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Ischemic Stroke during Low Intensity Anticoagulation Therapy after Mechanical Heart Valve Replacement

Objective To investigate the risk factors and the prevention and cure methods of ischemic stroke during low intensity anticoagulation therapy after mechanical heart valve replacement. Methods From March 2004 to July 2008，twentythree patients with ischemic stroke after mechanical heart valve replacement had been researched(ischemic stroke group). One hundred and twenty patients who had undergone mechanical heart valve replacement were randomly chosen in the same period as control group. Gender, age, the dose of warfarin , anticoagulation intensity(INR), INR review interval, left atrial diameter and heart rhythm were compared between the two groups, and the risk factors of ischemic stroke were analyzed by logistic regression analysis. Results (1) Patients in ischemic stroke group all discharged from hospital after treatment, and they were followed up for 1 month-3 years after discharged. All the patients’ neurological complications improved obviously, and no recurrent embolism and severe hemorrhage was found. (2) There was no statistical significance between two groups in gender, age and the dose of warfarin（Pgt;0.05）. (3) Nonconditional logistic regression analysis on influence factors showed that atrial fibrillation（P=0.000）, left atrial enlargement（P=0.002）, low anticoagulation intensity（P=0.012） and longtime INR review interval（P=0.047）were the risk factors of ischemic stroke during low intensity anticoagulation therapy after mechanical heart valve replacement. Conclusions (1)The prognosis of ischemic stroke during low intensity anticoagulation therapy after mechanical heart valve replacement is better than that of intracranial hemorrhage, and the occurrence of ischemic stroke is related to many risk factors. (2)The influences of risk factors should be minimized in order to avoid ischemic stroke. (3) Early low intensity anticoagulation therapy is safe and effective for patients with ischemic stroke after heart valve replacement.

风湿性二尖瓣病变左心室局部室壁运动减弱对术后心功能的影响

目的 探讨风湿性二尖瓣病变左心室局部室壁运动障碍对心瓣膜置换术后心功能的影响。方法 采用99m锝-红细胞(99mTc-RBC)门控心血池显像技术，测定20例风湿性二尖瓣病变患者术前左心室9个分区的局部射血分数和整体功能参数，并对比分析这些术前参数的变化与术后心功能转归的关系。结果 术后6例患者发生严重心功能不全，与心功能正常者比较,其术前左心室心尖区和前间壁的局部射血分数、整体峰值射血率和峰值充盈率均显著降低（P＜0.05），且相角程增大，左、右心室收缩明显不协调。结论 风湿性二尖瓣病变左心室心尖区和前间壁的室壁运动减弱程度与心瓣膜置换术后心功能不全的发生密切有关，术前采用99mTc-RBC门控心血池显像测定左心室局部室壁运动障碍对术后心功能的转归有一定预见性。

Effects of Tight Blood Glucose Control on the Shortterm Prognosis of the Patients after Heart Valve Replacement

Objective To investigate the effects of tight blood glucose control on the shortterm prognosis of the patients after heart valve replacement, in order to improve treatment effectiveness and lower postoperative complications. Methods A total of 240 patients including 150 males and 90 females underwent mitral valve replacement or mitral and aortic valve replacement were enrolled in this study from January 2007 to December 2008 at the cardiac surgery department of Renmin hospital of Wuhan university. The age of these patients ranged from 19 to 65 years old with an average age of 53.33 years. According to insulin administration time and blood glucose control level, they were randomly separated into two groups. In the experimental group, there were 121 patients who received continuous insulin infusion to maintain postoperative glucose level between 4.4 and 6.1 mmol/L, while 119 patients in the control group received insulin infusion when their glucose level went higher than 11.1 mmol/L to control the level between 6.1 and 11.1 mmol/L. Then the postoperative wound infection, malignant arrhythmia rate, the assisted ventilation time, intensive care unit(ICU) stay time and count of neutrophils were compared and analyzed. Results There was no hospitalized death in both groups. The rate of wound infection（3.31% vs.10.08%, χ2=4.430,P=0.035）, the assisted ventilation time（9.02±2.73 h vs. 10.01±3.58 h, t=2.280,P=0.024）, time for count of leukocytes to decrease to the normal level（11.04±3.16 d vs. 12.05±3.76 d, t=2.168,P=0.031）, average hospitalization time（13.49±3.81 d vs. 14.51±4.02 d,t=2.017,P=0.045）, and count of neutrophils on the third day（0.82±0.04 vs. 0.84±0.05, t=2.644,P=0.009） in the experimental group were significantly lower or shorter than those in the control group. But there was no significant difference between both groups in ICU stay time and the rate of malignant arrhythmia. Conclusion Tight blood glucose control can lower the rate of postoperative wound infection, shorten the assisted ventilation time and hospitalization time, and reduce the usage of antibiotics in patients after heart valve replacement. Accordingly, it can enhance the curative effect, reduce overall medical expenses, and improve prognosis.

