Re-valve replacement for recurrent heart valve disease

The patient had previously undergone heart valve surgery, including mitral stenosis and closed dilation, and recurrence of lesions after mitral valvuloplasty; after artificial heart valve replacement, because of artificial valve structure failure, or due to artificial valve The lesions that require re-operation after complications such as implantation; and patients with advanced valvular disease after valve replacement, who require reoperation, are collectively referred to as recurrent valvular disease. If surgery is needed to correct it, we call re-valvular surgery. 1. The main pathological changes of recurrent valvular disease are artificial valve structural dysfunction, artificial valve endocarditis, paravalvular leak, artificial valve thrombosis, thromboembolism, and local lesion recurrence after valvuloplasty. Other rare causes are severe hemolysis caused by artificial valves, excessive proliferation of peri-valve tissue, affecting the activity of artificial valve discs, and obstruction caused by surgical techniques such as long suture knots and seizure of discs. (1) Structural failure of artificial valve: Due to the wide application of the novel double-leaf valve, endogenous dysfunction of mechanical valve due to structural abnormalities is increasingly rare. However, due to the stress of the annulus, the valve or disc wears, corrodes and detaches, causing acute dysfunction. The patient immediately develops cardiogenic shock and can die in a short period of time. Biological valve degeneration or calcification, usually a chronic process, manifested as stenosis or insufficiency. After rheumatic mitral valve disease, the recurrence rate of general lesions is 2% to 4% of patients per year due to rheumatic fever. (2) artificial valve endocarditis: regardless of early or late artificial valve endocarditis, is a serious complication after surgery, the incidence rate is about 1.5%, the incidence of mechanical flaps (1.6%) Higher than the biological valve (1.1%). The medical treatment mortality rate is as high as 50%, and should be operated early. (3) Peripheral leakage: The incidence of paravalvular leak after mechanical valve replacement is higher than that of biological valve, generally about 1% to 4%. There is no obvious hemolysis or hemodynamic disorder in the mild paravalvular leak. It can be observed without surgery. Otherwise, surgery should be performed or a new artificial valve should be replaced. (4) Valve thrombosis or systemic embolism: These two complications are important causes of lesions and death after mechanical valve replacement. Thrombosis is a catastrophic complication, reported in the literature as 0.5% patient-year. Two-thirds of the patients die, and thrombolysis or emergency surgery should be performed depending on the time of occurrence and hemodynamic changes. In addition, because of the repeated occurrence of systemic thromboembolism from the origin of the artificial valve, it is also an indication for reoperation after excluding other causes. (2) Other causes: significant stenosis caused by mismatching of the artificial valve in the early stage; or excessive hyperplasia of the periorbital tissue of the host, affecting the activity of the valve, and surgery is necessary. 2. Features Compared with the first surgery, valvular surgery has the following characteristics: (1) The illness is long, the patient's general condition is poor, the heart function is severely damaged, often combined with different degrees of vital organ dysfunction; some due to acute valvular dysfunction, causing acute hemodynamic disorder, must be limited or emergency Surgery, in this case, it is difficult to perform adequate perioperative preparation. (2) The original chest is opened in the middle of the chest, because the posterior sternal tissue and the pericardium and myocardium are densely adhered. When the surgery is opened and separated again, it can cause damage to the large blood vessels and ventricular wall, causing acute massive hemorrhage, which can have serious consequences. It is also an important reason for the failure of surgery. (3) extensive removal of pericardial adhesions, not only prolonged the operation time, but also can cause extensive bleeding and oozing, causing hemolytic dysfunction, and even serious consequences. Therefore, it is now advocated to limit the separation, that is, to separate only the pericardial adhesions in the surgical field. (4) Due to the extensive pericardial adhesion in the ventricular area, the heart is fixed in the thoracic cavity. Therefore, when the valve is especially mitral, the exposure is limited and the difficulty of surgery is increased. (5) When the original grafted artificial flap is removed, there are certain technical difficulties. For example, excessive removal of the annulus tissue may damage adjacent important tissues, and residual tissue fragments or foreign bodies may cause embolism. (6) Periorbital abscess and tissue defects caused by endocarditis, which increases the chance of reinfection during the removal process. In view of the above reasons, revalvular valve surgery, especially recurrent valvular heart disease, has a significantly higher surgical mortality and postoperative complications than the first surgery. 