老年人心瓣膜病合并房顫及心衰的處理原則

1、老年人心瓣膜病合并房顫及心衰的處理原則,廣州市第一人民醫(yī)院 劉豐,隨著人口的老齡化,老年退行性鈣化性瓣膜病逐漸占有重要的地位,是目前老年人的特殊疾病。已經成為老年人心力衰竭、心律失常、暈厥、猝死的原因之一。 對冠心病具有重要預測價值,國外報道的發(fā)病率明顯高于國內。Pomerance 等 尸檢162 例死于心衰的患者, 分析其原因后發(fā)現(xiàn)鈣化性瓣膜病變占45 % ,僅次于冠心病。 Wong 等 在78

2、例65～102 歲的患者中 發(fā)現(xiàn)瓣膜退行性改變占74 %。 90～100 歲年齡組幾近100 %Springer. Verlag ,1982 :63～67.. J AM Geriatir soc ,1983 ,3l :156.,國內外報道十分不一致,主要原因有種族差異、也存在方法學的問題,,,The incidence and etiological classification of valvular disea

3、ses were examined on 358 cases from 3,000 consecutive autopsies of more than 60 years of age. The incidence of valvular disease was 11.9% (358 out of 3,000 cases) Jpn Circ J. 1982 Apr;46(4):337-45,Mitral stenosis was f

4、ound in 23 cases (6.4%), of which 21 cases were rheumatic and the remaining 2 were mitral ring calcification (MRC). Mitral regurgitation was observed in 126 cases (35.3%): 69 of papillary muscle dysfunction, 26 of mitral

5、 valve prolapse (MVP), 16 of MRC, 9 of ruptured chordae tendineae, 3 of rheumatic and 3 of congenital.Jpn Circ J. 1982 Apr;46(4):337-45,Aortic stenosis was noted in 33 cases (9.2%): 27 of calcified, 5 of rheumatic and

6、one of congenital. Aortic regurgitation was found in 169 cases (47.2%): 112 of degenerative, 47 of syphilitic, 7 of rheumatic and 2 of aortitis syndrome. There were 6 cases (1.7%) of tricuspid regurgitation.Jpn Circ J.

7、1982 Apr;46(4):337-45,Etiological classification revealed 6 cases (1.7%) of congenital, 36 (10%) of rheumatic, 49 (13.7%) of syphilitic, 27 (7.5%) of MVP, 69 (19.3%) of ischemic and 166 (46.4%) of degenerative valvular d

8、isease.Jpn Circ J. 1982 Apr;46(4):337-45,A total of 458 cases (11.5%) with valvular heart diseases in the aged (greater than or equal to 60 years) were found among 4,000 consecutive autopsies. They included 204 cases (

9、45%) of aortic regurgitation (AR), 171 cases (37%) of mitral regurgitation (MR), followed by 45 (10%) of aortic stenosis (AS) and 27 cases (6%) of mitral stenosis (MS). J Cardiol Suppl. 1988;19:29-38.,,an etiology of

10、the valvular diseases, degenerative type was found in 195 cases (43%), ischemic origin in 91 cases (20%), followed by inflammatory origin such as syphilitic in 51 and infective endocarditis in three, aortitis in two and

11、rheumatic in 49 (11%). Congenital origin was also found in 18 cases (4%).J Cardiol Suppl. 1988;19:29-38.,仍關注對老年人風心病,,。山西醫(yī)科大學第一臨床醫(yī)學院心內科從1979 - 01～2019 - 12 共收治風心病1 227 例,其中老年風心病215 例,對其逐年發(fā)病情況及95 例資料齊全者臨床特點作一回顧分析,,老年風心病21

12、5 例,所占比例為17.5 %。逐年住院比例由1979 年的9 %逐漸增長為2019 年的42.5 %。又從215 例老年風心病患者中取資料齊全者95 例,其中男49 例,女46 例,年齡60～80 歲,平均年齡64 歲,平均病程16.8 年。,,老年退行性心臟瓣膜病又稱老年鈣化性心臟瓣膜病(SCHVD) , 是一種與年齡相關的瓣膜退行性變。隨著增齡, 心血管系統(tǒng)逐漸老化, 處于血流不斷沖擊的瓣膜及其支架易發(fā)生退行性變、纖維化和鈣化,

13、造成主動脈瓣和(或) 二尖瓣關閉不全及狹窄, 若病變的心肌擴張和鈣化、纖維化涉及傳導系統(tǒng)可 以并發(fā)各種心律失常,A Novel Role of the Sympatho-Adrenergic System in Regulating Valve Calcification,Recent evidence has indicated that the sympathetic nervous system plays

