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1. Preoperative care
Same as preoperative care for extracorporeal circulation and open heart surgery , and explain the knowledge and importance of anticoagulation to patients and their families.
2. Postoperative care
Same as postoperative care after cardiopulmonary bypass and open heart surgery.
1. Pay special attention to the prevention of early postoperative arrhythmia.
2. Infection care and postoperative antibiotics should be used correctly and rationally.
3. The prothrombin time is measured on the morning of the 3rd day after anticoagulation care. The prothrombin time is required to be maintained at 1.5-2 times the normal value. Patients with mechanical valve replacement must take anticoagulants for life, and the following points should be noted:
(1) During hospitalization, nurses should record the daily prothrombin time and oral warfarin dose, and at the same time let Patients prepare a small record book to help them find out the rules of medication use, and allow patients to try self-administration so that they can form a habit and record it for life.
(2) When taking oral warfarin, you must master the principles of timing, quantification, and accurate dosage.
(3) Pay attention to signs of excessive anticoagulation: such as hematuria, nosebleeds, subcutaneous hemorrhage, gum bleeding, occult blood in the stool, etc. If the above symptoms occur, the dosage should generally be reduced or the medication should be discontinued for 1 day.
(4) Observe whether there is thrombosis, pay attention to the patient's consciousness and limb activities, and contact the doctor promptly if any abnormalities are found so that the dosage of anticoagulant drugs can be adjusted.
3. Health Guidance
1. Take warfarin anticoagulant medication regularly and regularly.
2. Regular follow-up visit to the hospital outpatient department once every 2 weeks after discharge, and once every 4 weeks after 3 months; if the prothrombin time is unstable, thrombin should still be measured 1-2 times a week original time.
3. Rest for half a year after discharge from hospital to avoid excessive activity and fatigue. However, the amount of activity can be gradually increased.
4. Pay attention to nutrition in your diet.
5. Take cardiotonic and diuretic drugs as directed by your doctor. Avoid taking medications that affect prothrombin time.
Patients’ rest activities and review after discharge (1) After valve replacement, it is generally necessary to rest for 6 months. During the rest period, you can do walking and light housework activities. The amount of activity should be gradually increased so as not to feel Tiredness is the measure. (2) After discharge, you should maintain a happy mood, maintain an optimistic and positive attitude and firm beliefs, and participate in some relaxing recreational activities... Items that patients should pay attention to after discharge (1) After discharge, in addition to regular review of coagulation In addition to proenzyme time and prothrombin activity, you should go to the hospital for review in 3 months, including physical examination (listening to valve sound quality, measuring body temperature, whether there is murmur in the precordial area, heart rate, etc.), electrocardiogram (to determine whether there is a heart rhythm disorder), and ultrasound Cardiogram, chest X-ray and biochemical tests such as serum potassium, sodium and chloride. Echocardiography shows...
Sixty years old is considered young for most of our current patients, and most of our current patients are over seventy years old. I haven't seen your echocardiogram, so I don't know the specific situation. However, double-valve replacement is a very mature operation in our department. You can live a normal life after the operation. How long you can live depends on your life span. However, many patients have survived for more than 20 years after double-valve replacement. . In our department, double-valve replacement, if imported valves are used, costs about 70,000 to 80,000 yuan.
When to operate for mitral valve stenosis
Mitral valve stenosis, surgical indications are as follows:
(1) For patients with mitral valve stenosis, under slight load In this case, the symptoms worsen, which means that the heart function compensation is in a critical state, and surgery should be performed to prevent the progression of the disease.
(2) Atrial fibrillation The incidence of atrial fibrillation is highest in patients with mixed mitral valve disease (stenosis combined with insufficiency), followed by patients with mitral valve stenosis, and lower in patients with mitral valve insufficiency.
Atrial fibrillation brings several serious problems to patients: ① Atrial fibrillation causes the loss of left atrial systolic function, resulting in a reduction of cardiac output by about 20-25%; ② The occurrence of atrial fibrillation worsens clinical symptoms, especially in the early stages of atrial fibrillation. , rapid heart rate can cause pulmonary edema; ③ Atrial fibrillation increases the chance of left atrial thrombus and embolism, which is approximately 7 times higher than that of sinus heart rate. It can be seen clinically that the occurrence of multiple premature atrial fibrillations is often a precursor to the occurrence of atrial fibrillation. Timely surgical treatment can avoid the occurrence of atrial fibrillation and related complications.
