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生物瓣衰竭48枚外科病理学分析

Surgical pathology analysis of the causes of failure of 48 bioprosthetic heart valves in 40 Chinese cases

摘要:

目的 探讨生物瓣置换术后瓣膜衰竭的病理学变化及其相关因素.方法 回顾性分析2006年1月至2014年12月瓣膜置换术后因瓣膜功能衰竭在中国医学科学院阜外医院接受二次手术摘除的患者资料,利用大体观察、X线摄影及组织病理学染色等方法,观察生物瓣的钙化、撕裂、纤维组织过度生长及感染性心内膜炎等改变,再结合患者的首次瓣膜置换年龄、瓣膜材料类型和植入部位等临床资料,利用U检验、x2检验和Fisher确切概率法等进一步分析其与病变的关系.结果 收集到的生物瓣共48枚(40例,其中女性26例),牛心包瓣和猪主动脉瓣各24枚.植入部位包括二尖瓣位29枚、主动脉瓣位14枚和三尖瓣位5枚.首次瓣膜置换年龄为12~71岁(中位数58岁),瓣膜寿命5d至27年(平均111.1个月).生物瓣衰竭的原因有结构性瓣膜毁损32枚(66.7%),感染性心内膜炎9枚(18.7%),非结构性瓣膜毁损7枚(14.6%);未见血栓形成.生物瓣钙化程度与瓣膜寿命呈正相关(R =0.52,P=0.000).牛心包瓣平均瓣膜寿命大于猪主动脉瓣[(146±74)个月比(77±68)个月,Z=-3.24,P=0.001],猪主动脉瓣的钙化比例低于牛心包瓣(41.7%比75.0%,x2=5.37,P=0.019),但瓣叶撕裂的比例较高(66.7%比16.7%,x2=12.34,P=0.000).60岁前瓣膜置换的瓣膜钙化检出率高于60岁后瓣膜置换的瓣膜(45.1%比2/17,x2=5.51,P=0.019),但是瓣叶撕裂比例更低(12.9%比58.8%,P=0.002).寿命≤5年的瓣膜感染性心内膜炎检出率高于寿命>5年的瓣膜(6/14比8.8%,P=0.019).结论 结构性瓣膜毁损是本组生物瓣衰竭的主要原因,早中期衰竭的瓣膜中感染性心内膜炎的比例较高.60岁前、后首次瓣膜置换的瓣膜衰竭模式不同,较年轻的患者易出现生物瓣钙化.

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abstracts:

Objective To investigate the pathological changes and related factors leading to failure of bioprosthetic valves.Methods The surgical explanted bioprosthetic valves in Fuwai Hospital,Chinese Academy of Medical Sciences and Peking Union Medical College from January 2006 to December 2014 were retrospectively reviewed.Calcification,cusp tears,pannus and infectious endocarditis of bioprosthetic valves were evaluated by gross examination,X ray photography and histopathological analysis.Meanwhile,the age and the site at implantation,and the tissue type of bioprosthetic valves,the implantation duration were obtained by chart review and used to be analyzed with the modes of valve failure.U test,x2 test and Fisher exact test were used to analyze the data.Results Total 48 bioprostbetic valves were collected from 40 cases with 26 females.Their age at the time of implantation was 12 to 71 years (median 58 years).The tissue types of bioprosthesis included 24 bovine pericardial valves and 24 porcine aortic valves respectively.The implantation sites included mitral in 29 valves,aortic in 14 valves and tricuspid in 5 valves.The implantation duration ranged from 5 days to 27 years (mean (111 ± 77) months).The study showed that the commonest mode of valve failure was structural valve deterioration (32 valves,66.7%).The fewer modes of valve failure were infectious endocarditis (9 valves,18.7%) and non-structural valve deterioration (7 valves,14.6%).No thrombosis was found in this series.The degree of calcification was correlated positively with implantation duration (r =0.52,P =0.000).The implantation duration of bovine pericardial valves was longer than that of porcine aortic valves ((146 ± 74) months vs.(77 ± 68) months,Z =-3.24,P =0.001).Porcine aortic valves had a higher incidence of cusp tears than bovine pericardial valves (66.7% vs.16.7%,x2 =12.34,P =0.000) despite they had a relatively lower incidence of calcification (41.7% vs.75.0%,x2 =5.37,P =0.019).For the age at the time of implantation,the patients ≤ 60 years old had more calcification of bioprosthetic valves compared with those > 60 years old (45.1% vs.2/17,x2 =5.51,P =0.019) whereas the patients ≤60 years old had fewer cusp tears (12.9% vs.58.8%,P =0.002).Infectious endocarditis was found more frequently in the valves failure within 5 years than those failure after 5 years (6/14 vs.8.8%,P =0.006).Conclusions Structural valve deterioration is the principle cause of bioprosthetic valve failure while infectious endocarditis mainly involves the valves failure in early and middle terms after surgery.The mode of valve failure in the patients ≤60 years old is different from that in the patients > 60 years old at the time of implantation.More calcification would occur in bioprosthetic valve in the younger patients.

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