The Analysis Of The Clinical Results Of 28 Cases Of Combined Mitral-Aortic Valve Replacement For Patients Above 60 Years Old

Background: Combined mitral-aortic valve disease is the most common double cardiac valve disease. Abroad, according to autopsy results and large numbers of surgical reports, this combined form makes up 48%-87% of all double cardiac valve disease, and domestically, the percentage is 35% or so. There are mainly two kinds of causes for this disease: rheumatoid and non-rheumatoid. Retrogressive pathological changes and infective endocarditis often occur in the latter group. Surgical treatment of double cardiac valve disease started in 1950s, but in our country, not until the late 1970s and early 1980s had surgeries been gradually applied in the treatment of this disease. Nowadays surgical treatment of double cardiac valve disease has been widely used all of the country. In the past, the mortality of double cardiac valve surgery, especially the double valve replacement, is as high as 10% to 25%. But recently, thanks to the development of the skills in extracorporeal circulation and myocardial protection, and the improvement of surgical methodsand perioperative management, the mortality has considerably dropped.Purpose: By way of statistical analysis of the clinical results of combined mitral-aortic valve replacement for the old patients, important factors such as perioperative management and myocardial protection are stated and analyzed. The purpose is to offer reference for the surgical application of combined mitral-aortic valve replacement under extracorporeal circulation for patients above 60 years old.Methods: 28 cases of DVR during September, 2001 and September 28th, 2006 are reviewed and analyzed, among which 17 patients were male and 11 were female. Their ages were between 60 and 73, and the average age was 66.2±7.8. Their weights were from 55 to 82 kg, so averagely 61.6±11.9 kg. In this group, 25 cases were rheumatistic heart diseases, 1 case had grumous denaturation, and 2 cases belonged to retrogressive pathological changes of old people. The history of disease was from six months to fifteen years, so the mean time was 11.6 years. None of these patients had had heart surgeries before. Among these patients, there were five cases ofacute left heart failure, six cases of pulmonary hypertention accompanied by chronic pulmonary incompetence, three cases of hepatic insufficiency, three cases of renal inadequacy and three cases of diabetes. In this group, 12 cases belonged to NYHA grade II, 11 cases belonged to NYHA grade III, and 5 cases belonged to NYHA grade IV. General anesthesia and endotracheal intubation was used in all cases, and operation was conducted in mild hypothermia. MVR was by right atriotomy. Mitral valves were replaced by continuous suture while aortic valves were replaced by interrupted suture. Key's valvuloplasty was used for severe tricuspid insufficiency.Results: In 10 cases, the hearts resumed beating automatically, which took up 35.7%. And in the other 18 cases, the hearts resumed beating after electronic shock, which took up 64.3%. The time for the extracorporeal circulation in DVR is 125±23 min. During the CPB the mean urine quantity is 800±105 ml. The mean time of aortic clamp is 74±15 min. In 11 cases, valvular thrombus in the left atrium was cleared up. Key's valvuloplasty tricuspid figuration was used in 22 cases. In one case, dilatation of the root of valvular ring was conducted because of narrow valvular ring in aorta, and left atriumwas repaired by using the patient's own pericardium. Averagely speaking, patients lived in hospital for 12 to 15 days. There was no death in hospital. After operations, there were 5 cases of low cardiac output syndrome, 8 cases of arrhythmia, including 5 cases of auricular fibrillation, one case of short-term atrioventricular block of grade III, one case of supraventricular tachycardia, and one case of frequent ventricular premature beat. There were also two cases of chronic cardiac tamponade, which happened in the 5th day and the 8th day after operation respectively. One was cured by performing pericardial cavity drainage again.The other case, sternotomy was performde again to stop bleeding. There was one case of infection behind sternum, which was cured by dressing, nutritive supporting treatment and antibiotic treatment. No complication, such as bleeding or embolism, was found. 23 cases were interviewed afterwards, which occupied 82.1%, during the time span of three months to five years. No death was reported during the follow-up interview period. The functions of the hearts were reported to have improved dramatically, with 19 cases of grade II and 4 cases ofgrade III. Most patients'life quality was greatly improved after the operation.Discussions: Old patients who suffer from double cardiac valve disease usually have longer history of heart disease and poor heart functions. Together with diseases of other systems, state of illness is very complicated. Damaging factors during operations will have more obvious influence on old people. So it is of vital importance to protect the major organs during the process of the operation. We can lower the extent of damage to the heart and all the other organs by improving operational skills and shortening the time of operation. There is something special in the perioperative management. By strengthening it, we may lower perioperative complication as well as the mortality.The rate of operational success can be raised by making good preparation and choosing the best time for operation. In order to avoid complication and lower mortality, improving the function of the heart is the emphasis. The treatments such as tonifying the heart, diuresis and vasodilatation should be given according to the nature of heart valve disease, the extent of heart muscle damage and thechange in hemodynamics. At the same time, nutrition should be strengthened to improve the overall condition of the patient.Coronary angiography should be routinely performed for old patients. Besides, diseases in other organs, for example high blood pressure, diabetes, and pulmonary hypofunction will add to the difficulty of postoperative recovery after operation. Before operations, systematic checkups should be carried out, if certain problem is found out, treatment should be given accordingly so as to guarantee the good functions of all the other organs.Myocardial protection plays a crucial part in the surgical treatment of valves disease. Improper myocardial protection is the No. 1 factor causing perioperative death. Therefore, a thorough and complete myocardial protection is the basic premise for the success of the operation. Besides, myocardial protection during the process of operation has an important influence on the precaution of prognosis. Oxygenic hematocryal cardioplegia can provide more oxygen and ground substance for the anoxic heart muscle, lessen reperfusion damage and heart muscle edema, which will be helpful for the recovery of the function of the heart after operation.Preservation of subvalvular apparatus can maintain normal tensive ring and geometrical form of the left ventricle protect the continuum of mitral valvular ring-papillary muscle, guarantee enough pulling function of the tendinous cord, improve mechanical systole function in the left ventricle, decrease energy consuming, hence to lower the occurrence of low cardiac output syndrome, benefit the recovery of heart function after operation, and have a long lasting effect on the long-term improvement of heart functions. Correction of tricuspid insufficiency is especially important for achieving a desirable curative effect and long-term effect.Because of the decrease of functions in various organs, old patients may have more complication and a quick change of disease condition. So they need more careful treatment and observation after operation. Multi-organic failure should be protected. The core of attention should be maintaining circulation and stable breath.