3. Surgery Due to the difference between valvular lesions and the first surgical procedure, re-valvular surgery includes the following common surgical methods: (1) valvuloplasty: patients who have undergone mitral stenosis, or mitral regurgitation after remodeling and recurrence, valvular lesions are not serious, can be repaired again. (2) Valve replacement after valvuloplasty: A closed or direct valvuloplasty has been performed. Valve replacement surgery is required for lesions that are severely damaged by the valve. (3) Re- or multiple valve replacement: patients who have undergone artificial valve replacement, early or late postoperative surgery due to endogenous lesions or complications of the valve, requiring repeated or multiple replacement surgery. (4) Artificial valve valve repair. (5) Artificial valve thrombectomy. Modern, most scholars advocate rheumatic mitral stenosis dilatation, or mitral regurgitation in patients with recurrent disease after resection and repair, generally no secondary repair surgery, but artificial valve replacement. In addition to the separation of the mediastinum and pericardial adhesion, the basic technique is the same as the first valve replacement. Treating diseases: heart valve disease Indication 1. Artificial valve structure decay Degeneration or calcification of the biological valve is one of the important reasons for reoperation. With the progress of the postoperative time, the above degeneration is inevitable. The decay of the biological valve is related to the type and age of the bioprosthesis. In patients under 20 years of age, the decay rate can be as high as 20% of patients per year; while in patients over 70 years old, it is only 0.2% of patients per year. In addition, the mitral valve bioprosthesis has a lower attenuation rate than the aortic valve region. Such patients, with or without symptoms, should be operated once the diagnosis is made. The structural failure of the mechanical valve can be manifested as changes in stent fracture, flap wear, deformation, expansion, etc., even disc detachment, card or openness, or unsynchronized opening and closing activities of the bilobed flap. Most patients have acute circulatory dysfunction and need emergency surgery. 2. Artificial valve exogenous dysfunction The prosthetic valve suture knot remains too long or the residual chordae in the heart chamber can be stuck between the disc and the annulus, so that the disc can not be opened; the artificial valve type is too large or the flap is placed in the wrong direction. It can also limit the activity of the disc. The biological valve can be accidentally injured in the valve leaflet, the valve is too large and the valve frame is deformed, and the suture is wound around the ventricular surface, which can cause acute valve insufficiency. It is necessary to replace the new biological valve with emergency surgery. A small number of patients only need to remove exogenous factors without having to replace the valve. 3. Complications associated with artificial valves It mainly includes artificial valve endocarditis; artificial valve thrombosis; or repeated occurrence of systemic thromboembolism from artificial valve source. Embolization of other causes, especially repeated multiple embolization, is also an indication for reoperation. 4. Artificial valve flap leakage Small paravalvular leaks occur early in the operation, and there is no abnormal hemodynamic changes, which can be temporarily observed. If severe hemolysis or hemodynamic changes occur, surgery must be repaired. However, the valve replacement surgery must be performed again in the following cases: 1 the first application of the artificial valve is a biological valve; 2 extensive or multiple valve leakage, the formation of a large defect in the annulus tissue is difficult to ensure complete repair of the patient; Peripheral leakage caused by endometritis, if the artificial valve is defective, the valve should be replaced. 5. Children with restenosis In principle, valvular heart disease should be treated with medical treatment to correct heart failure. After maturity, replace the adult model valve. However, due to the serious development of the disease, when the valve surgery is necessary, due to the use of the small artificial valve, as the body grows and develops, the original implanted valve has not adapted to the requirements of cardiac output, and the symptoms of valvular stenosis are required. The valve of the model was re-operated. 6. Other valvular lesions appear later in the valve replacement According to a large group of follow-up observations, rheumatic mitral valve disease, advanced surgery after angioplasty or valve replacement, often around 10 months after surgery, patients with obvious aortic valve disease, need to perform aortic valve replacement surgery again . It may be that the aortic valve disease is mild in the first mitral valve operation. Later, because rheumatic valvular disease is a chronic progressive disease, the aortic valve disease gradually worsens. In addition, some patients with left valvular disease have tricuspid valve disease in the late postoperative period, and most of them are functional regurgitation. There are similar reports in the literature, the reason is not completely clear, may be due to long-term mitral valve disease, pulmonary hypertension can not fully return to normal, or due to aggravation of rheumatic myocarditis, resulting in enlarged right ventricular hypertrophy. Such tricuspid valve lesions are sometimes quite severe, with progressive right heart failure, ineffective medication, hepatomegaly, ascites and lower extremity edema. In the event of severe tricuspid regurgitation and right ventricular dysfunction, surgery must be performed again, and tricuspid annuloplasty or valve replacement should be performed to relieve the condition. Contraindications 1. Systemic or local acute infection Common respiratory or genitourinary infections, such as the condition allows, should be operated after infection control. However, medical treatment of patients with infective endocarditis cannot be controlled, and emergency surgery should be performed. 2. Important organ damage This type of condition is more common in the first valve replacement, due to the failure of artificial valve, progressive heart failure without timely surgery, combined with serious damage to important organs, difficult to withstand reoperation, should be based on the experience and equipment conditions of the operator, For relative contraindications. 