Retrospective Study For 20 Years Of Mitral-Aortic Valve Replacement

【Objective】The subject consists of three parts . The objective of the first part is to study the changes of perioperative factors in mitral-aortic valve replacement patients,including operation and cardiopulmonary bypass.The objective of the second part is to analyze the risk factors for postoperative in-hospital death in mitral-aortic valve replacement patients. The objective of the third part is to learn about the working and living conditions,drug administration,anticoagulation,complications and risks related of long-term survival of the patients underwent mitral-aortic valve replacement through seven to twelve years of follow up.【Methods】(一) 20 years of changes for mitral-aortic valve replacement 1885 case of patients who experienced mitral-aortic valve replacement during the period between 1990 and 2009 were divided to four groups.preoperative etiology,risk factors, operation method, postoperative results were compared with each other and the changes were observed.The indicators entered into analysis were gender, age, etiology, previous heart surgery, preoperative New York Heart Association cardiac function grade,preoperative important ultrasound index, preoperative pulmonary hypertension, extracorporeal circulation time, cross-clamp time,preservation of subvalvular apparatus, accompanying tricuspid surgery, accompanying coronary artery bypass surgery, accompanying other cardiac surgery, ICU stay time, breathing machine assistance time, postoperative complications and death.(二) Analysis of risk factors for in-hospital death in mitral-aortic valve replacement patients1. 1885 cases of mitral-aortic valve replacement patients during 1990 and 2009 in changhai hospital were enrolled in the study(include accompanying tricuspid surgery and coronary artery bypass surgery ). Referring to foreign analysis method in valvular surgery risk study,logistic analysis was used in this subject. different kinds of factors that might influence postoperative in-hospital death were considered as independent variables, discharge status (live or death) was considered as dependent variable. the final surgical risk factors were analyzed.2. Referring to literature and contacting with clinical practice,the following factors that might affect in-hospital death were enrolled in the study: gender, age, disease duration, NYHA classification of cardiac function, preoperative diabetes, a history of thrombosis, infective endocarditis, previous history of cardiac surgery, preoperative cerebral vascular accident history, atrial fibrillation, pulmonary hypertension, left ventricular ejection fraction, left ventricular end diastolic diameter, left atrial volume, right atrial volume, a merger of the tricuspid regurgitation, the indicator of FEV1/FVC <60%, preoperative serum creatinine Cr> 110umol / L, priority of surgery (emergency surgery,urgent surgery, elective surgery), cardiopulmonary bypass time (minutes), the times of cardiopulmonary bypass, special circumstances (cardiopulmonary bypass machine could not be stopped or multiple times aortic clamping, left ventricular rupture, protamine allergies, heart fibrillation, cardiac arrest or other special circumstances) occurred during surgery, preservation of subvalvular apparatus, concomitant congenital malformation surgery, concomitant surgical treatment of atrial fibrillation, concomitant coronary artery bypass surgery, Concomitant left atrial thrombus clearance, concomitant left atrial plication, the use of perioperative intra-aortic balloon pump. Among which, age,disease duration (months), left ventricular ejection fraction, left ventricular end diastolic diameter, left atrial volume, right atrial volume were Continuous variables.3. Each of the continuous variables was divided into death group and non-death group for normality test. As long as any one group does not meet the normality distribution,non-parametric test would be carried out to determine whether the factor could enter the full logistic model.when the factor in the death group and the non-death group are all normally distributed, t-test would be carried out to determine whether the factor could enter the full model of logistic , P <0.05 was significant. X~2 test would be carried out for categorical data to determine whether the factor enter into the full model of logistic , P <0.05 was significant.4. A single factor with significant statistical meaning would enter into the logistic regression analysis. the final result would be risk factors for hospital death. Clinical analysis of the risk factors would be carried out.(三)Analysis of mid-term and long-term follow-up results for 553 cases of mitral-aortic valve replacement patients1. 553 cases of surgical patients underwent mital-aortic valve replacement during Jan 1999 and Dec 2003 were enrolled in the study.2. Utilizing the regular follow-up data of Changhai Hospital for patients underwent mital-aortic valve replacement during Jan 1999 and Dec 2003,we collected the address, home phone, work phone of the patients.Ways of letter, telephone, e-mail , online communication, patient return visit were all used to contact with the patients.The study focus on learning about the mid-term and the long-term postoperative cardiac function, living status, drug administration, warfarin administration,prothrombin time monitoring. Long-term complications were observed,including valvular structural damage, thrombosis, bleeding complications, thromboembolic complications, infective endocarditis , paravalvular leakage, etc. following studies were carried:①Comparison of preoperative and postoperative cardiac function of the patients.②Analysis of long-term morbidity, mortality of the patients and the reasons that led to such complications.③Analysis of long-term survival.【Results】(一)20 years of changes for mitral-aortic valve replacement1. 