Objective To explore clinical application and significance of coronary angiography （CAG） prior to heart valve replacement for patients with rheumatic valvular heart disease （RVHD）. Methods We retrospectively analyzed clinical data of 313 RVHD patients who underwent heart valve replacement in the First Affiliated Hospital of Chongqing Medical University from January 2002 to June 2012. All the patients received screening CAG before surgery. According to CAG results，313 patients were divided into two groups. In the coronary artery lesion （CAL） group，there were 29 patients including 17 male and 12 female patients with their age of 60.0±5.2 years. In the non-coronary artery lesion （non-CAL）group，there were 284 patients including 98 male and 186 female patients with their age of 57.0±5.4 years. Surgicaloutcomes were compared between the two groups. Univariate analysis and multivariate logistic regression were performed to analyze risk factors of CAL for RVHD patients. Results CAG showed 29 patients with CAL，and the overall prevalence of CAL was 9.27%. In CAL group，11 patients underwent concomitant coronary artery bypass grafting with 2.2 grafts for each patient on the average. Postoperatively 1 patient （3.45%） died of low cardiac output syndrome （LCOS）. In non-CAL group，5 patients （1.76%） postoperatively died mainly because of LCOS，ventricular fibrillation，sudden cardiac arrest or respiratory failure. Cardiopulmonary bypass time and aortic cross-clamp time of CAL group were significantly longer than those of non-CAL group （P＜0.05）. There was no statistical difference in postoperative mortality，incidence of LCOS，acute renal failure，respiratory failure，reexploration for bleeding，intraoperative blood loss，mechanical ventilation time or hospital stay between the two groups（P＞0.05）. There was no significant correlation between the types of valvular lesions and CAL. Age≥ 55 years （OR=5.534，P=0.005），male gender （OR=2.335，P=0.038） and diabetes mellitus （OR=4.265，P=0.006） were independent risk factors of CAL for RVHD patients undergoing heart valve replacement. Conclusion For RVHD patients with independent risk factors of CAL （age≥55 years，male gender and diabetes mellitus），CAG must beseriously considered before heart valve replacement. RVHD patients with CAL can obtain similarly satisfactory surgicaloutcomes of heart valve replacement as RVHD patients without CAL by appropriate surgical strategy and strengthened perio-perative management.
Surgical Therapy for Valve Diseases Combined with Coronary Heart Diseases in Patients Over or Below 70 Years Old YU Lei, GU Tianxiang, SHI Enyi, XIU Zongyi, FANG Qin, ZHANG Yuhai. (Department of Cardiac Surgery, The No. 1 Hospital of China Medical University, Shenyang 110001, P.R. China)Corresponding author: GU Tianxiang, Email: cmugtx@sina.comAbstract： Objective To summarize the experiences of valve replacement combined with coronary artery bypass grafting (CABG) in senile patients by comparing clinical outcomes of valve diseases combined with coronary heart diseases in patients over or below 70 years old. Methods We retrospectively analyzed the clinical data of 49 patients who received valve replacement combined with CABG in our department from May 1999 to December 2007. Based on the age, the patients were divided into ≥70 years group (17 cases) with its patients at or above 70 years old and lt;70 years group (32 cases) with its patients younger than 70. The percentage of chronic obstructive pulmonary diseases (COPD) before surgery in ≥70 years group was higher than that in lt;70 years group(Plt;0.05). No significant difference was found in the other relevant factors between the two groups. The clinical index of patients in the two groups were compared and analyzed. Results There were significant differences between the two groups in such factors as the percentage of biovalve use (82.4% vs. 12.5%, χ2=23.311, P=0.000), the time of mechanic ventilation (34.5±29.3 h vs. 18.0±16.1 h, t=-2.542,P=0.014), the time of ICU stay (4.4±1.5 d vs. 3.3±0.7 d, t=-3.522, P=0.001), the time of hospital stay (21.4±7.7 d vs. 18.1±1.8 d, t=-2.319, P=0.025), the percentage of IABP use (29.4% vs. 6.3%, χ2=4.862, P=0.037), the percentage of pulmonary function failure (35.3% vs. 6.3%, χ2=6.859, P=0.009), the percentage of acute renal failure (23.5% vs. 3.1%, χ2=5.051, P=0.025), and the percentage of cerebrovascular accident (11.8% vs. 0.0%, χ2=3.933, P=0.048). There was no significant difference between the two groups in factors like the anastomosis of distal graft (2.5±3.1 vs. 2.4±14, t=0.301, P=0.758), the