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心血管手術風險預測研究與現狀

手術風險預測模型是術前風險評估的重要工具，在外科臨床工作中起著十分重要的作用，它對手術適應證的確定、手術相關危險因素的識別、評分標準的確立以及不同中心手術療效的比較都具有十分重要的意義。而心臟外科手術因受到多方面因素的影響，其圍術期的病死率仍較高。因此，在心臟外科臨床研究領域很早便開展了有關建立手術風險預測模型的工作。 從國外研究背景來看，至1986年美國胸外科醫師協會（The Society of Thoracic Surgeons，STS）公布的第一個心臟術后風險預測模型Parsonnet評分系統起，近20余年間在北美、歐洲及澳洲等地區相繼出現了一系列高質量的手術風險預測模型。目前，被廣泛應用的預測評分系統包括Parsonnet評分系統、歐洲心臟手術風險評估系統(the European System for Cardiac Operative Risk Evaluation ，EuroSCORE)、STS評分系統及美國心臟病學院/美國心臟協會（American College of Cardiology/American Heart Association，ACC/AHA）評分系統等。  而從國內研究現狀來看，由北京阜外心血管病醫院牽頭聯合全國32家心臟中心率先建立了首個國內大型多中心冠狀動脈旁路移植術數據庫及中國冠狀動脈旁路移植術評分系統（SinoSCORE），同時完成了EuroSCORE對我國冠心病患者手術死亡預測能力的評價研究。但目前國內有關其他重要預測評分系統的評價研究以及對我國心臟瓣膜病患者手術風險預測評價研究的報道仍相對缺乏。北京阜外心血管病醫院撰寫的“不同心臟手術風險預測評分系統對中國冠狀動脈旁路移植術后患者早期死亡的預測”論文，收集了該院2006年11月至2007年12月年間1 559例18歲以上施行單純冠狀動脈旁路移植術（CABG）患者的臨床資料，參照STS評分系統、EuroSCORE、Parsonnet評分系統和ACC/AHA評分系統的評分及分組方法，采用HosmerLemeshow(HL)卡方檢驗及受試者工作特征（ROC）曲線下面積的統計學方法，完成了4種預測評分系統對我國行CABG患者早期死亡的預測評價研究，提示除STS評分系統對單純CABG患者具有潛在的臨床應用可能外，其他3種評分系統對單純CABG術后早期死亡風險預測的準確性均較差。而上海第二軍醫大學長海醫院撰寫的“EuroSCORE模型對心瓣膜手術患者死亡風險的預測”論文，收集了該院1998年1月至2008年12月年間4 155例各類心臟瓣膜手術患者的臨床資料，參照additive和 logistic EuroSCORE評分及分組方法，采用HL卡方檢驗及ROC曲線下面積的統計學方法，完成了EuroSCORE模型對心臟瓣膜手術患者在院死亡率的預測評價研究，提示EuroSCORE模型對該中心心臟瓣膜手術患者死亡風險預測的準確性較差。 兩篇論文的研究均表明，目前國際上公認的幾種重要的手術風險預測評分系統對我國心臟手術患者術后早期死亡的預測效能均存在不同程度的限制，而建立適合我國患者心臟手術的風險預測模型及評分標準具有必要性及重要性。討論中作者均提出由于地域及人種的差異，我國心臟手術患者的病因學與國外患者存在較大的差異，尤其是心臟瓣膜病的流行病學特點差異，是導致最終結論差異的重要原因。但兩篇論文也同樣存在一定的研究局限： （1）均為單中心研究，雖樣本量較大，但我國地域廣大，各心臟中心接診患者的病種、病情輕重程度及診療技術仍存在一定差異，故應用單中心研究對研究結論的正確性可能會造成不同程度的影響，因此仍需擴大樣本量以得到更為準確的研究結論。（2）臨床資料的收集以回顧性研究為主，且各臨床變量的采集標準國內尚未統一，評分系統中變量的定義也存在一定差異，故每例患者評分預測的真實結果存在一定偏倚，對研究結論的準確性也存在影響。隨著對手術風險預測模型的臨床研究重視程度不斷地增加，目前我國各心臟診療中心均已開始建立各自的心臟外科臨床數據庫，故建議加強國內相關臨床研究的學術交流，統一數據庫建立方法及臨床變量的采集標準，建立符合我國國情的大型多中心心臟外科臨床數據庫，用以進一步規范我國心臟手術術前風險評估工作，這對制定相關臨床指南以及進一步降低心臟手術 在院病死率及并發癥發生率，必將起到非常積極的作用。綜合國內外心臟手術風險預測模型的建立方法和納入因素，目前均沒有考慮到“人”的因素，也就是說同樣的手術，由技術水平不同的醫師或醫院實施，其結果實際上存在很大的差異，而術后處理不恰當也可造成較大的差異。因此，目前在制定手術風險預測模型時，實際上是建立在外科醫師手術技術水平相當、正確實施手術和正確處理患者的基礎上。就當前而言，要將醫師的水平和能力考慮在內，確實非常困難，實際上也無法做到，這也是目前各種風險預測模型所存在的共同限制。　　“不同心臟手術風險預測評分系統對中國冠狀動脈旁路移植術后患者早期死亡的預測”和“EuroSCORE模型對心瓣膜手術患者死亡風險的預測”兩篇論文均緊緊把握了目前我國心臟外科術前風險預測模型相關臨床研究的重要方向，研究目標明確，樣本量較大，科研設計合理，統計學方法正確，結論可信，具有較高的學術價值和社會價值，對臨床工作具有一定的指導意義，希望在今后的研究工作中能不斷完善。

