心脏外科的现状

心脏外科的现状心脏外科的现状What The Cardiac Surgeon Do天津武警医学院附属医院心胸外科于洪泉主任，教授心脏内、外科心脏内、外科 =112心脏病 心脏内科医师 心脏外科医师 治疗心脏病患者痊愈、健康、长寿心脏外科医师心脏外科医师n n冠状动脉外科，冠状动脉外科，冠状动脉外科，冠状动脉外科，n n冠心病的并发症冠心病的并发症冠心病的并发症冠心病的并发症n n瓣膜疾病瓣膜疾病瓣膜疾病瓣膜疾病n n先天性心脏病先天性心脏病先天性心脏病先天性心脏病n n大血管疾病大血管疾病大血管疾病大血管疾病n nAFAF“It was the best of times,it was the worst of times”CABG MortalityObserved vs.Expected Observed vs.Expected CABGCABG MortalityMortalityWhat we do,as cardiac surgeons,can offer the patients with CAD better in the era of drug eluting stents?LIMALIMALADFrom Tatoulis et al.Ann Thorac Surg 2004;77:93-101Tatoulis et al.Ann Thorac Surg 2004;77:93-1012100 Publications on Off-Pump CABG over the last 5 years.so what do we know about the benefits of avoiding CPB?n nReduced post-op transfusion?Reduced post-op transfusion?n nReduced atrial fibrillation?Reduced atrial fibrillation?n nReduced length of stay?Reduced length of stay?n nReduced cost?Reduced cost?n nReduced mortality?Reduced mortality?n nReduced CVA?Reduced CVA?n nReduced neurocognitive deficit?Reduced neurocognitive deficit?OPCAB Surgery:Conclusions to Daten nCoronary surgery off-pump is Coronary surgery off-pump is performed in hundreds of performed in hundreds of centers across the worldcenters across the world.The evidence is structured in .The evidence is structured in 1200 peer-reviewed articles.1200 peer-reviewed articles.n nThe The selection of the patientsselection of the patients is related to the experience of is related to the experience of the center.the center.Complete and arterial revascularizationComplete and arterial revascularization are are possible without patient selection.possible without patient selection.n nCoronary surgery off-pump Coronary surgery off-pump reducesreduces,after adjustment for,after adjustment for variability in risk,variability in risk,early mortality and some major morbidity early mortality and some major morbidity eventsevents:neurocognitive dysfunction,stroke and renal failure.:neurocognitive dysfunction,stroke and renal failure.n nOff-pump coronary surgery Off-pump coronary surgery allows and mandates a rigorous allows and mandates a rigorous re-engineeringre-engineeringRE-DOn nAfter Stent Anginan nRe-Stent or Operationn nAfter operation anginan nRe-Stent or Operationn nSevere or Complex CADn nThree vessel diseasesn nLeft mainn n男性，66岁，n nOMI2n nAMIacute HFn nEF=30%n nCABG x 3,post 7 days EF=56%ComparisonComparison of survival following coronary of survival following coronary artery bypass grafting vs.percutaneous artery bypass grafting vs.percutaneous coronary intervention in diabetic and non-coronary intervention in diabetic