3. Older critically ill patients Recurrent valvular disease in elderly patients, especially those over 80 years of age, combined with other important diseases such as coronary heart disease, diabetes, chronic obstructive pulmonary disease, liver and kidney dysfunction, should be treated with caution. Preoperative preparation According to the severity of hemodynamic changes in patients undergoing reoperation, the patient's cardiac function, and general general condition, the timing of surgery can be divided into three types, and preoperative preparation is also different. 1. Selective surgery: The patient's cardiac function is still in a stable state, allowing more time to prepare, and then undergoing surgery after the condition is improved. The routine preoperative preparation is the same as the first surgery patient, but special attention should be paid to the following: (1) Anticoagulant treatment: patients who used anticoagulant therapy, stopped taking anticoagulant before surgery, and re-examined prothrombin when the original time reached normal level. (2) Re-valvular replacement surgery, intraoperative bleeding and postoperative oozing are common complications. It is necessary to prepare enough coagulation biological products such as fresh blood, plasma, fibrinogen, prothrombin complex complex and platelets. (3) Prepare the femoral artery and venous intubation before opening the chest, in case of emergency, cardiac arrest, major bleeding, etc., immediately carry out the stock-strand diversion and cooling, and quickly open the chest to do the right atrial insertion. The tube establishes extracorporeal circulation, and then the chest is opened for emergency surgery. (4) Preparation for extracorporeal circulation and more than 3 transfusion channels must be performed before anesthesia. 2. The cardiac function status of patients undergoing limited operation is progressively worsened. The application of drug therapy can only achieve short-term improvement, and can be aggravated again in the short term. This situation is more common in patients with bioprosthetic failure, should be prepared in a short period of time, usually within 1 week of surgery. Preoperative preparation In addition to the requirements of patients undergoing elective surgery, special attention should be paid to the following points: (1) active drug treatment; absolute bed rest, application of cardiotonic, diuretic, vasodilator drugs and a small amount of hormones, control heart failure, correct electrolyte imbalance, improve nutritional status, when the condition improves, it should be timely surgery. (2) Close observation of the condition, the heart function failed to improve after medication, or found that liver, kidney, lung and other important organ function damage, if not surgery will lead to further deterioration, should be based on the specific circumstances of the patient, change to emergency surgery. (3) Perform necessary examinations within a limited time, including coronary angiography, major organ function tests, etc., and prepare for relevant measures, such as intra-aortic balloon counterpulsation, left heart assist pump, and peritoneal dialysis. Wait. (4) The extracorporeal circulation should be increased by colloidal prefilling, and a membrane oxygenator is used. According to the condition, ultrafiltration dehydration and application of pulsation pump are adopted to reduce postoperative complications. 3. Emergency surgery due to acute dysfunction of artificial valve, causing acute heart failure or pulmonary edema, and even cardiac arrest, drug treatment is difficult to maintain the low level of circulatory function, surgery must be performed on the same day, it is possible to save the patient's life. The main point of preoperative preparation is to fight for the patient to establish extracorporeal circulation before the heart stops. Therefore, it is necessary to prepare all rescue equipment in peacetime. Once the above situation occurs, it should be determined. If it is dangerous, it can be operated in a monitoring room with better equipment conditions. Rescue measures include: (1) Immediate tracheal intubation assisted breathing, using positive end-expiratory breathing; intravenous infusion of positive contractile function drugs, commonly used in combination with dopamine and dobutamine, improve cardiac output, maintain major organs Blood perfusion, and intravenous injection of cedilan and furosemide, rapid diuresis and dehydration. Patients with sudden cardiac arrest should immediately press and defibrillation, wait for the heart to recover, the situation is slightly improved, and emergency surgery should be performed in time. (2) For patients with a basic and unambiguous diagnosis, excessive examination will lose favorable surgical opportunities, and bedside color Doppler echocardiography will help judge the function of artificial valve only under the condition of the condition. . (3) termination of anticoagulant therapy, intravenous injection of vitamin K1110~20mg before surgery, surgery can be performed, but the original time of prothrombin must be checked before closing the chest, so that it can reach the normal level, if necessary, additional dose can be added. (4) At the same time of opening the chest, quickly establish a stock-share diversion preparation, such as blood pressure is difficult to maintain or cardiac arrest, immediately carry out stock-strand diversion and cooling, use the easiest way to enter the chest, through the right atrium for vena cava Intubation, establishment of extracorporeal circulation, then block the aorta, injection of cardiac arrest, for intracardiac surgery. Surgical procedure 1. Into the chest path For patients who have