(3) The incidence of embolism complications is higher in patients with mitral valve stenosis, which is 4 times that of patients with mitral valve insufficiency. Therefore, patients with mitral stenosis who have left atrial thrombus or a history of embolism should undergo surgery, even if they are asymptomatic.
(4) Pulmonary hypertension: Although most patients with pulmonary hypertension cannot return to normal immediately after surgery, they can gradually decline, and the degree depends on the pulmonary vascular disease. Surgery must be performed before severe pulmonary vascular disease occurs. There are still some patients with mitral stenosis with severe pulmonary hypertension who have never experienced symptoms of pulmonary venous hypertension, but have signs of pulmonary hypertension, right ventricular hypertrophy, and low cardiac output at rest. Such patients, even if they are asymptomatic , should also undergo surgery.
Why do we need to go to the intensive care unit during cardiac surgery?
With the development of medicine, the intensive care unit (ICU) has become an indispensable and important part of modern hospitals. Especially the intensive care unit of the cardiovascular department, which is directly related to the safety and recovery of surgical patients, and is one of the key links in improving the success rate of surgical operations. After cardiac surgery, the patient's heart, lungs, kidneys, brain and other functions are in an unstable state. Abnormal changes are detected in a timely manner through monitoring, and advanced medical technology and equipment are used to correct them immediately, so that various abnormal indicators can quickly return to normal ranges to ensure The functions of the patient's various organs are in a stable state, allowing the patient to pass through the dangerous stage. Therefore, patients after cardiac surgery must enter the intensive care unit for intensive care. In order to give you a more comprehensive understanding of the intensive care unit, the following is an introduction to the general situation of the intensive care unit.
(1) The purpose and requirements of establishing a monitoring room: The purpose of establishing a monitoring room is to concentrate the strength of technical personnel and apply modern and sophisticated monitoring medical equipment to provide optimal postoperative monitoring of patients. The intensive care unit is equipped with specially trained high-level professional doctors and nurses. There is a 24-hour duty system in the intensive care unit. Medical staff must guard the patient day and night, monitor the patient's vital signs at any time, and quickly organize rescue when the patient has an accident.
(2) Requirements for entering the intensive care unit: The patients entering the intensive care unit are all post-cardiac surgery and critically ill patients. Due to the relative concentration of patients, the chance of cross-infection is high, so all personnel entering the intensive care unit must Wear work clothes and change shoes. Family members of patients are not allowed to visit or accompany them in the room.
(3) Requirements for patients after entering the intensive care unit: When the patient enters the intensive care unit, medical staff must continue to monitor his or her vital signs. The main means of monitoring are monitors with various functions. As soon as the patient enters the intensive care unit after surgery, medical staff must quickly connect the ventilator, ECG monitoring lines, arterial pressure gauge, central venous pressure line, urinary catheter, gastric tube, infusion pump, etc. These wires and tubes are important channels for monitoring and maintaining life. Patients must cooperate closely and cannot pull them out on their own to avoid accidents and endangering the patient's life. In order to help the patient get through the intubation stage safely, medical staff usually use restraints to fix the patient's hands or feet beside the bed to prevent the patient from extubating himself when he is unconscious. Generally, the condition is stable within 1-3 days after the operation. Finally, various pipes can be pulled out one after another.
Types of valve replacement surgery
Heart valve disease is a very common heart disease. There are about one million patients with valve disease in our country. In all heart disease surgeries, valve Nearly 1/3 is sick. In the early stage of valvular disease, patients often experience shortness of breath, palpitation, coughing, etc. when the amount of activity increases; in the late stage, patients also experience dyspnea, palpitation, edema, etc. when resting, which seriously affects the patient's mobility and quality of life. If heart valve disease is not treated in time, it will cause heart failure and circulatory failure, which directly threatens the patient's life and can lead to death in severe cases.