and non-diabetic patients:retrospective cohort diabetic patients:retrospective cohort study of 6320 proceduresstudy of 6320 procedures.Pell JPPell JP,Pell ACPell AC,Jeffrey RRJeffrey RR Diabet Med.Diabet Med.2004 Jul;21(7):790-2.,2004 Jul;21(7):790-2.,n n6320 eligible procedures,5042(80%)CABG and 6320 eligible procedures,5042(80%)CABG and 1278(20%)PCI 1278(20%)PCI n n831(13%)patients had diabetes with no significant 831(13%)patients had diabetes with no significant difference by procedure(13%vs.12%).difference by procedure(13%vs.12%).Results:n nA total of 382 deaths occurred over a mean A total of 382 deaths occurred over a mean follow-up of 2.3 years.follow-up of 2.3 years.n nDiabetic patients had a poorer prognosis following Diabetic patients had a poorer prognosis following both surgery(adjusted hazards ratio(HR)1.43,both surgery(adjusted hazards ratio(HR)1.43,95%confidence interval(CI)1.08,95%confidence interval(CI)1.08,1.891.89)and)and percutaneous intervention(adjusted HR 2.58,percutaneous intervention(adjusted HR 2.58,95%CI 1.43,95%CI 1.43,4.634.63).).n nDiabetic patients,no significant difference was Diabetic patients,no significant difference was detected in those with two-vessel disease.detected in those with two-vessel disease.n nIn those with impaired left ventricular function In those with impaired left ventricular function and triple-vessel disease,PCI was associated with and triple-vessel disease,PCI was associated with a significantly higher risk of death(adjusted HR a significantly higher risk of death(adjusted HR 3.58,95%CI 1.40,9.19).2ys=3.6times3.58,95%CI 1.40,9.19).2ys=3.6timesSingle-vessel versus bifurcation stenting for the treatment Single-vessel versus bifurcation stenting for the treatment of distal left main coronary artery disease in the drug-of distal left main coronary artery disease in the drug-eluting stenting era.Clinical and angiographic insights eluting stenting era.Clinical and angiographic insights into the Rapamycin-Eluting Stent Evaluated at Rotterdam into the Rapamycin-Eluting Stent Evaluated at Rotterdam Cardiology Hospital(RESEARCH)and Taxus-Stent Cardiology Hospital(RESEARCH)and Taxus-Stent Evaluated at Rotterdam Cardiology Hospital(T-SEARCH)Evaluated at Rotterdam Cardiology Hospital(T-SEARCH)registries.registries.Am Heart J.2006.152(896-902)Am Heart J.2006.152(896-902)ValgimigliValgimigli M M,Malagutti PMalagutti P,Rodriguez Granillo GARodriguez Granillo GA,n n2002 to 2004,94 patients affected by distal LM 2002 to 2004,94 patients affected by distal LM disease underwent disease underwent percutaneouspercutaneous intervention at intervention at our institution either with SVS(n=48)or BS(n our institution either with SVS(n=48)or BS(n=46).