老年性心瓣膜病应

老年性心瓣膜病应该如何治疗?

目前,尚无有效的方法能阻滞本病的进展。其治疗主要在于以下几个方面:①对于心功能代偿和无临床症状的病人,可动态观察病情变化,一般不必治疗。②对各种易患因素如高血压、冠心病和糖尿病等进行积极治疗,并积极防治各种合并症如心衰、心律失常、感染性心内膜炎、栓塞等。③对已发生并发症如房室传导阻滞、病窦综合征等应及时安装起搏器,对症状期病人应定期随访,以免发生意外。④对瓣膜严重钙化有明显血流动力学障碍的有症状病人,应劝其手术或进行其他介入性治疗。

  1. 内科药物治疗 – 可应用改善钙磷代谢的药物和(或)钙拮抗药,但能否阻滞钙在瓣膜或瓣环的沉着,尚无足够资料证明其疗效。同时应注意劳逸结合、对症处理。发生心力衰竭时可应用洋地黄或其他正性肌力药物、血管扩张药和利尿药物。有心绞痛发作时可给予硝酸甘油、钙拮抗药和β受体阻滞药。对于缓慢心律失常和房室传导阻滞者,特别是有晕厥者应及时安装人工心脏起搏器。
  2. 瓣膜置换术 – 目前已公认这是一种有效的治疗方法。随着手术的改进,病死率已大大降低(约3%~18%)。目前世界范围内老年人每年接受瓣膜置换术者达73万多人。Agarwa指出20世纪80年代以来,65岁以上老年人换瓣术存活率已达85%~95%。Roiux对335例换瓣术后的随访观察发现,大于75岁者5年存活率为70.8%,心功能由Ⅳ级提高到Ⅱ级者99.6%。对合并有严重冠心病者如同时进行冠脉搭桥术,则预后改善更为明显。
    • 手术指征:目前多主张跨瓣压差≥6.65kPa(50mmHg)。瓣口面积≤0.75cm2为“金标准”。对MAC而无症状的严重二尖瓣反流患者应进行运动耐量的评价。另外,判定左室的收缩功能对于决定是否行换瓣术是至关重要的。对有症状的轻到中度二尖瓣反流病人也应进行血流动力学监测,客观评定运动状态下病人是否合并有肺动脉及肺静脉高压。
    • 影响换瓣术预后的因素:①年龄:高龄者病死率高。Cormie研究发现> 70岁者其术后1年内病死率是<70岁年龄组的2.5倍;②心功能:Acar指出术前心功能明显减退者,其病死率是正常心功能病人的5~20倍;③冠心病:严重冠脉病变者(冠脉狭窄>70%)其术后病死率较非冠心病者增高2.7倍;④有肺、肝、肾疾患或糖尿病、周围血管疾病者,其预后较差;⑤跨瓣压差:一般来说手术存活率与跨瓣压差呈反向关系。阜外医院罗军等报道,围手术期瓣膜替换术主要死亡原因依次为:低心输出量综合征。严重室性心律失常、人工瓣心内膜炎、脑部并发症和肾功能衰竭,而死亡主要相关因素依次为:心肌保护不满意,心脏阻断时间≥120min或体外循环时间≥160min,既往有瓣膜手术史,心胸比率≥0.7,术前心功能Ⅲ、Ⅳ级和主动脉瓣狭窄等。
  3. 球囊瓣膜成形术(PBAV) – 自1986年该方法向临床推广应用以治疗老年钙化性瓣膜病获得成功以来,目前已成为一种重要的非手术介入治疗手段。PBAV操作简单、不需开胸。安全且费用低。病人易于接受,尤其适合于不宜手术治疗的老年病人。法国一项对442例(其中1/3的病人>80岁)行PBAV的老年人观察资料表明,术后瓣口面积由平均0.48cm2增加到0.82cm2,其病死率7.6%,随访4个月,心功能明显改善者为46%。Muilins用两根球囊扩张导管进行瓣膜扩张,发现效果显然优于单球囊。扩张后狭窄的瓣口面积至少可增加50%,血流动力学各项指标也显著改善,左心排出量明显增加,跨瓣压力阶差显著降低,临床症状也显著改善。随访17个月病人情况良好,疗效满意。合并有冠脉疾患者,在做PBAV的同时作PTCA,疗效更为显著。尤其对单支血管病变合并其他疾病的高危患者,将是一项很有前途的治疗措施。其主要并发症有出血、低血压、栓塞及瓣膜反流,但程度均较轻。Acar对56例>78岁老年人行PBAV,成功率达93%。并发心包填塞者为1.8%。急性心肌梗死者3.6%,血管创伤5.3%,总病死率为7.1%。但是PBAV术后瓣口再狭窄是目前一个尚未解决的重要问题。Waller认为球囊扩张主要是使主动脉壁扩张,钙化斑块破裂,术后再狭窄可能是因为过度扩张的主动脉壁弹性回缩所致。一些随访结果显示80%左右患者在手术后5~17个月发生瓣口再狭窄。由于这种过高的晚期再狭窄率,近年来一些学者认为PBAV仅为一种短期缓解症状的姑息疗法。
  4. 其他 – 1988年高频超声消融主动脉瓣上的钙化斑块首先应用于动物实验。Brace后来将这一方法用于治疗5例钙化性主动脉瓣狭窄,术后跨瓣压差明显降低,瓣口面积明显扩大,未见严重主动脉瓣反流或脑动脉栓塞等并发症。此项技术可能是一种有前途的治疗方法之一。目前尚无可靠的方法阻止本病的发生和发展。因此,对本病的易患因素如高血压、高血脂、冠心病以及各种并发症如心律失常、心功能不全、感染性心内膜炎进行积极的预防和治疗。本病在多数情况下并未引起严重的血流动力学障碍,临床表现轻甚至无症状,一旦临床症状出现,则病情迅速恶化,多死于严重的并发症如心律失常、心力衰竭。

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