Rheumatic valvular heart disease is more common in our country. Others, such as congenital heart valve developmental malformation and senile valve degeneration, can cause heart valve disease.
Valvuloplasty is usually used for mildly diseased mitral or tricuspid valves, while for severe heart valve disease, especially rheumatic heart valve disease, valve replacement is often chosen. The main methods of valvuloplasty include Key's plasty, DeVega plasty, and C-shaped ring plasty. Valve replacement uses artificial valves to replace human heart valves, such as mechanical valves, biological valves, etc. Mechanical valves have a long life, but require Lifelong anticoagulation is prone to complications, while biological valves do not require lifelong anticoagulation, but have a short lifespan. There are also tissue engineering valves developed using bioengineering technology, which have not yet been used in clinical applications.
Replacement of artificial valve
Mild congenital valve disease can be observed and followed up. Early rheumatic valve disease can also be treated with drugs. Once the clinical symptoms are obvious and the heart function decreases, it should be treated Consider surgery. The human heart is like a power blood pump,
promoting repeated circulation of blood throughout the body and maintaining the metabolism of various organs and tissues. The heart has four valves: aortic valve, mitral valve, aortic valve, and tricuspid valve. These valves are like "one-way valves" that ensure blood circulation in a certain direction and a certain flow rate. If the valve becomes diseased due to congenital malformation, acquired rheumatism, or bacterial infection, it will lose its normal anatomical structure and physiological function, and stenosis or insufficiency will occur, resulting in obstruction or reflux of blood, thus affecting the "blood pump" function of the heart. Over time, cardiac hypertrophy causes "pump failure", which is life-threatening. Early clinical symptoms of heart valve disease are palpitations, shortness of breath, susceptibility to respiratory infections, edema in heart failure, paroxysmal dyspnea, hepatomegaly, oliguria, irregular heartbeat, etc.
Mild congenital valvular disease can be observed and followed up. Early rheumatic valvular disease can also be treated with drugs. Once the clinical symptoms are obvious and the heart function decreases, surgery should be considered. Valve surgery includes valve commissure separation, valve repair and valve replacement. For congenital valve clefts, leaflet prolapse, chronic degenerative disease or mild rheumatic valvular insufficiency, repair surgery can often successfully reconstruct the valve function. For severe valve deformity or thickened calcification, , stiffness, or bacterial growth, the valve needs to be removed and replaced with an artificial valve.
There are many types of artificial valves currently used clinically, which are mainly divided into two categories: one is artificial mechanical valves made of artificial materials (such as silica gel, polymers, etc.); the other is It is a biological tissue valve made of the same or heterogeneous biological tissue. Mechanical valves have good durability and are not prone to failure, but there is a risk of thromboembolism and require long-term anticoagulation. Biological valves do not require anticoagulation and have a low incidence of thrombosis, but are prone to degeneration, calcification, and failure, so the reoperation rate is high. . In short, so far, many experts at home and abroad are still continuing their research and trying to find a perfect artificial heart valve that is neither thrombotic nor easily damaged.
Life after valve replacement
The 3 months after surgery will be mainly about rest. 3-6 months after surgery, half a day of light work and half a day of rest can be considered based on cardiac function, physical condition and nature of work. Physical labor must be done step by step, from light to heavy. If there is no discomfort, you can do it competently; if you feel tired, flustered, or short of breath, you should stop immediately. Six months after the operation, you can consider returning to full-time work according to the situation, and gradually return to normal work.
Three months after the operation is an important stage for overcoming the trauma of the operation and rehabilitating the body. You should recuperate carefully and conscientiously do the following:
(1) According to the physical condition, perform appropriate Indoor and outdoor activities should be done according to one's ability and done step by step so as not to cause panic and shortness of breath.
(2) The weather is cold in winter. If you feel slightly uncomfortable, seek medical advice immediately.
(3) The diet should be nutritious, with many varieties, and eat more fruits.
(4) Pay attention to adjusting your mentality, keeping a happy mood, and participating in entertainment activities appropriately.
(5) Continue to take various medications as prescribed by your doctor, especially digitalis preparations and warfarin.
(6) You should go to the hospital for a detailed examination three months after the operation, and the future recuperation policy will be decided based on the results.