had a chest incision in the incision, the following surgical incisions are available depending on the location of the replacement valve and the severity of pericardial adhesion. (1) Chest midline incision: The mid-thoracic incision of the chest is well exposed to various parts of the heart and is a commonly used incision for secondary surgery. Such as multi-valve re-replacement, this incision should be used to facilitate exposure. Due to the formation of a dense adhesion zone in the original incision of the sternum, re-operation of the sternum can damage the myocardium and large blood vessels in the pericardium, causing massive bleeding. Therefore, care should be taken to prevent damage. Surgical operation: remove the scar tissue and subcutaneous tissue of the original skin incision, remove the original sternal steel wire suture, use the electric knife to cauterize the original sternal incision periosteum, and use the swinging sternum to cut from the bottom to the top of the sternum surface until the pericardial adhesion At the office. After the sternum is sawn, use a small spreader to gently open it, use an electric knife or scissors to cling to the sternal cutting edge to alternate the two sides of the adhesion, and gradually expand the spreader, such as the pericardium extensive adhesion, and dense, now It is advocated to make a limited separation, only to separate the adhesion of the surgical area, that is, the left side is separated to the root of the pulmonary artery, and the right side is exposed to the right heart. In a small number of patients, the posterior sternal adhesion is loose. In the absence of a oscillating saw, the xiphoid can be lifted, and the sternal adhesion can be separated sharply under direct vision, and the sternum can be opened while separating, or the sternum can be opened with a sternum knife until the incision is fully revealed. . The method of hemostasis in the sternal bone marrow is the same as the first surgery. (2) right chest anterolateral incision: In recent years, through the practice of surgery, this incision is feasible for mitral or tricuspid reoperation, and can avoid the disadvantage of re-cutting the sternum. When this incision is selected, the aortic valve closure function must be normal, because the aorta is not blocked during cardiac surgery, and blood is prevented from flowing back during intracardiac surgery, which affects the operation. The patient was placed in a supine position with a right chest pad height of 45° to 60°. The self-adhesive defibrillation electrode sheet was placed on the skin in front of and behind the surgical field, and then the field was disinfected. Do the right anterior lateral incision, enter the chest through the fifth intercostal space, cut the happy bag in front of the sacral nerve, and make a limited separation. The right atrium was placed in the superior and inferior vena cava, and the femoral artery or aorta was intubated according to the pericardial adhesion. The moderately hypothermia (26 °C) extracorporeal circulation was used to induce ventricular fibrillation. The perfusion pressure was maintained at 75-80 mmHg. Open the left atrium for mitral valve surgery. (3) Incision in the upper part of the sternum: This incision is used for aortic valve reoperation. Before partially opening the upper part of the sternum, the femoral artery and the femoral vein were intubated, the external defibrillation electrode was placed in the chest, and after the chest was disinfected and the surgical towel was placed, the sternum was horizontally opened from the upper part to the third or fourth intercostal space. Make the inverted T-shape, or slant the right side of the sternum to the right side, so that the J shape, the mediastinum only for limited separation, revealing the ascending aorta for blocking and incision; revealing the right atrium for vena cava insertion tube. 2. Separation of mediastinal pericardial adhesions The extent of pericardial adhesions in patients with recurrent valvular disease undergoing valve replacement should vary depending on the number of reoperations, the severity of pericardial adhesions, and the type of surgery. However, the following requirements should be met: 1 The adhesion of the surgical field must be separated to facilitate the field exposure and intracardiac operation; 2 The requirements for cardiac decompression, myocardial protection and cardiac defibrillation can be performed. Some people advocate that the pericardial adhesion should be completely separated to improve the conditions of myocardial protection and overcome the difficulty of surgical operation. However, extensive separation of adhesions not only increases the chance of damage to the myocardium; it also often leads to extensive oozing that is difficult to control after surgery, prolongs the operation time and increases the risk of surgery. Therefore, there is currently a limited separation, that is, only the surgical field is separated to meet the requirements of surgical operations. The principle of separation adhesion is to use a knife or scissors as much as possible for sharp separation and not to damage the epicardium. Generally, the happy bag is cut longitudinally before the interventricular space, and gradually expanded to the right and right sides to reveal the right atrium and part of the right ventricle. If the adhesion is loose, part of the left ventricle and apex are peeled off to the left side. If the adhesion is tight, the right atrium and the right ventricle may retain part of the pericardium. The right atrial surface near the entrance of the superior vena cava, transversely cut the happy bag, revealing the superior vena cava, and placing the vena cava band in the pericardium. At the junction of the aortic root and the pulmonary artery, longitudinally cut the happy bag, separate the adhesion to