. https://doi.org/10.1016/S1010-7940(99)00134-7

  2. 2. Online STS Risk Calculator (2014). http://riskcalc.sts.org

  3. 3. 饶栩栩, 黄震东, 岑润超, 等. 我国风湿性心脏病的流行现状[J]. 中华心血管病杂志, 1998, 26(2): 98-100.

  4. 4. Lutter, G and Frank, D. (2016) Interventional Mitral Valve Replacement. Herz, 41, 31-36. https://doi.org/10.1007/s00059-015-4389-x

  5. 5. Almeida, J., Santos, A., Barreiros, F., et al. (2007) Stuck Leaflet of Bileaflet Prosthesis in Mitral Position—Five Cases to Make Us Think. Interactive CardioVasc Thoracic Surgery, 6, 379-383. https://doi.org/10.1510/icvts.2006.145193

  6. 6. 倪一鸣, 李任远, 冯强. 动态卡瓣—人工主动脉碟瓣功能障碍的特殊现象[J]. 中华胸心血管外科杂志, 2005, 21(1): 26.

  7. 7. 贺林, 谢明星, 吕清, 等. 超声心动图在人工机械瓣卡瓣诊断中的临床应用[J]. 临床超声医学杂志, 2014, 16(11): 721-723.

  8. 8. Hurrel, D.G., Schaff, H.V. and Tajik, J.A. (1996) Thrombolytic Therapy for Obstruction of Mechanical Prosthetic Valves. Mayo Clinic Proceedings, 95, 216-222. https://doi.org/10.4065/71.6.605

  9. 9. Shapira, Y., Herz, I., Vaturi, M., Porter, A., Adler, Y., Birnbaum, Y., Strasberg, B., Sclarovsky, S. and Sagie, A. (2000) Thrombolysis Is an Effective and Safe Therapy in Stuck Bileaflet Mitral Valves in the Absence of High-Risk Thrombi. Journal of the American College of Cardiology, 35, 1874-1880. https://doi.org/10.1016/S0735-1097(00)00640-9

  10. 10. Montorsi, P., Cavoretto, D., Alimento, M., Muratori, M. and Pepi, M. (2003) Prostheticmitral Valve Thrombosis: Can Fluoroscopy Predict the Efficacy of Thrombolytic Treatment. Circulation, 108, II79-84. https://doi.org/10.1161/01.cir.0000087900.45365.45

  11. 11. Masiello, P., Mastrogiovanni, G., Leone, R., Del Negro, G., Iesu, S., Triumbari, F. and Di Bennedeto, G. (1996) One Leaflet Immobilization after Mitral Valve Replacement with a Bileaflet Prosthesis. The Journal of Heart Valve Disease, 5, 114-116.

  12. 12. Kumano, H., Suehiro, S., Shibata, T., Hattori, K. and Kinoshita, H. (1999) Stuck Valve Leaflet Detected by Intraoperative Transesophageal Echocardiography. The Annals of Thoracic Surgery, 67, 1484-1485. https://doi.org/10.1016/S0003-4975(99)00212-X

  13. 13. Fujii, H., Suehiro, S., Shibata, T., Hattori, K., Watanabe, H. and Yoshikawa, J. (2002) Value of Intraoperative Transesophageal Echocardiography in Preventing Serious Complications during Valvular Surgery. A Report of Four Cases. The Journal of Heart Valve Disease, 11, 135-138.

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