(7) If you feel unwell, seek medical advice at any time.
(8) Patients taking warfarin should monitor iNR regularly and adjust the dosage under the guidance of a doctor.
Indications for heart valve surgery
If the normal heart valve is invaded by rheumatic fever or bacteria, causing deformation, thickening, adhesion, or even calcification of the valve leaflets and severe adhesion of the subvalvular structure, Or the valve leaflets are poorly aligned or prolapsed, or the chordae tendineae are too long or broken, resulting in insufficiency, which makes the valve unable to function as a one-way valve to maintain one-way blood flow, and the original valve needs to be removed under extracorporeal circulation. Replace with an artificial valve to restore its physiological function and improve the patient's quality of life. For patients with good valve quality and no obvious calcification and insufficiency, valvuloplasty can be used.
You should pay attention to the following issues before deciding to have surgery.
(1) Rheumatic activity. Routine preoperative examination of antistreptolysin (ASO) should be less than 1:400; erythrocyte sedimentation rate (ER), which is normally less than 15mm/hour for men and less than 20mm/hour for women. . Abnormal ASO and ER indicate rheumatic activity and should be treated with anti-rheumatic treatment until the patient gets better before surgery. Otherwise, due to the presence of inflammation in the heart, the risk of surgery increases, and rheumatic activity will intensify after surgery.
(2) Heart function. The heart function should be adjusted before surgery so that it is in the best condition before surgery. The risk of surgery increases significantly when the heart function is insufficient
. However, for those with severe cardiac insufficiency that cannot be controlled medically, surgical correction should be considered as soon as possible.
(3) Age. The optimal age for valve surgery is 20 to 50 years old. If you are too young, you are prone to recurrence after surgery due to postoperative rheumatism. If you are too old, you are prone to coronary heart disease and other organ diseases, and the surgery is risky. Increase.
1. Indications for mitral valve replacement surgery:
Once the diagnosis is clear, especially if there is interstitial pulmonary edema and paroxysmal nocturnal dyspnea, and the heart function is lower than level II, Valve replacement surgery should be considered for patients with calcification of the valve leaflets or severe disease of the subvalvular device, or combined with insufficiency, or reoperation. If combined with coronary heart disease or severe pulmonary hypertension, surgical treatment can also be performed.
2. Indications for aortic valve replacement surgery
Severe aortic valve disease cannot be treated with plastic surgery, such as highly dilated annulus and torn valve leaflets caused by degenerative changes. Fissure, and obvious curling, deformation, and even calcification of the valve leaflets caused by rheumatic heart disease. Left ventricular failure and infective endocarditis are not absolute contraindications, but the risk of surgery for left ventricular failure and infective endocarditis that cannot be controlled by medical treatment increases significantly.
3. Indications for tricuspid valve replacement surgery
If medical treatment of severe tricuspid valve disease fails, and the plastic treatment is no longer possible or the tricuspid valve is severely displaced, valve replacement is required. Operation.
4. Indications for closed mitral valve dilatation or direct vision valvuloplasty surgery
For patients with mitral valve stenosis, if they are younger and their heart function is in Class II to III (NYHA ), and no obvious calcification and insufficiency of the valve are found, no obvious contracture of the valve leaflets, and no history of left atrial thrombosis or infarction, closed mitral valve dilatation or open mitral valve valvuloplasty can be performed under general anesthesia.
Determining whether valve surgery is better for valvuloplasty, closed expansion or valve replacement, mainly depends on the condition of the patient's valve itself, and also takes into account the need for reoperation after valvuloplasty or closed expansion. Those with significant valve calcification are absolute indications for valve replacement surgery. For young patients, valve replacement surgery should be considered due to the susceptibility to rheumatism, the definite need for reoperation, and financial issues. For those over 45 years old with well-controlled rheumatoid arthritis, valvuloplasty surgery can be considered, which can make the valvuloplasty surgery last longer. For elderly patients over 60 years old, biological valve replacement can be considered to avoid various complications caused by anticoagulation.
Issues of continued treatment after valve surgery
After valve replacement patients are discharged from the hospital, they need to continue taking medication to further improve and maintain cardiac function. Commonly used drugs after discharge from hospital mainly include the following.