心瓣膜置换术后心室颤动的高危因素分析

目的 探讨心瓣膜置换术后心室颤动(VF) 发生的高危因素及其可能的防治措施. 方法 回顾性收集968例心瓣膜置换术患者的临床资料,按术后是否发生VF分为两组,VF组:58例,术后均发生VF;对照组:从910例未发生VF的患者中随机选择70例作为对照.选择术前临床指标、超声心动图(UCG)、心肺转流术(CPB)、心瓣膜病变类型和术式、术后24小时循环及电解质状况等指标,用Logistic回归方法分析术后发生VF的高危因素. 结果 年龄≥65岁、心胸比率≥0.8、NYHA心功能Ⅳ级、急诊或再次手术、主动脉阻断时间≥120分钟、术后24小时循环不稳定、低钾、低镁等电解质紊乱是其发生的独立危险因素. 结论 VF是心瓣膜置换术后的早期严重并发症;患者的年龄、心脏基础病变的严重程度、围术期的处理可以影响术后VF的发生;早期手术、缩短主动脉阻断时间、维持术后24小时内循环稳定、防止电解质紊乱和缺氧、酸中毒的发生,是预防心瓣膜置换术后VF发生的有效措施.

The Effective Orifice Area and Haemodynamics of 19mm St. Jude Regent Valve——An Early in Vivo Study

Abstract: Objective To investigate the in vivo effective orifice area (EOA) and whether prosthesispatient mismatch (PPM) is going to happen after 19mm St.Jude Regent valves replacement were performed. Methods Twentythree patients with valvular heart diseases were divided into 2 groups according to aortic annular diameter. 19mm St. Jude Regent valves were replaced in aortic valve place (Regent valve group), and 21mm other doubleleaflet mechanical valves were replaced in aortic place (other valves group). All of the operations were accomplished under cardiopulmonary bypass in West China Hospital. All of the patients were followed up in 3 to 6 months after their surgery processes. Color Doppler echocardiography was used to measure the hemodynamic parameters in their followup. Then left ventricular mass (LV mass), EOA and effective orifice area index (EOAI) etc. were calculated and compared by using SPSS 12.0. Results No cardiac episodes were detected during the perioperative period and 36 months after operation. LVmass reduced in 36 months after operation in both groups. No statistical significance of EOA, EOAI and LVmass reduction were detected between the two groups. Conclusions (1)The EOA and in vivo hemodynamic effects of 19mm Regent valve are similar to 21mm other double leaflet mechanical valve. (2)It is safe to use 19mm Regent valve in those patients whose aortic annular diameter are small and need double valve replacement. Using 19mm Regent valve will not cause short time cardiac episodes and PPM. (3)More further works should be done to make sure what is the standard of PPM in Chinese people, such as enlarging the patients number and prolonging the followup time. (4) Further clinical and followup works should be done to make St.Jude Regent valve’s feature out.

Efficacy of Salvianolate on Myocardium Protection in Extracorporeal Circulation of Cardiac Valve Replacement