Current issues should be emphasized on preoperative evaluation of heart valvular disease

Preoperative evaluation is crucial for heart valvular surgery. This article discusses some issues that need to be emphasized: the impact of hypertension on the severity of aortic valve lesions, and how to improve the accuracy of clinical assessment; the identification of functional tricuspid regurgitation, in order to choose the appropriate surgical technique; the need for right ventricular function testing, and the use of risk scoring models, to better grasp surgical timing and indications and improve efficacy; and the importance of evaluating atrial mitral and/or tricuspid regurgitation complications in chronic atrial fibrillation, and making rational choices for interventional and surgical treatment.

Progress in Evaluating Quality of Life in Postoperative Patients with Valvular Heart Disease Using SF-36 Health Survey

Abstract：　Quality of life （QOL） refers to an individual’s perception and subjective evaluation of their health and well-being, and has become an important index to evaluate the outcomes of clinical treatment in the last past decades. There are a large number of different instruments to evaluate QOL, and the 36-Item Short Form Health Survey （SF-36） is currently one of the most widely used instruments. In recent years, SF-36 has been used to evaluate QOL of valvular heart disease patients to investigate the risk factors those influence their postoperative QOL, provide more preoperative evaluation tools for clinical physicians, and improve postoperative outcomes of patients with valvular heart disease. However, it is now just the beginning to use SF-36 to examine QOL of valvular heart disease patients. Because of significant differences in sample size, follow-up period, country and culture, current research has some controversial results. This review focuses on the progress in evaluating QOL in postoperative patients with valvular heart disease using SF-36.

The Advancement of Early Enteral Nutrition in Critical Patients after Cardiopulmonary Bypass

Early enteral nutrition after cardiopulmonary bypass (CPB) has been shown to have beneficial effects on intestinal integrity, lower mortality and also on the patient’s immunocompetence. Even in critical patients after CPB, enteral nutrition should be reasonable to start early and also be supplemented by parenteral nutrition in order to meet energy requirement. We conclude that enteral nutrition is preferable in the majority of patients with severe hemodynamic failure, but gastrointestinal complication and hypocaloric feeding should be simultaneously noticed. This paper comprehensively described enteral nutrition’s protective mechanism and effects on digestive system, enteral nutrition’s implementing methods after CPB, and problems or prospects needing attention in execution.

原發性左心房低度惡性纖維粘液瘤樣肉瘤一例

The analysis of mitral valve replacement on the old

Objective To study effects of mitral valve replacement(MVR) on the old with mitral valve diseases(MVD). Methods The documents of 265 cases undergoing MVR were reviewed, who aged 60 years old or over between June 1991 and June 2003. Demographices, clinical preoperative conditions, indications to surgery, early postoperative course and long-term outcome were collected via hospital documents and outpatient follow-up. Many risk factors were analysed. Results Follow-up rate amounted to 93.7%(236/252). The mortality was 4.9% (13/265) within 30 days. Heart failure and renal failure were the main cause of death. Compared with younger patients(lt;60 years old), long-term survival rate was lower in the old, 5-year 87.52% vs 96.84%, 10-year 81.23% vs 94.87%. There were 15 late deaths(0.17% case/M), most of whom died of heart failure, cancers and lung infections. Risk factors for MVR in the old included New York Heart Association class Ⅳ, diabetes, and lung incompetence. Conclusions The patients with MVD over 60 years old tended to present high postoperatively mortality and morbidity.