1. Cardiotonic drugs, diuretics and potassium supplements
Generally need to be taken for 3 months to half a year.
The main cardiotonic drugs are digoxin, the main diuretics are hydrochlorothiazide or furosemide, and the main potassium supplements are potassium chloride, etc. When taking digoxin for a long time, you should pay attention to changes in heart rate. If the heart rate slows down to less than 60 beats/min, or an irregular heartbeat occurs, you should stop taking digoxin and go to the hospital for diagnosis and treatment in time. Diuretic drugs can be increased or decreased according to the daily urine output and whether there is edema in the lower limbs. At the same time, the amount of potassium supplement can be adjusted according to the test results of blood potassium concentration.
2. Anticoagulant drugs
Replacement of a mechanical valve requires lifelong anticoagulation, and replacement of a biological valve requires anticoagulation for 3 to 6 months. Currently, warfarin is mainly used for anticoagulation. During the anticoagulation period, prothrombin time and activity should be rechecked regularly. The recheck should be done 4 to 5 days after increasing or decreasing the dose. If the patient is stable after 3 rechecks, the recheck interval can be gradually extended. The dosage should not be adjusted too large each time to avoid excessive fluctuations in measured values.
3. Vasodilator drugs
Those with high pulmonary artery pressure or high blood pressure should take vasodilator drugs.
4. Antibiotics
If there are still respiratory, urinary system and skin infections after discharge, sufficient antibiotics should be used for a short period of time to prevent abuse.
In addition to the above drug treatments, if the heart beats slowly and weakly after cardiac surgery, or if the heart rate is slow before surgery and the condition is serious, in order to prevent postoperative slow heart rate or various refractory arrhythmias, , often a temporary epicardial pacemaker is installed during surgery. In this way, doctors can safely administer drugs as needed after surgery without worrying about various arrhythmias. After installing the pacemaker, be sure to check that it is working satisfactorily, and the leads should be fixed to the chest wall after surgery without being broken or contaminated. Generally, after the pacemaker is placed for 1 to 2 weeks, the lead can be pulled out if not necessary. If the pacemaker cannot be stopped, a cardiologist should be consulted to determine whether a permanent pacemaker is needed in the heart.
Before discharge, the patient should adjust the dose of anticoagulant and review echocardiography, chest X-ray, electrocardiogram and blood biochemistry examination. The results show that there is no pericardial effusion, arrhythmia, electrolyte imbalance and other symptoms, and he can be discharged from the hospital to recuperate. .
Precautions after valve surgery
Recuperation activities and review after discharge from the hospital
(1) After valve replacement surgery, it is generally necessary to rest for 6 months. During the rest period , you can take walks and light housework activities.
The amount of activity should be gradually increased until you don’t feel tired.
(2) After discharge from the hospital, you should maintain a happy mood, maintain an optimistic and positive attitude and a firm belief. You can participate in some relaxing recreational activities. Don't be impatient and worried. Faster recovery.
(3) There may be some mental and emotional changes and memory loss after extracorporeal circulation surgery. Most patients will disappear soon
so there is no need to worry.
(4) Although the skin incision has healed after surgery, it will take a long time for the sternum to heal (about half a year), so heavy physical activities cannot
be performed. As the body recovers, some patients will feel tension or even pain in the muscles of the neck, shoulders, and chest. At this time, they need to do light activities, and they will get better after gradually performing functional exercises.
(5) You must go to the hospital for a review six months after discharge. At this time, the cardiac function gradually improves, and the postoperative effects can be evaluated
. If you encounter the following situations, you should go to the hospital for review in time: ① Chest pain rather than incision pain. ②The heart rate is lower than 60 beats/min or higher than 120 beats/min. ③ Heart rhythm disorders occur, such as frequent premature ventricular contractions, paroxysmal supraventricular tachycardia, and irregular heartbeat or pulse. ④ Sustained high fever above 380C, or infection. ⑤ Edema in the lower limbs, sudden weight gain, shortness of breath, palpitation, shortness of breath, and coughing up frothy sputum. ⑥Nausea and vomiting without obvious inducement, sclera and skin jaundice, etc. ⑦ Sudden syncope, coma, hemiplegia, aphasia or lower limb pain, chills, paleness, etc. ⑧ There are bleeding phenomena such as subcutaneous bleeding, hematuria and melena. ⑨Other obvious symptoms.