1990-2009 operation quantity changes in different periods The operation quantities for 1990-1994, 1995-1999,2000-2004,2005-2009 period were 295 cases, 410 cases, 591 cases, 589 cases, respectively. Since 2000 the number of patients increased significantly compared with the year before 2000.There is a flat between 2000-2004 and 2005-2009 periods.2. Perioperative changesThe proportion of male patients were 50.8%, 53.2%, 43.5%, 40.9%,respectively, in four different periods.Male patients were more than female before 2000 and less than female after 2000.The difference is significant. Patients mean age gradually increased.Rheumatic valve disease remains a major cause. Infective endocarditis and degenerative heart valve disease have an increasing trend.The patients with cardiac function gradeⅢare the main body in different periods. Cardiac function of the patients has a trend of improvement overall.The patients with preoperative hypertension, diabetes, chronic obstructive pulmonary disease and the actual ratio of the patients increased year by year. The patients with preoperative atrial fibrillation significantly increased,however, the proportion had a decline trend. Patients with abnormal preoperative serum creatinine has been growing. Patients with preoperative pulmonary hypertension increased.A downward trend has been reflected in preoperative left ventricular end systolic diameter, left ventricular end diastolic diameter . In 2005 -2009 preoperative mean left atrial volume was significantly reduced compared with 1990-1994 period.LVEDD> 70mm patients and their ratio have significantly reduced,which reflected earlier surgical intervention. Cardiopulmonary bypass time and aortic clamping time were significantly shortened.Operations preservation of subvalvular apparatus significantly increased. The proportion of tricuspid valve annuloplasty gradually increased. Double valve replacement patients with accompanying coronary artery bypass graft gradually increased. Postoperative mechanical ventilation time and ICU stay time were significantly shortened. The incidence of postoperative complications and mortality decreased significantly.(二) Analysis of risk factors for in-hospital death in mitral-aortic valve replacement patientsAfter a normality test, continuous variables age,disease duration, left ventricular ejection fraction, left ventricular end diastolic diameter, left atrial volume, right atrial volume were determined to be tested by non-parametric test. after Kolmogrov-Smirnov non-parametric test, age and disease duration can enter the full logistic model; Categorical variables including preoperative cardiac functional grade, history of preoperative embolization, preoperative serum creatinine Cr> 110umol / l, priority of surgery (emergency Surgery, urgent surgery, elective surgery), cardiopulmonary bypass time, bypass times, special circumstances during surgery, and perioperative aortic balloon pump (IABP), concomitant coronary artery bypass surgery enter the full model of logistic through X2 test. Multiple logistic regression analysis showed that eight factors, according to their weights in the regression equation,were related with in-hospital death for patients underwent mitral-aortic valve replacement,which were perioperative aortic balloon pump, intraoperative special circumstances, preoperative serum creatinine Cr> 110umol / l, priority of surgery, preoperative cardiac functionⅢ-Ⅳgrade, preoperative history of embolism, cardiopulmonary bypass time, bypass times.,age. The regression coefficients of these factors were 2.653,2.215,1.258, 1.202,1.146,0.896,0.669,0.023.(三) Analysis of mid-term and long-term follow-up results for 553 cases of mitral-aortic valve replacement patientsActual quantity of the patients who had been followed up was 482,during which,33 patients died, 449 survived.The survival rate was 93.15%.95.1% of patients can live a normal life and participate in general work (except for heavy manual work) or do general housework; 4.3% were living only takeing care of themselves, could not do housework. 0.6% of patients were often in bed. Preoperative cardiac function, cardiac function postoperative 1 year and postoperative 5 year were compared with each other. Postoperative cardiac function improved significantly. There were no obvious difference between cardiac function postoperative 1 year and postoperative 5 year. Cardiac function was also analyzed during the patients lived up to 10 years postoperatively.Postoperative cardiac function improved significantly compared with preoperative cardiac function.There is a decline for cardiac function postoperative 10 year. Long-term complications: among all the patients only 1 case of valve structure deterioration occurred, 2 patients developed valve thrombosis, 11 patients had transient ischemic attack, 26 cases of patients had embolization.Bleeding complications was seen in 63 patients. 6 patients developed prosthetic valve endocarditis. 3 patients had paravalvular leakage,.18 patients developed valve-related death.overall death number was 33 cases. Survival analysis showed that left ventricular end diastolic diameter, preoperative pulmonary hypertension, postoperative valve-related complications were risk factors for long-term survival of mitral- aortic valve replacement surgery patients.【Conclusions】During the past 20 years, valve surgical techniques, anesthesia and cardiopulmonary bypass techniques became more sophisticated .Big changes have taken place in different aspects. The incidence of postoperative complications and mortality significantly decreased. Surgery treatment has a trend of earlier intervention. Preoperative cardiac function has generally improved.However,the patients with cardiac functionⅣgrade ,and patients with hypertension, diabetes, chronic obstructive pulmonary disease, preoperative abnormal blood creatinine ,preoperative pulmonary hypertension and tricuspid valve plasty increased . The actual number of patients with accompanying coronary artery bypass surgery continues to increase.Patient age, preoperative cardiac function gradeⅢ-Ⅳ, history of preoperative embolization, preoperative serum creatinine Cr> 110umol / l, priority of surgery (emergency operation, urgent surgery, elective surgery), cardiopulmonary bypass time, special circumstances (cardiopulmonary bypass machine could not be stopped or multiple times aortic clamping, left ventricular rupture, protamine allergies, heart fibrillation, cardiac arrest or other special circumstances) , the use of perioperative intra-aortic balloon pump were risk factors of in-hospital death for mitral-aortic valve replacement patients. Patients underwent mitral-aortic valve replacement lived in good condition. Cardiac function improved significantly after operation.Most patients had normal life. Patients could adhere to anticoagulant medicine administration(mechanical valve replacement patients). Most patients could regularly monitor prothrombin time under the guidance of the doctor or adjust the dose of warfarin themselves. Few patients (17.8%) developed postoperative valve-related complications. Mean follow up time was 9.1±2.0 years.The number of deaths / total number of follow-up patients was 6.8%, valve-related deaths / total number of follow-up patients was 3.7 %.A part of patients live in remote rural areas, who have relatively low educational level and poor economic conditions,and transportation and communication are not convenient.The patients can not regularly monitor the prothrombin time and have a relatively high valve-related complications and mortality.The patients should be paid close attention.