reveal the ascending aorta until the pericardial pleats; and in the crypt between the aorta and superior vena cava, incision of the visceral pericardial separation of the aorta The transverse sinus, the aortic adventitia placement of the band, is conducive to the placement of blocking forceps. Then, at the entrance of the inferior vena cava, longitudinally cut the happy bag, separate the adhesion of the inferior vena cava and place the band, and expand the surface of the heart to facilitate placement of the electrode plate on the surface of the heart during defibrillation. As above, the inferior vena cava is difficult to separate, and the band can be placed from the pericardium. Pericardial adhesion can be separated by electrosurgical cutting or scissors sharply, close to the parietal pericardium, so as not to damage the myocardium and coronary vessels, the operation should be gentle, to prevent heart pressure caused by heart rhythm disorder or cardiac arrest. In patients with poor myocardial function, the vena cava and aortic intubation must be performed first, and the extracorporeal circulation machine should be connected, and the flow preparation should be completed before separation. When the ventricular palpebral separation is difficult, it can be performed after the flow to avoid myocardial tearing caused by separation during pulsation. 3. Establish extracorporeal circulation In addition to the general requirements for extracorporeal circulation preparation, the following points should be noted: (1) Prepare extracorporeal circulation before opening the chest; expose and separate the common femoral artery and femoral vein, and intubate if necessary to prepare for stock-strand bypass to prevent bleeding when separating pericardial adhesion; The blood, prepare 3 suctions connected to the extracorporeal circulation, once the bleeding, ensure timely return to the income of the circulating blood circuit device. (2) Patients with heart failure or pulmonary edema, using ultrafiltration device; patients with liver and kidney dysfunction, using a pulsatile pump, patients with renal failure can undergo peritoneal dialysis after completion of cardiac surgery. If the heartbeat is weak or the bleeding is forced to prematurely assist the circulation, or when the separation and adhesion time is expected to be long, it is not advisable to lower the temperature in advance to prevent cardiac arrest. (3) After the chest has been officially diverted, the temperature is lowered to 33 ° C in the nasopharyngeal temperature, the aorta is blocked, and the myocardial cardioplegia is injected. After the myocardial arrest, the temperature is further lowered to 26 ° C. Re-warm after the operation in the heart is completed. (4) Disposal of the left heart decompression tube from the left atrium of the right superior pulmonary vein to prevent the heart from expanding. When the intracardiac operation is completed and the assisted circulation is performed, it is necessary to emphasize monitoring the left atrial pressure and arterial pressure to determine the myocardial contraction function, control the amount of blood transfusion, grasp the assisted circulation time, and decide whether or not to stop the flow. (5) Insert the ultrasonic esophageal probe to observe the opening and closing function of the replacement valve, and whether there is gas in the heart. It is especially helpful for judging myocardial contractile function and can guide the assisted circulation time. 4. Myocardial protection In this type of patients, due to poor preoperative cardiac function, especially in patients undergoing emergency surgery, there are different degrees of myocardial insufficiency; in addition, difficult operation, long time to block aorta, left ventricular adhesion, and surface ice debris cooling The myocardial protection of patients requiring valve replacement is more strict, which is also an important part of the success of the operation. The following measures are usually taken: (1) The whole body is cooled by 26 ° C or below. (2) It is recommended to use cold blood cardioplegia, or to apply cold crystal cardioplegia for the first time, and to start cold blood cardioplegia for the second time. Methods of use: anterograde perfusion with mitral and tricuspid valve surgery; aortic and double-valve surgery, the first use of perfusion, and later with retrograde coronary sinus perfusion. The initial amount is 10-15 ml/kg, the maintenance amount is 5-8 ml/kg, and the perfusion is once every 20 min. The temperature of the cardioplegia was maintained at 4 to 15 ° C (cold crystal cardioplegia 4 ° C, blood cardioplegia 15 ° C). The perfusion pressure was <100 mmHg, and the aortic root pressure was 40 mmHg. Reverse irrigation is perfused with a height drop of 60-80 cm H2O, so that the coronary venous pressure is lower than 20 mmHg, and the method of continuous perfusion of cold or warm blood cardioplegic solution may be selected according to the condition. (3) The surface of the heart is cooled with ice particles, and the heart cavity is perfused with 4 ° C ice brine to cool down. (4) Before the aortic occlusion forceps were opened, the aortic roots were re-perfused with hot blood for one time. The blood contained in the roots was 200 ml, 20% mannitol 20 ml, and heated to 33-35 ° C to reduce reperfusion injury. This method is especially suitable for patients with long-term blocking, cardiac hypertrophy and poor cardiac function. (5) According to the state of myocardial function, the auxiliary circulation time is appropriately extended. If it cannot be separated from the extracorporeal circulation, the left heart bypass can be used, or an auxiliary circulator device such as intra-aortic balloon counterpulsation can be applied. 