Surgery Treatment of Chronic Moderate Ischemic Mitral Regurgitation in Coronary Artery Disease

Objective To investigate the treatment and prognosis of moderate ischemic mitral regurgitation (IMR) in coronary artery disease(CAD). Methods From January 1998 to May 2006, 28 patients of CAD with moderate IMR underwent coronary artery bypass grafting (CABG) and mitral valve plasty(MVP, 24) or mitral valve replacement (MVR,4). The Reed method were used in 9 cases, the annuloplasty ring were used in 15 cases. Mechanical valve were implanted in 1 case and biological valve in 3 cases. Results There was no operative or hospital death. Twentysix patients were followed up to a mean period of 41 months. There were two late death(one was MVP, the other was MVR). In MVP cases, nineteen patients were in New York Heart Association (NYHA) functional class Ⅰ and Ⅱ, 3 in class Ⅲ, which was better than that of preoperative one. Ultrasonic cardiography (UCG) examination showed no mitral regurgitation in 5 cases, mild in 7, light in 6, moderate in 3, severe in 1. Left atrial volume (LAV) and left ventricular enddiastolic volume (LVEDV) were 54.1±12.7ml and 60.9±14.8 ml, decreased more significantly than that preoperatively (Plt;0.05). In MVR cases, 2 cases were survival and followed. One patient was in NYHA functional class Ⅰ, 1 in class Ⅱ, which was better than that of preoperative one. Conclusion Moderate IMR with CAD should be treated carefully. MVP with annuloplasty ring have better early results. For patients with bad heart function and abnormal left ventricular wall motion, the late results need more studies.

Application of CORFLO Feeding Tube after Video-assisted Thoracoscopic Ivor Lewis Esophagogastrectomy for Esophageal Cancer and Cardiac Adenocarcinoma

ObjectiveTo explore the feasibility of CORFLO feeding tube in enternal nutrition after video-assisted thoracoscopic Ivor Lewis esophagogastrectomy for esophageal cancer and cardiac adenocarcinoma. MethodsA total of 107 patients with esophageal cancer and cardiac adenocarcinoma undergoing video-assisted thoracoscopic Ivor Lewis esophagectomy or resection of cardiac adenocarcinoma in our department between October 2014 and January 2016 were enrolled, among whom 10 patients received jejunostomy and 97 patients (60 males, 37 females, median age of 66 years, range, 47-75 years) received the insertion of CORFLO feeding tubes. ResultsIn 97 cases with insertion of feeding tubes, median insertion time was 7 (3-11) min and median depth was 83 (75-90) cm. The first-attempt success rate during the operation was 77.3% (75/97), and the second attempt at the bedside postoperatively was successful in 8 cases. The overall success rate was 85.6% (83/97). Insertion was successful in 77 esophageal cancer patients and 6 cardiac adenocarcinoma patients. Conclusion Blind insertion of CORFLO feeding tube in video-assisted thoracoscopic Ivor Lewis esophagogastrectomy for esophageal cancer and cardiac adenocarcinoma is feasible and safe. This noninvasive method is simple, effective and repeatable.

升主動脈和弓部動脈瘤的外科治療

目的 總結升主動脈和弓部動脈瘤手術治療經驗,以期進一步提高手術療效. 方法 自2000年7月至2002年5月應用深低溫停循環(DHCA)和上腔靜脈逆行腦灌注(RCP)技術手術治療升主動脈和弓部動脈瘤20例,其中急癥手術5例.施行全弓置換術2例,全弓置換和象鼻手術3例,半弓置換術15例.同期行Bentall手術8例,升主動脈置換術或同時行主動脈瓣置換術12例,冠狀動脈旁路移植術1例. 結果 術后早期死亡1例,短時間淺昏迷1例,呼吸功能不全2例,腎功能不全2例,無晚期死亡. 結論 DHCA和RCP技術是手術治療升主動脈和弓部瘤的安全、有效方法,急性A型夾層動脈瘤的手術方式取決于內膜破裂口的位置;正確掌握DHCA和RCP技術、手術方式和手術技術、圍術期處理是提高手術療效的關鍵因素.

三尖瓣硬質人工瓣環成形術的中期效果評價

目的評價硬質三尖瓣成形環對三尖瓣成形的中期效果。方法對風濕性心瓣膜病伴中、重度三尖瓣關閉不全患者應用硬質Carpentier三尖瓣成形環行三尖瓣成形術15例(人工瓣環成形組),術前三尖瓣每搏反流量31.9±7.6ml;并與同期16例行Kay及DeVega三尖瓣成形術患者(對照組)進行比較,對照組術前三尖瓣每搏反流量25.3±6.9ml。術后對所有患者均進行隨訪,用彩色超聲心動圖觀察術后三尖瓣反流情況。結果兩組均無手術死亡,術后心功能分級均較術前提高1～2級。出院前和術后6個月,兩組患者三尖瓣反流量差別無統計學意義,術后隨訪1、2、3年,人工瓣環成形組三尖瓣反流量小于對照組(Plt;0.05,0.05,0.01)。結論應用硬質三尖瓣成形環對三尖瓣進行成形,其中期效果明顯優于Kay和DeVega成形術。