Abstract： Objective To investigate the effect of salvianolate on myocardium against ischemiareperfusion injury (IRI) in valve replacement with cardiopulmonary bypass (CPB), its outcome and mechanism, and the applicability and safety of salvianolate as a protection agent for CPB central muscles. Methods Thirty patients undergoing cardiac valve replacement were randomly divided into two groups by lot. In the control group, there were 15 patients including 5 males and 10 females, while in the 15 patients in the trial group, 7 were male and 8 were female. Salvianolate of 200 mg was given to the patients in the trial group intravenously. Hemodynamic parameters, blood gas analysis results, recovery of heartbeat, the dosage of dopamine used, and assisted ventilation time were recorded for both groups before aorta clamping, 2 h, 8 h, and 24 h after aorta declamping. Besides, ICU detention time, the amount of urine in 24 hours, and the amount of drainage in 24 hours after operation were also recorded. Blood samples were taken to determine serum cardial troponin I(cTnI), creatine kinase MB isoenzyme (CK-MB), malondialdehude (MDA), and superoxide dismutase (SOD) in both groups respectively at different times including after the induction of anesthesia, aorta opening, termination of CPB, end of operation, and one day after operation. Results There was no significant difference in hemodynamic parameters, the dosage of dopamine used, spontaneous recovery of heartbeat, and the amount of urine in 24 hours and drainage after operation for 24 hours between the two groups (Pgt;0.05). The rate of ventricular rhythm, blood lactic acid level, the time of assisted ventilation and ICU detention time for the trial group were significantly lower than those for the control group (Plt;0.05), while partial pressure of oxygen in artery(PaO2) was significantly lower in the trial group 8 h after aorta declamping (Plt;0.05). The levels of serum CK-MB, cTnI, and MDA after operation for both groups were higher than those before operation; and those levels for the trial group were significantly lower than the control group at various time points (Plt;0.05). The concentration of SOD decreased after operation in both groups (Plt;0.05), and it was higher in the trial group than the control group at different time points. The decrease of SOD level in the trial group was less than that in the control group. Conclusion Salvianolate can protect myocardium from ischemiareperfusion injury in cardiac valve replacement with CPB effectively, through promoting the activity of antioxidative enzymes and eliminating oxygen free radicals. Patients can be treated with salvianolate for antimyocardial ischemia reperfusion injury.

抑肽酶对心瓣膜置换术患者围术期IL-6、IL-8释放的影响

目的 了解抑肽酶对心瓣膜置换术患者围术期全身炎症应答的影响。方法 将接受心瓣膜置换术的16例患者随机分为：对照组(n＝8)，不用抑肽酶；治疗组(n＝8)，于预冲液中加入抑肽酶300万单位，分别于术前、停机、停机后1小时和术后1天抽取外周血2ml，收集血清用酶联免疫吸附测定(ELISA)双抗夹心法检测白细胞介素-6(IL-6)和白细胞介素-8(IL-8)。结果 体外循环术后患者血清IL-6和IL-8水平升高(P＜0.05)；术后1天仍高于术前；停机后1小时治疗组IL-6水平和停机时IL-8水平低于对照组，但差别均无显著性意义(P＞0.05)。结论 尽管抑肽酶有抗炎症效应，但仅预冲液中加入抑肽酶300万单位无法有效抑制心瓣膜置换术患者围术期促炎性细胞因子IL-6和IL-8的释放。

腺苷含血心脏停搏液在心瓣膜置换术中对心肌的保护作用

摘要: 目的 研究含血心脏停搏液中加入外源性腺苷在心瓣膜置换术中对心肌的保护作用。 方法 将32例行心瓣膜置换术患者随机分为两组，腺苷组在含血心脏停搏液中加入外源性腺苷，对照组单用含血心脏停搏液，分别经主动脉根部或切开主动脉经冠状动脉窦直接灌注。于术前、主动脉开放后6 h、24 h、72 h采集患者桡动脉血，监测心肌肌酸激酶同工酶(CKMB)、肌钙蛋白I(cTnI)；观察心脏停搏情况，术后机械辅助通气时间及术后正性肌力药物的应用情况；透射电子显微镜观察心肌超微结构的改变。 结果 两组患者均无死亡。腺苷组诱导心脏停搏时间较对照组短(P=0.021)；腺苷组的CK-MB水平在主动脉开放后6 h、24 h，cTnI水平在主动脉开放后6 h、24 h、72 h均较对照组低(Plt;0.05);两组机械辅助通气时间和术后多巴胺使用剂量差异无统计学意义(Pgt;0.05)；腺苷组心肌超微结构心肌损伤较对照组明显减轻。 结论 外源性腺苷加入心脏停搏液中能显著提高对心肌的保护效果。

主动脉瓣二尖瓣置换术同期右上肺叶切除术一例

Anticoagulation therapy after mechanical heart valve replacement

Hemorrhage and thromboembolism are the most important long-term complications of anticoagulation therapy after mechanical heart valve replacement. The anticoagulation therapy intensity should be lowered in order to decrease the hemorrhagic complication. In recent years, the chief progresses of anticoagulation therapy are the using of International Normalized Ratio (INR) in anticoagulation therapy monitoring and the low intensity anticoagulation therapy. The proper anticoagulation intensities at home are INR 1.5-2.0 and prothrombin time ratio (PTR) 1.3-1.5. It is beneficial to adopt this low intensity anticoagulation therapy for decreasing the death rate from hemorrhage, protecting pregnant women and new borns from hemorrhage and malformation, and improving the life qualities of the patients.