=46).n na median follow-up of 587 days(range,328-a median follow-up of 587 days(range,328-1179),the cumulative incidence of MACE was 1179),the cumulative incidence of MACE was similar between the 2 groups(31%in the BS vs.similar between the 2 groups(31%in the BS vs.28%in SVS group,HR 0.96,95%CI 0.46-1.49,28%in SVS group,HR 0.96,95%CI 0.46-1.49,P=.92),P=.92),n nMACE=death/myocardial infarction or target MACE=death/myocardial infarction or target vessel revascularization.vessel revascularization.n neven in the DES era,distal LM treatment remains even in the DES era,distal LM treatment remains an independent predictor of poor outcomean independent predictor of poor outcomeSirolimus-eluting versus paclitaxel-eluting stent Sirolimus-eluting versus paclitaxel-eluting stent implantation for the percutaneous treatment of left implantation for the percutaneous treatment of left main coronary artery disease:a combined RESEARCH main coronary artery disease:a combined RESEARCH and T-SEARCH long-term analysis.and T-SEARCH long-term analysis.Valgimigli MValgimigli M,Malagutti PMalagutti P,Aoki JAoki J,J Am Coll Cardiol.2006.47(507-14)J Am Coll Cardiol.2006.47(507-14)n n2002 to 2004,110 patients underwent PCI for LM 2002 to 2004,110 patients underwent PCI for LM stenosis stenosis n n55 patients were treated with SES and 55 with PES.55 patients were treated with SES and 55 with PES.n nAt a median follow-up of 660 days(range 428 to 885),At a median follow-up of 660 days(range 428 to 885),the cumulative incidence of MACE was similar(25%in the cumulative incidence of MACE was similar(25%in the SES group vs.29%,in the PES group;hazard ratio the SES group vs.29%,in the PES group;hazard ratio 0.88 95%confidence interval 0.43 to 1.82;p=0.88 95%confidence interval 0.43 to 1.82;p=0.74),0.74),n nthe composite death/myocardial infarction(16%in the the composite death/myocardial infarction(16%in the SES group and 18%in the PES group)and target SES group and 18%in the PES group)and target vessel revascularization(9%in the SES group and 11%vessel revascularization(9%in the SES group and 11%in the PES group).in the PES group).n nAngiographic in-stent late loss(mm),evaluated in 73%Angiographic in-stent late loss(mm),evaluated in 73%of the SES group and in 77%of the PES group.of the SES group and in 77%of the PES group.4/9/20244/9/202431314/9/20244/9/202432324/9/20244/9/202433334/9/20244/9/20243434Natural Historyn n50%死于48小时之内n n1人/小时n n3672死于48小时之内n n71死于2个月之内n n89死于3个月之内n n91死于6个月之内n n时间生命4/9/20244/9/20243939预后n