time of aortic occlusion (89.3±25.4 min vs. 88.5±31.0 min, t=0.108,P=0.913), the time of cardiopulmonary bypass (144.6±44.8 min vs. 138.3±52.9 min, t=0.164, P=0.871) and the mortality (5.9% vs. 6.3%, χ2=0.002,P=0.959). The perioperative myocardial infarction rate was zero in both groups. ≥70 years group patients were followed up for 2 months to 9 years with only 1 case missing. One patient who had undergone mechanic valve replacement died of cerebral hemorrhage 1.5 years after operation. Two died of heart failure and lung cancer 3 months and 6 years after operation respectively. For all the others, the cardiac function was at class Ⅰ to Ⅱ and their life quality was significantly improved. The follow up time of lt;70 years group was 1 month to 6 years and 5 cases were missing. Four patients who had undergone mechanic valve replacement died of complications in relation to anticoagulation treatment. One died of severe low cardiac output. Another died of traffic accident. Conclusion Surgery operation and effective perioperative treatment are key elements in improving surgery successful rate and decreasing mortality in patients with valve and coronary artery diseases. Valve replacement combined with CABG is safe for patients older than 70 years old.
Abstract: Objective To summarize the experience of combined coronary artery bypass grafting(CABG) and valve replacement. Methods From May 1997 to March 2006, the results of 80 consecutive patients undergone valve replacement (MVR) and CABG were analyzed. CABG were performed withtotal grafts in 159 grafts (mean 1.99 grafts), with mitral valve replacement (MVR) in 49 patients, with aortic valve replacement (AVR) in 18 patients, with MVR+AVR in 13 patients(mechanical valve replacement in 68 and biological valve replacement in 12). Results The hospital time after operation was 19.2±13.4d. The hospital mortality rate was 12.5% (10/80). The primary cause of death included low cardiac output yndrome, acute renal failure, nervous system complications ,ventricular fibrillation and cardiac arrest. Multivariate testing of preoperative and operative description identified that preoperative myocardial infarction, worse cardiac function, radiographic cardiac enlargement and low ejection fraction were associated with an increase of hospital mortality (P＜0.05). There were postoperative complications including bleeding, severe ventricular arrhythmia, nervous system complications and incision infection. Followup of 58 patients (82.86%, range 6 to 60 months) showed the symptoms of angina pectoris and heart failure were significantly relieved. There were 2 longterm deaths (cerebral infarction and lung infection). Conclusion Combined CABG and valve replacement is an effective way for treatment of coronary artery and valvular heart disease. Improving the heart function preoperatively, strengthening myocardial protection, shortening operation and myocardial ischemia time, and complete revascularization are the key factors for success operation.
Objective To evaluate the left ventricular remodeling after valve replacement for valvular heart disease with giant left ventricle. Methods The clinical material of 92 patients with valvular heart disease and giant left ventricle after valve replacement was retrospectively reviewed. The results of ultrosonic cardial gram（UCG） and the changes of cardiac function before and after operation were compared. Results There was no operative death. The value of left ventricular end-diastolic dimension （LVEDD）, left ventricular end-systolic dimension （LVESD）, left atrial dimension （LAD）, left ventricular ejection fraction （LVEF）, left ventricular fractional shortening （LVFS）, stroke volume （SV） and cardiothoracic ratio in 2 weeks and 2 months after operation were more decreased than those before operation（P〈0. 05）. The value of LVEDD and LAD in 2 months after operation were much more decreased than those in 2 weeks after operation （P〈0. 05）. The cardiac function in early stage after operation was more decreased than that before operation,but the cases of cardiac functional class Ⅱ （38 cases, 41.3% ） in 2 months after operation was significantly more than those before operation （5 cases, 5.4 % ）. Conclusions The early effect of left ventricular remodeling is significant for valvular heart disease with giant left ventricle after valve replacement. The diameter of left ventricle and left atrial are significantly decreased after operation. The protection for cardiac function should be carefully taken in order to prevent the occurrence of complication after operation.