5. Mitral valve replacement The mitral valve replacement is performed with a right atrial-atrial septal incision. In the lateral wall of the right atrium, about 2 cm away from the sulcus of the room, a longitudinal incision is made. If the right atrium is small, the incision can be extended to the inferior vena cava intubation. Expand the surgical field. However, care should be taken not to damage the boundary (including the intercondyal conduction bundle) and the atrioventricular sulcus (including the right coronary artery). After the atrial margin is pulled by the suture, the interatrial septum is revealed, and the space is cut at the center of the fossa ovalis, and then extended upwards and downwards. The ascending incision can reach part of the upper edge muscle bundle, and the incision must stop at the inner coronary sinus 1.5 cm or more. . The margin of the right atrial septum is fixed to the pericardium of the parietal layer by suture, and the left side of the suture is sutured with the right atrial wall. The hook is only required to be gently pulled to reveal the mitral valve. At the end of the operation, the interatrial septum and right atrial incision were closed with continuous sputum and continuous suture. The mitral valve and the artificial valve are exposed to remove possible thrombus and to check for valve failure. If it is a mechanical valve, remove the broken bracket or damaged disc to avoid falling off. Then, the artificial valve is clamped with a vascular clamp, and after the exposure is revealed, the valve suture on the suture ring is cut and removed, and the artificial valve is removed. If the suture ring has been covered by the new endocardial growth, it can be cut along the direction of the suture ring with a round head blade at the seam ring near the host suture ring, and gradually extend to both sides. After the slit ring is cut about 3 cm, the tissue embedded in the slit ring can be peeled off to the ventricular wall to free a slit ring. If the annulus tissue grows firmly to the suture ring and the separation is difficult, the braid of the suture ring can be directly cut until the ventricular surface, and a part remains in the tissue. After the incision of the free suture ring is formed, use the scissors or the blade to close the incision to enlarge the incision. After the artificial valve is gradually removed, the excess fiber scar, granulation, valve suture and gasket are trimmed to remove the residual suture ring as much as possible. When the artificial valve is removed, the suture ring must be found from the annulus and removed at this site. Otherwise, the mitral annulus and its surrounding important tissues may be damaged, and even the pericardium of the atrioventricular ring may be perforated. The ventricular chamber must be flushed with a large amount of saline before the flap is sewed. The treatment of artificial valve endocarditis is related to endocarditis. The method of repositioning the artificial valve with the suture is the same as the first surgery. However, it must include a full layer of thickened annulus, that is, the needle from the atrial surface is inserted from the endocardium of the atrial surface of the atrial surface to avoid leaving a rough surface and affecting the movement of the disc. 6. Aortic valve replacement The ascending aorta uses a transverse or oblique incision to fully expose the aortic valve. However, resection of the aortic valve area is generally more difficult than the mitral valve area. Because the inner wall of the aorta is close to the artificial valve suture ring, the gap is narrow and difficult to be exposed. When the artificial valve is removed, the incision may be slightly inadvertent, and the annulus may be damaged to cause tissue defect, which must be very cautious. Use the vascular clamp to hold the artificial valve for traction. In the position of the right coronary valve, use a round-edged knife to make a curved incision on the suture ring or the bio-valve bracket that is close to the metal annulus, and gradually deepen to separate the valve from the suture ring. . The entire stent was removed by the same method of cutting and separating. And under direct vision, remove the residual fabric, sutures, gaskets and excess fibrous hyperplasia of the seam ring. Before the sulcus, the aspirator is sent into the left ventricle, and a large amount of saline is flushed from the aortic valve to absorb any foreign matter that may remain. Generally, the suture method of re-replacement of the aortic valve is the same as that of the first operation, but when the infection or residual aortic annulus is weak, the artificial valve suture is sutured first, the needle is passed through the aortic wall, and a gasket is placed on the wall. Knot. In patients with artificial aortic valve endocarditis, in addition to removing the infected artificial valve, it is necessary to remove the infected lesion and wash it with a large amount of antibiotic solution; the aortic valve abscess should be removed, the abscess is closed, and the defect is closed or sutured. The autologous pericardial patch was used for repair, and the flap was sutured by an external wall suture method. If the aortic annulus has a peri-abdominal abscess and the aortic valve root is invaded and the artificial valve cannot be fixed, the valved artificial blood vessel transplantation is used, the proximal coronary artery is ligated on both sides, and the left saphenous vein is used to make the left anterior descending artery and the right Bridge surgery between the coronary artery and the aorta. See the endocarditis for the operation. 7. Preservation of bioprosthetic ring secondary valve replacement Goha et al reported that in order to avoid tissue damage caused by resection of the annulus during the second replacement surgery of bioprosthesis, a simplified surgical operation was designed, the suture ring of the biological valve was retained, and the leaflets and stents with the failure of the replacement were horizontally removed from the suture ring. The suture ring of the biological valve is retained, and the double-leaf slit ring is sewn on the remaining bio-valve ring, and a good effect is obtained. 