n预后决定于严重性和范围，n n体质和年龄，n n医师的经验n n成功治疗在于早期诊断n n成功在于急诊手术初期处理n n立即住院ICU/ORn n术前准备，血液化验，n nECG监护n n动脉监测n nSwan-Ganz Cathetern nFoley Cathetern n硝普纳 收缩压90100n nEsmolol 心率6070n急诊手术急诊手术4/9/20244/9/20244646瓣瓣 膜膜 病病Traditional indication in mitral valve stenosisn nSymptomatic+valve area 1.0Cm2n nDyspnea on exertion,&paroxysmal nocturnal dyspnean nArrhythmias AF,left atrium thrombosisn nSignificant cardiac enlargementn nPulmonary hypertension&pulmonary edema,right ventricular failuren nAll clinical abnormalitiesn nCardiac cachexiaOperation riskn nPulmonary dysfunction Po2 n nHepatic dysfunction TBIL n nRenal dysfunction Cr,BUNn nBleedingn nInfection(wbc,pus)Indications for Operation in Mitral Valve Stenosis(quantity)n nNo more depended on the symptomatic,No more depended on the symptomatic,but based on the hemodynamic but based on the hemodynamic abnormalities.abnormalities.n nMitral valve stenosis 1.5Cm2 with Mitral valve stenosis 4.5Cm2.enlargement of the left atrium 4.5Cm2.n nMitral valve stenosis 1.5Cm2 with Mitral valve stenosis 15-20mmHg,30mmHg.Echo.15-20mmHg,30mmHg.n nNYHA IV 5-10%operations risk,NYHA I-NYHA IV 5-10%operations risk,NYHA I-II 1%.II 90%,15 year 89%90%,15 year 89%n nLong term results in NYHA IV are Long term results in NYHA IV are inferior to those obtained in early inferior to those obtained in early surgery patientssurgery patients二尖瓣关闭不全的手术适应证二尖瓣关闭不全的手术适应证Traditionaln n出现所有的临床不正常出现所有的临床不正常出现所有的临床不正常出现所有的临床不正常n n活动后呼吸困难活动后呼吸困难活动后呼吸困难活动后呼吸困难n n充血性心衰充血性心衰充血性心衰充血性心衰n n心律失常心律失常心律失常心律失常n n心脏明显增大心脏明显增大心脏明显增大心脏明显增大n n临床结果证实这种状态的患者已具有不可逆的心临床结果证实这种状态的患者已具有不可逆的心临床结果证实这种状态的患者已具有不可逆的心临床结果证实这种状态的患者已具有不可逆的心室功能和心肌的损害室功能和心肌的损害室功能和心肌的损害室功能和心肌的损害n n5 5年存活率年存活率年存活率年存活率50506060，in NYHA VI,but in NYHA VI,but over 90%in NYHA II.over 90%in NYHA II.二尖瓣关闭不全的手术适二尖瓣关闭不全的手术适应症（量化）应症（量化）n n超声证实大量二尖瓣反流超声证实大量二尖瓣反流n n左心房增大左心房增大4.5-5.0厘米伴或不伴近厘米伴或不伴近期阵发性房颤期阵发性房颤n nLVEDD6.0Cmn n静止心功能或运动引起心功能下降静止心功能或运动引起心功能下降LVESD，EFn nNo more 根据患者的症状根据患者的症状，but based on 血流动力学的异常血流动力学的异常理想的术前状态理想的术前状态n n患者的情况是可矫正的二尖瓣关闭不全患者的情况是可矫正的二尖瓣关闭不全n n术前左心室功能正常术前左心室功能正常EF70%(65mmLVEDD65mm，左心室的收缩功能下降，左左心室的收缩功能下降，左左心室的收缩功能下降，左左心室的收缩功能下降，左心室舒张末期压力升高）心室舒张末期压力升高）心室舒张末期压力升高）心室舒张末期压力升高）n n尽管这时患者可能还没有明显的症状，但这时已尽管这时患者可能还没有明显的症状，但这时已尽管这时患者可能还没有明显的症状，但这时已尽管这时患者可能还没有明显的症状，但这时已有明确的手术适应症有明确的手术适应症有明确的手术适应症有明确的手术适应症n n及时手术治疗能够获得术后心脏功能的完全恢复及时手术治疗能够获得术后心脏功能的完全恢复及时手术治疗能够获得术后心脏功能的完全恢复及时手术治疗能够获得术后心脏功能的完全恢复和生活质量的明显改善，并使手术的危险性减少和生活质量的明显改善，并使手术的危险性减少和生活质量的明显改善，并使手术的危险性减少和生活质量的明显改善，并使手术的危险性减少到最低。到最低。到最低。到最低。