(6) Artificial valve failure can lead to very serious consequences. If the following symptoms occur, you should seek medical treatment in time. If more than 2 of the following symptoms appear, consider it as artificial valve failure. If necessary, seek medical attention. Repeat valve replacement surgery: ① Progressive dull heart sounds and heart murmurs. ② Heart function suddenly deteriorates and cannot be controlled by drugs.
③ Embolism occurs in the brain, kidneys, intestines and limbs. ④Severe high fever and confirmed infective endocarditis. ⑤Hemolysis occurs, manifested as progressive anemia, hematuria, etc. ⑥Echocardiography proves that the artificial valve has poor mobility or thrombus.
(7) When the patient has an irregular heartbeat, he should rest in time and go to a nearby hospital for an electrocardiogram examination. If he has premature atrial beats, he should take adequate rest and take digoxin and other powerful drugs. Cardiac drugs can control it. If it is premature ventricular contractions, drugs should be used to control it as soon as possible. At the same time, the cause should be actively searched to see if there is hypokalemia, hypotension, etc. to treat the root cause. Other types of arrhythmias should also be controlled in time.
(8) Anti-rheumatic treatment should be active, mainly using intramuscular injection of long-acting penicillin or oral treatment with enteric-coated aspirin.
(9) Sexual life should be controlled and attention should be paid to avoid pregnancy. If there are special circumstances, pregnancy should be considered after cardiac function has recovered well.
(10) For those who develop atrial fibrillation within 3 months before surgery, atrial fibrillation can be eliminated after surgery as long as the cardiac function is maintained.
Atrial fibrillation lasts for a long time before surgery. Since patients are more adaptable to atrial fibrillation, even if atrial fibrillation exists after surgery, it will have little impact on cardiac function and does not need to be treated. After cardiotonic diuresis, if atrial fibrillation still exists and the patient is not adaptable to it, he can go to the hospital for drug defibrillation or electric defibrillation treatment after his cardiac function has improved significantly six months after the operation. People with stubborn atrial fibrillation have poor heart function. Do not forcefully correct the fibrillation to avoid danger. Instead, they should be treated with cardiotonic diuresis.
(11) Heart function is an indicator of the degree of disease in patients. The effect of treatment can be determined based on the changes in cardiac function before and after surgery.
In short, although the patient's symptoms have been significantly improved after valve replacement, in order to maintain the heart function, maintain the normal operation of the artificial valve, and prevent various complications after valve replacement, we must persist Follow up regularly and keep in touch with the doctor so that problems can be discovered and treated promptly.
Items that should be observed after valve surgery
Items that should be observed after patients are discharged from hospital
(1) After discharge, in addition to regular review of prothrombin time In addition to prothrombin activity and prothrombin activity, you should go to the hospital for review in 3 months, including physical examination (listening to valve sound quality, measuring body temperature, whether there is any murmur in the precordium, heart rate, etc.), electrocardiogram (to determine whether there is a heart rhythm disorder), echocardiography, Chest X-ray and biochemical tests such as serum potassium, sodium, and chloride. Echocardiography shows a small amount of regurgitation with a prosthetic valve, which is normal. This kind of regurgitation is specifically designed to wash away the valve leaflets and prevent the occurrence of thrombus during the valve design.
(2) Pay attention to changes in cardiac function, heart rate and rhythm.
(3) Pay attention to whether there is expectoration, hemoptysis, difficulty breathing, etc. in the lungs.
(4) Is there any bleeding phenomenon, such as gum bleeding, nose bleeding, hematuria, melena, etc.
(5) Whether there is embolism, such as syncope, hemiplegia, aphasia, unilateral limb pain, chills or myocardial infarction.
(6) Whether the sound quality of the valve suddenly appears murmur and whether there is any unexplained fever.
(7) The prothrombin time and activity are controlled within a good range, the prothrombin time is controlled at 18 seconds to 22 seconds, and the prothrombin activity is controlled at 35% to 45%.