8. Artificial valve selection The replacement artificial valve is selected according to factors such as the cause of the valve change again, the age of the patient, the size and location of the annulus. In general, the valve structure is degraded, and patients who are under the age of 60 should use mechanical valves, and it is better to use the artificial valve with better performance than the original. Bioprostheses should be used in patients over the age of 60 or who are not eligible for anticoagulant therapy. In patients with mechanical valve thrombosis, a lower mechanical valve such as a double-leaf valve can be used. In addition, the use of this artificial valve changes the original flow field of the valve flow, which is beneficial to avoid re-embolization. 9. Heart chamber exhaust In patients with valve replacement again, the heart was fixed due to adhesion, and the gas in the left ventricle was not easily discharged. The incidence of postoperative embolization was significantly higher than that of the first operation. Therefore, the ability to completely ventilate is also one of the key steps in the successful operation of patients with valve replacement. The main measures are as follows: (1) Ventilation method for mitral valve surgery: Before closing the interatrial septum, stop the left atrial attraction, bulge the lungs, discharge the air bubbles hidden in the pulmonary veins, and knot them below the liquid level. Then, from the small opening position of the artificial valve, a thin catheter is sent into the left ventricle, a large amount of cold saline is injected from the tube, and the heart is gently squeezed, so that the air bubbles in the left ventricle are discharged from the artificial valve opening. After the injected saline overflows from the left ventricle and submerges the left atrium, the catheter is removed. Before the right atrial incision is completely closed, the inferior vena cava is blocked, and the blood is drained. After the gas is exhausted, the right atrial incision is closed. (2) Exhaust method of aortic valve surgery: Before closing the aortic incision, stop left atrial drainage, use a catheter to send into the left ventricle from the large opening of the artificial valve, inject saline, and gently squeeze the heart The left room gas was discharged until there was saline overflow from the aortic incision, and it was confirmed that the catheter was removed after no gas was discharged. Before the aortic incision is sutured, the saline is vented from the incision and the incision is closed. Regardless of mitral or aortic valve surgery, the patient should be adjusted to the head low position before the open aortic occlusion forceps, and then the aortic occlusion forceps should be released in sections to perform root venting. The method can be performed by inserting a needle at the aortic root, continuously attracting the negative pressure pump, or venting the hole at the root of the aorta. However, it should be noted that the inner diameter of the venting needle inserted into the aorta should be thick enough and there should be side holes or grooves to be effective. The time of venting should be sufficient, and it must be stopped after the heart valve is powerful, and the valve opening and closing activity is good, so as to exhaust the gas attached to the artificial valve. Esophageal probe ultrasound is useful for monitoring residual cardiac gas. Suspected that the left ventricular gas is not exhausted, a long needle of 16 can be used to puncture the left ventricle from the right ventricle through the interventricular septum. 10. Defibrillation and chest closure There is no complete separation of pericardial adhesions after reoperation, end of endocardial surgery, and heart jumps. There are three ways to place electrode plates: (1) A defibrillation electrode plate is placed on the anterior wall of the left ventricle and the anterior wall of the right ventricle. (2) Open the left mediastinal pleura, and place the defibrillation electrode plates on the left and right ventricles outside the pericardium. (3) Before the operation, the external chest electrode is placed on the back, and the other electrode plate is placed on the right front chest wall during the operation, and the distractor is released to perform external defibrillation; It has recently been reported that the application of a disposable electrode film to the chest is more convenient for defibrillation. In general, the first option is adopted. If the open aortic occlusion forceps restores coronary blood supply and the heart is in a state of non-fibrillation, a temporary pacing lead should be used to timely epicardial pacing to avoid defibrillation after ventricular fibrillation. After the end of the cardiac surgery and the stop of the extracorporeal circulation, the bleeding must be completely stopped, and the pericardial adhesion separation site should be examined in detail to see if there is any residual bleeding. In the case of extensive oozing, fibrinogen should be administered intravenously or transfused with platelet components. After complete hemostasis, place the mediastinum and pericardial drainage tube. If necessary, open the left pleural cavity and place a drainage tube to prevent the pericardial tamponade. Epicardial pacing electrodes are routinely placed in patients undergoing reoperation. complication The postoperative complications of patients with recurrent valvular disease undergoing valvular replacement are basically the same as those of the first operation, but the incidence of cardiac tamponade, low cardiac output syndrome, air embolism, and multiple organ failure is higher. 1. Cardiac tamponade in patients with recurrent valvular heart disease undergoing valve replacement, only the part of the pericardial adhesion is separated or excised, the pericardial cavity is incomplete, and the pericardium can not be closed again. Therefore, the so-called cardiac tamponade is actually A large amount of blood clots in the anterior superior mediastinum caused by hemorrhage, which oppresses the heart and vena cava, restricts diastolic heart and reduces cardiac output. The clinical manifestations are increased heart rate, decreased urine output, increased or no central venous pressure, followed by decreased blood pressure and decreased cardiac output. Combined with increased postoperative drainage, or sudden drainage tube blockage, should cause high suspicion. According to recent reports, the incidence of reoperation bleeding is about 10.4%. In addition, since cardiac tamponade and hypovolemia often coexist at the same time, there are no characteristic symptoms and signs, and diagnosis is sometimes difficult. After the patient has been transfused to replenish the volume, but the blood pressure does not rise significantly, and the heart function deteriorates. At this time, the possibility of cardiac tamponade should be considered. In an emergency situation, it has been reported in foreign countries that the chest is stopped in the monitoring room. Increase the infection rate of surgery. However, according to the aseptic condition of the intensive care unit, it is proposed to disassemble the incision under the xiphoid in the monitoring room for exploration, and temporarily relieve the symptoms of cardiac tamponade. Immediately after the diagnosis, the patient is sent to the operating room, and the chest is completely opened again by the original incision. 2. In the vascular embolization, when the original replacement artificial valve is removed, foreign matter such as residual tissue fragments and sutures may fall off, and embolism may occur after operation; the perfusion of the pericardium in the cardiac chamber is not complete, and the incidence of postoperative embolism is higher than that. First operation. Embolization can occur in various parts, but cerebral embolism is the most common, mainly in the coma and the corresponding parts of the nervous system signs. Need to be differentiated from intraoperative brain hypoxia, cerebral edema, hemorrhage, etc., CT scan of the brain is helpful. If the patient has been awake after the operation, and then coma, and gradually worsened, the chance of using a gas plug is more common. Mild cerebral embolism can be gradually restored by treatment with head cooling, hypertonic dehydration, assisted breathing, and application of protective brain cells. The main artery of the brain should be treated with hyperbaric oxygen chamber within 24 hours. After 5 atmospheres, the oxygen can be compressed and dissolved in the blood to obtain a good therapeutic effect. Patients with foreign body embolization have a worse prognosis than those with airway. 3. Patients with multiple organ failure and recurrent valvular heart disease undergoing valvular replacement have a greater impact on cardiopulmonary function due to the failure of the original implanted artificial valve, especially in patients with acute mechanical dysfunction. Changes, causing poor perfusion of important organs; and due to surgical difficulties, prolonged extracorporeal circulation and aortic occlusion, causing disorders and bleeding of coagulation mechanism, and pericardial adhesion affect myocardial protection and other factors, postoperative low cardiac output The incidence of the syndrome is higher than that of the first surgery patient. This multi-organ function failure caused by a comprehensive factor of cardiogenicity is often caused by heart failure, which causes lung function damage. In severe cases, liver and kidney failure may occur. In addition, the lungs are the most vulnerable organs in the human body. In addition, such patients have pathological changes caused by pulmonary hypertension. Therefore, another common type of multiple organ failure after reoperation is early postoperative. Pulmonary insufficiency, hypoxemia, increased heart damage, decreased cardiac output, decreased glomerular filtration rate and renal cortical ischemia, elevated urea nitrogen and muscle liver, and renal failure. Rheumatic valvular disease, such as severe pulmonary hypertension, causes right heart failure and tricuspid valve dysfunction, systemic venous system congestion, liver function can be impaired, re-operation due to a large number of imported blood, more burdensome liver. The occurrence of heart failure combined with liver failure, further coagulation disorder, causing gastrointestinal bleeding. In addition, due to the body's defense and immune function, due to respiratory and even systemic infections, complicated by multiple organ failure, its prognosis is poor, and the mortality rate can be as high as 80%. The main preventive measures are to strengthen the protection of important organs during the perioperative period, especially the cardiopulmonary function, prevent and timely treat low-heart discharge syndrome; strengthen respiratory support to prevent respiratory failure; if there is heart, liver, lung, kidney and more dirty If the device is depleted, the blood purification device should be actively used. Acute renal failure should be treated as early as peritoneal or hemodialysis; uncontrollable heart failure can be treated with continuous ultrafiltration dehydration; liver failure can be exchanged with plasma, pulmonary failure, mechanically assisted breathing is an extremely effective method; Nutritional support treatment is also very important.

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