先天性心脏病先天性心脏病 室间隔缺损的手术适应症n n原则上讲室间隔缺损的先天性异常均应该接受原则上讲室间隔缺损的先天性异常均应该接受原则上讲室间隔缺损的先天性异常均应该接受原则上讲室间隔缺损的先天性异常均应该接受手术治疗手术治疗手术治疗手术治疗,自然寿命是平均自然寿命是平均自然寿命是平均自然寿命是平均4040岁左右岁左右岁左右岁左右n n应尽早手术治疗在婴幼儿时期即出现肺动脉高应尽早手术治疗在婴幼儿时期即出现肺动脉高应尽早手术治疗在婴幼儿时期即出现肺动脉高应尽早手术治疗在婴幼儿时期即出现肺动脉高压或反复充血性心衰压或反复充血性心衰压或反复充血性心衰压或反复充血性心衰n n如果室间隔缺损中等大小，没有严重的肺动脉如果室间隔缺损中等大小，没有严重的肺动脉如果室间隔缺损中等大小，没有严重的肺动脉如果室间隔缺损中等大小，没有严重的肺动脉高压，最佳的手术时期是高压，最佳的手术时期是高压，最佳的手术时期是高压，最佳的手术时期是3 36 6岁岁岁岁n n任何室间隔缺损的分流量大于任何室间隔缺损的分流量大于任何室间隔缺损的分流量大于任何室间隔缺损的分流量大于1 1：1.21.2以上均以上均以上均以上均应接受手术治疗，不论患者的年龄有多大应接受手术治疗，不论患者的年龄有多大应接受手术治疗，不论患者的年龄有多大应接受手术治疗，不论患者的年龄有多大n n参军，上学异常心脏杂音列为不合格的标准参军，上学异常心脏杂音列为不合格的标准参军，上学异常心脏杂音列为不合格的标准参军，上学异常心脏杂音列为不合格的标准n n艾森曼格综合症艾森曼格综合症艾森曼格综合症艾森曼格综合症,细菌性心内膜炎细菌性心内膜炎细菌性心内膜炎细菌性心内膜炎n n现代的手术技术已使这种手术变得相当安全现代的手术技术已使这种手术变得相当安全现代的手术技术已使这种手术变得相当安全现代的手术技术已使这种手术变得相当安全现状现状n n发病率：心房纤颤是一个历史悠久的疾病，并且发病率：心房纤颤是一个历史悠久的疾病，并且是最常见到心律失常，这种疾病带来许多的并发是最常见到心律失常，这种疾病带来许多的并发症和病死率。其患病人数在美国达症和病死率。其患病人数在美国达220220万，发病率万，发病率在美国在美国5050岁以下的人群中是岁以下的人群中是0.5%0.5%，在，在8080岁以上岁以上多达多达1010。n n并发率：有心房纤颤的许多患者同时合并有高血并发率：有心房纤颤的许多患者同时合并有高血压，冠心病，心衰，瓣膜病，同时又多达压，冠心病，心衰，瓣膜病，同时又多达3232的的患者不合并任何其他疾病。由于房颤引起的心房患者不合并任何其他疾病。由于房颤引起的心房血栓形成和血栓脱离造成中风的发病率血栓形成和血栓脱离造成中风的发病率5%a year,5%a year,比无心房纤颤动患者高比无心房纤颤动患者高5 5倍，约倍，约25%25%。而在中风患。而在中风患者中者中1515的患者合并有心房纤颤。的患者合并有心房纤颤。4/9/20244/9/20248686药物治疗治疗n nThe medical treatment of AF is cumbersome and unsatisfactory,n n临床上通常通过减慢心室率来缓解患者的症状。临床上通常通过减慢心室率来缓解患者的症状。n n为了避免心房血栓形成，临床上给予患者抗凝治为了避免心房血栓形成，临床上给予患者抗凝治疗，但抗凝治疗：一是难以普及，二是难于监测，疗，但抗凝治疗：一是难以普及，二是难于监测，抗凝不足和抗凝过量均造成严重的并发症。抗凝不足和抗凝过量均造成严重的并发症。n n心房纤颤本身又使心房丧失收缩，使心室收缩力心房纤颤本身又使心房丧失收缩，使心室收缩力下降下降10102020，在已有心脏功能不全的患者表现，在已有心脏功能不全的患者表现出难以耐受的症状。出难以耐受的症状。n n这种情况在老年患者更为突出。这种情况在老年患者更为突出。4/9/20244/9/20249292近年的进展近年的进展n nBuilding upon the pioneering work of Cox and colleaguesn nRenew interest in developing alternative treatments for AF.n nRecent reported series have demonstrated the feasibility of treating patients undergoing cardiac surgery 4/9/20244/9/20249595优势条件优势条件n n我我院院心心脏脏外外科科具具有有其其他他医医院院不不具具备备的的优优势势条条件件即即精精通通胸胸外外科科的的手手术术和和解解剖剖，开开展展经经胸胸腔腔的的微微创创手手术术和和胸胸腔腔镜镜手手术术进进行行持持续续性性心心房房纤纤颤颤的的手手术治疗经验成熟。术治疗经验成熟。n n国国内内心心脏脏病病专专家家胡胡大大一一教教授授认认为为，外外科科开开展展手手术术治治疗疗持持续续性性心心房房纤纤颤颤具具有有优优越越性性，并并且且同同心心脏脏内内科科可可以以形形成成互互补补优优势势。胡胡大大一一教教授授在在北北京京同同仁仁医医院院胸胸心心外外科科率率先先开开展展了了这这项项手手术术，取取得得很好的结果。很好的结果。4/9/20244/9/20249696外科治疗持续性心房纤颤我院心脏内科在心律失常的介入治疗方面具有先进我院心脏内科在心律失常的介入治疗方面具有先进的优势（技术优势、设备优势）同心脏内科一同开的优势（技术优势、设备优势）同心脏内科一同开展这项新的治疗，能充分发挥其内在的相互优势，展这项新的治疗，能充分发挥其内在的相互优势，如阵发性房颤内科可以通过心脏导管进行射频治疗，如阵发性房颤内科可以通过心脏导管进行射频治疗，持续性心房纤颤通过外科微创的方法进行治疗。心持续性心房纤颤通过外科微创的方法进行治疗。心脏导管治疗不成功的患者可以接受外科治疗，外科脏导管治疗不成功的患者可以接受外科治疗，外科治疗不成功的患者可以再接受心脏导管进行治疗，治疗不成功的患者可以再接受心脏导管进行治疗，形成技术上的互补。形成技术上的互补。主要适应症n n风湿性心脏病伴有持续性心房纤颤的患者n n持续性心房纤颤药物治疗效果不好或不易难受的患者n n内科射频治疗无效的患者n nLA60mm谢谢大家 欢迎讨论联系方式：天津武警医学院附属医院联系方式：天津武警医学院附属医院 心胸外科心胸外科于洪泉于洪泉 TelTel：13116161503 13116161503，0220226057895660578956E EMail:Mail: