心脏瓣膜疾病的新指南中有更好的瓣膜，更好的程序

一个新的, less invasive approach for replacing malfunctioning heart valves is now recommended for certain patients, and younger patients can now receive natural tissue valves instead of mechanical ones, 根据新的治疗指南.

The recommendations released Wednesday by the 美国心脏协会 and American College of Cardiology affect some of the estimated 5 million Americans with heart valve disease. 这种疾病可以在出生时出现，也可以由感染引起, 心脏病发作或其他形式的心脏病.

Major advances have taken place in the diagnosis and treatment of aortic and mitral valve disease since the last guidelines in 2014, 罗伯特·伯诺说, M.D., professor of cardiology at Northwestern University Feinberg School of Medicine in Chicago and an author of the new guidelines.

四个瓣膜控制血液流入和流经心脏. Diseased valves can lead to a backflow of blood or complete blockage of blood flow.

从历史上看，心脏直视手术是更换故障瓣膜的唯一选择. But the new guidelines endorse broadening the use of a procedure approved by the Food and Drug Administration in 2011.

叫做经导管主动脉瓣置换术, 或TAVR, the procedure is recommended for people with severe narrowing of the aortic heart valve that is causing symptoms, 比如呼吸急促和疲劳, 对他们来说开胸手术风险太大. But it can also be an option for some patients at lower surgical risk, said Catherine Otto, M.D., co-chair of the guidelines writing committee and a professor of medicine at the University of Washington in Seattle.

The 2014 guidelines primarily recommended TAVR to extend the lives of patients considered too sick for surgery or who faced a high risk of surgical complications. 新的指南现在为手术风险较低的患者提供了这种选择.

The procedure involves replacing the valve via a catheter threaded through a blood vessel.

Also new to the guidelines is the option for people as young as 50 who require surgery to replace a diseased aortic or mitral valve to receive a valve made of natural animal tissue as opposed to a mechanical valve made of artificial materials. 以前的指导方针说，患者必须至少60岁才能接受组织瓣膜.

Mechanical heart valves typically don’t need to be replaced and were previously recommended for younger patients who needed a valve that could last decades. 但是机械瓣膜需要终生服用血液稀释剂华法林, 以香豆素这个品牌闻名.

虽然华法林不贵, 它需要频繁的血液检查, 饮食限制和可能的体育活动限制, 奥托说.

The guidelines say patients and doctors should work together to decide which type of procedure and valve is best for the patient.

Avoiding warfarin is one reason many people in need of a new heart valve prefer natural tissue valves, Bonow说. 但是做组织瓣膜, 也叫生物瓣膜, 年龄越小意味着患者最终需要一个新的, 奥托说.

“If you’re 50 and get a biologic valve, you’ll need [a new] one before 70,” she said.

最后，这取决于病人的个人喜好. 例如, some patients may want to avoid multiple surgeries and are therefore willing to take warfarin, 奥托说.

“Others would rather have multiple procedures to avoid taking anticoagulant drugs,” she said.

One challenge doctors face in helping patients make that decision is that it’s not yet clear precisely how long valves placed during a TAVR procedure last.

“大多数研究对较新的TAVR瓣膜进行了两到三年的跟踪研究, 在瓣膜坏掉之前,奥托说. “大多数情况下，我们预计在这段线上电子游戏飞禽走兽内不会看到情况恶化.” With surgery, however, valves last for more than 10 years in nearly all patients, she said.

Bonow看到的手术组织瓣膜可以使用20年之久, 尽管他说，老年患者的瓣膜比年轻人的持续线上电子游戏飞禽走兽更长.

无论阀门类型如何, the guidelines recommend antibiotics before dental procedures for people who have had their heart valves replaced – as well as those who’ve had a valve repaired, 这是指南的新增内容. That’s because bacteria can enter the bloodstream during dental treatments 和se patients face a higher risk of endocarditis, 心脏内膜和心瓣膜的细菌感染.

但是病人不应该避开牙医的办公室, 奥托说, 因为定期清洗可以降低心脏瓣膜感染的风险.

Another potential complication in people with heart valve disease is atrial fibrillation, 一种增加血栓和中风风险的不规则心跳. 以前的指南推荐使用华法林治疗心房颤动, 但也可以使用新的血液稀释剂, 新的指导方针说.

一些病人急于从华法林换成一种新的血液稀释剂, 奥托说, but insurance providers do not always cover the switch because the newer drugs are more expensive. 她希望新的建议能说服保险公司为这些新药买单.

该指导方针发表于 循环 和 美国心脏病学会杂志.