(8) Maintain a certain amount of urine every day, and add digoxin and diuretics if necessary.
(9) Pay attention to joint pain, redness and swelling, and pay attention to hepatomegaly and jaundice.
Rheumatic heart valve disease can cause the following major complications:
(1) Congestive heart failure
50% of patients with rheumatic heart disease are prone to Causes congestive heart failure. Year-round erosion of rheumatic inflammation, impaired cardiac systolic function, and cardiac overload, such as severe mitral stenosis, can cause heart rate problems during pregnancy, childbirth, strenuous physical activity, and infection. It accelerates, causing the diastolic period of the left ventricle to shorten and the pressure of the left atrium to increase, causing the pressure of the pulmonary capillaries to increase, and the plasma to leak into the tissue space or alveoli, causing acute pulmonary edema. The patient may have severe paroxysmal dyspnea, cyanosis, and pink cough. Foamy sputum, full of rumbles in the lungs, etc. are called congestive heart failure.
(2) Arrhythmia
The most common arrhythmias are premature atrial contractions, atrial fibrillation, paroxysmal tachycardia, etc. Among them, the incidence of atrial fibrillation can be as high as 40 to 50%. Atrial fibrillation is often preceded by frequent premature atrial contractions, atrial flutter or paroxysmal atrial fibrillation, and then develops into persistent atrial fibrillation.
(3) Embolism
Patients with mitral stenosis and atrial fibrillation are most likely to suffer from infarction. In patients with mitral stenosis, blood stasis occurs due to dilation of the left atrium and left atrial appendage. If atrial fibrillation occurs again, thrombosis is likely to form. Fresh thrombi are easy to fall off and cause embolism, which can cause embolism in the brain, kidneys, mesentery, spleen, limb blood vessels and coronary arteries.
(4) Subacute infective endocarditis
Patients with simple high-grade stenosis are rarely complicated by infective endocarditis due to valve stiffness, thickening and calcification.
When mild mitral stenosis is combined with mitral valve or aortic valve regurgitation, infective endocarditis is prone to occur.
(5) Pulmonary infection
In patients with valvular disease, due to increased left atrial pressure, pulmonary congestion, reduced pulmonary compliance, and pulmonary interstitial edema,
When the body's resistance is reduced, it is easy for repeated lung infections to occur, which can induce and aggravate heart failure.
(6) Others
In patients with severe mitral stenosis, the huge left atrium may compress the recurrent laryngeal nerve, causing hoarseness,
or compression. The esophagus causes difficulty swallowing.
Mitral valve replacement
Indications
1. Mitral valve stenosis and severe valve calcification.
2. Mitral valve stenosis, severe valve contracture, severe subvalvular disease, which cannot be repaired by plastic surgery.
3. Mitral valve stenosis and insufficiency, the latter cannot be solved by plastic surgery.
4. Simple mitral valve insufficiency that cannot be corrected by plastic surgery.
[Preoperative preparation]
Stop diuretics 24 to 48 hours before surgery. The rest is the same as the establishment of extracorporeal circulation.
[Anesthesia]
Endotracheal intubation, intravenous fentanyl anesthesia, and hypothermic extracorporeal circulation anesthesia. Give gik solution before starting to protect the myocardium.
[Surgical steps]
1. Make incision and establish extracorporeal circulation (see Establishing extracorporeal circulation).
2. Cardiac incision ① A longitudinal incision is made behind the atrioventricular groove into the left atrium. If the interatrial groove is too short, the lower end of the incision can be extended downward and posteriorly; ② Incision through the right atrium: 2cm above the atrioventricular groove. Opens the right atrium and extends outward and downward along the atrioventricular groove. After entering the right atrium, make a longitudinal incision in the fossa ovale, and expand it upward and downward. When extending downward, it should be biased toward the inferior cavity; when extending upward, avoid inward deflection to avoid accidental injury to the aortic sinus.
3. Cut the flap and use a retractor to expose the mitral valve. After determining the indication for valve replacement, use a thick silk thread to sew the large valve as a traction line, and use a right-angle clamp to clamp the traction line to expand the large valve. Make a small incision on the large flap about 3mm away from the valve annulus, and then use scissors to cut the large flap forward and backward along the valve annulus at a distance of 3mm from the valve annulus. At the same time, cut off the papillary muscle at the tip of the papillary muscle, but do not cut too much. to avoid damaging the left ventricular wall. After reaching the junction of anterior and posterior, continue to remove the small flap in the same way, trying to preserve the third row of chordae tendineae of the small flap, or not remove the small flap. Finally, use a valve measuring device to measure the size of the valve annulus to determine the number of artificial heart valves required [Figures 11-5].
4. Suture with 20-inch support padded double-ended needle nylon thread for interrupted mattress sutures. Insert the needle from the atrial side of the valve annulus, exit the needle from the ventricular side, and immediately sew in from the ventricular side to the atrial side. Suture loops for artificial heart valves. The sutures should be evenly distributed on the valve annulus and the suture circle of the artificial valve, and the stitch spacing should be adapted to each other. The position of the sutures coming out of the suture circle should be as close to the edge as possible. The distance between mattress sutures is 1 to 2 mm [Figure 16]; continuous sutures can also be used, but they must be easy to expose. You can use one thread as the first needle with a supporting pad to perform mattress suture, and then the continuous sutures progress to both sides, and finally meet and tie the knot; you can also use several sutures for continuous sutures, and all continuous sutures should be noted that each stitch must be The sutures are tightened to avoid paravalvular leakage.
5. After all the implanted sutures (mattress suture method) are straightened, put the artificial valve into the annulus, confirm that the implantation is in place, and tie them one by one. Five nylon threads should be tied Knots should not be left too long when trimming, and when tying knots, pay attention to tying the knots on the outside of the suture circle (i.e., close to the edge) to prevent the threads from falling toward the center and hindering the function of the artificial valve [Figure 17].
6. Check the closing and opening functions of the artificial valve.
7. Rinse Thoroughly rinse the cardiac chambers with cold salt water.
8. Suture the incision and then suture the left atrium incision, or suture the atrial septal incision and then suture the right atrium incision. All heart incisions are sutured in two continuous lines, and the sutures must be tightened during suturing to prevent blood leakage.
9. Before exhausting and suturing the left atrial incision, the left atrium and left ventricle should be filled with physiological saline to drive out the gas; if the right atrial route is used, the left atrium and left ventricle should be sutured when suturing the interatrial septum. The left ventricle was filled with normal saline, and the right atrium and right ventricle were filled with saline when the right atrium incision was sutured. After the cardiac incision is sutured, the left ventricle and ascending aortic root are exhausted. The aortic root can be exhausted by using the needle hole filled with cardioplegic solution. It can be connected to the left heart drainage tube for exhaust, or it can be left open. To exhaust, the left chamber was exhausted using a slotted needle.
10. Open the ascending aorta blocking forceps as soon as possible (if the blocking time is long, in order to reduce the time of blocking the ascending aorta, you can open the ascending aorta blocking forceps after sewing the interatrial septal incision. Open the ascending aorta clamp without waiting to close the right atrium. After that, the heart can often restart automatically. If it cannot restart automatically, the myocardium has a certain tension or ventricular fibrillation has occurred, electric shock can be used to defibrillate.
[Intraoperative Precautions]
1. The front and middle parts of the large valve are adjacent to the aortic valve. When suturing, avoid suturing the aortic valve, which may cause the aortic valve to close. Not complete.
2. The circumflex branch of the left coronary artery is accompanied by the small valve annulus. If the suture is too deep, it may damage this branch of the coronary artery.
3. The posterior junction is close to the right fiber triangle. Avoid suturing too deeply and damaging the conductive bundle.
4. When cutting off the small flap and its chordae tendineae, avoid damaging the posterior wall of the left ventricle. The third row of chordae tendineae of the small flap may not be cut, so as to protect the posterior wall of the left ventricle and avoid the occurrence of left ventricular rupture. Complications of posterior wall rupture. When using retractors and suction devices, care must be taken to avoid damaging the posterior wall of the left ventricle. Sometimes mitral valve replacement can be completed without removing the small valve, but attention should be paid to whether the papillary muscles may hinder the function of the artificial valve.