14、 an important role inregulating bone deposition and resorption the beta 2-adrenergic receptors(β2-AR).In order to test the effect β2-AR on changing the human valve lCs towards osteogenic phenotype cells were treated with

15、 the selectlveβ2-AR agonist ,salmeterol ,in the presence and absence of osteogenic media for 21 days .,Supplement circulation vol 114,no 18 october 31 ,2019,,Salmeteroltereatment in the presence of osteogenic media si

16、gnificantly reduced the ALP activity from 10.2±2.9nmol/min/mg proteiy in the osteogenic treated cellc ,to 4.7±1.9nmol/min/mg protein(p< 0.04,n=3).There was no increase in the ALP activity when human valae lc

17、s were treated with salmeterol alone .,Supplement circulation vol 114,no 18 october 31 ,2019,老年瓣膜病合并房顫,老年退行性心臟瓣膜病又稱老年鈣化性心臟瓣膜病(SCHVD) , 是一種與年齡相關的瓣膜退行性變。隨著增齡, 心血管系統(tǒng)逐漸老化, 處于血流不斷沖擊的瓣膜及其支架易發(fā)生退行性變、纖維化和鈣化, 造成主動脈瓣和(或) 二尖瓣關閉不全及

18、狹窄, 若病變的心肌擴張和鈣化、纖維化涉及傳導系統(tǒng)可 以并發(fā)各種心律失常,老年瓣膜病合并房顫,國內姜氏:107 例鈣化性心臟瓣膜病中檢 出各類心律失常者82 例, 發(fā)生率為 76.16%。室上性心律失常居首位, 占 52.14%; 其次為傳導阻滯, 占24.13%; 室 性心律失常占13.14%。,,,,The risk of thromboembolism is well known;

19、 other outcomes of atrial fibrillation are less well recognised, such as its relationship with dementia, depression and death. Such consequences are responsible for diminished quality of life and considerable economic co

20、st. Drugs Aging. 2019;19(11):819-46,,瓣膜病合并房顫的治療原則,首先老年瓣膜病合并冠心病、高血壓者居多, 其次為糖尿病, 表明動脈粥樣硬化的易患因素如高血壓、高膽固醇、高血糖也是導致瓣膜鈣化的重要因素。因此老年人應盡早防治各種引起動脈硬化的因素, 這樣可能延緩退行性心瓣膜病的發(fā)生, 從而減少各類心律失常的發(fā)生, 降低死亡率,其次此癥除與心房肌缺血有關外, 一個主要 因素是心房肌的退行性變,

21、這與瓣膜的退行性病變是一致 的。一些心房纖顫, 部分快速性心房纖顫經治療轉復竇律后伴有T 波倒置外, 其余在心室率正常情況下心電圖并無缺性改變, 亦無臨床癥狀, 并反復房顫發(fā)作, 不易轉復, 這種心房纖顫可用心肌及瓣膜的退行性變來解釋, 因而不宜強行糾正,室性心律失常雖可暫時糾正, 但極易復發(fā), 這亦與心肌的退行性變有關。,,Two alternatives are possible: restoration and m

22、aintenance of sinus rhythm, or control of ventricular rate, leaving the atria in arrhythmia. Pharmacological options include antiarrhythmic drugs, such as class III agents, beta-blockers and class IC agents. These drugs

23、have some adverse effects, and careful monitoring is necessary. Drugs Aging. 2019;19(11):819-46,,In elderly patients (arbitrarily defined as aged >75 years), the management of atrial fibrillation varies; it requires

24、an individual approach, which largely depends on comorbid conditions, underlying cardiac disease, and patient and physician preferences. Drugs Aging. 2019;19(11):819-46,,Another serious challenge in the management of c

25、hronic atrial fibrillation in older individuals is the prevention of stroke, its primary outcome, by choosing an appropriate antithrombotic treatment (aspirin or warfarin). Several risk-stratification schemes have been v

26、alidated and may be helpful to determine the best antithrombotic choice in individual patients Drugs Aging. 2019;19(11):819-46,關于抗血栓治療,(瓣膜病)antithrombotic therapy in native and prosthetic valvular heart disease is part

27、of the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Gr

28、ade 2 suggests that individual patients' values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2019; 126:179S-187S).,Among the key recommendations in this chapter are t

29、he following: For patients with rheumatic mitral valve disease and atrial fibrillation (AF), or a history of previous systemic embolism, we recommend long-term oral anticoagulant (OAC) therapy (target international norma

30、lized ratio [INR], 2.5; range, 2.0 to 3.0) [Grade 1C+]. For patients with rheumatic mitral valve disease with AF or a history of systemic embolism who suffer systemic embolism while receiving OACs at a therapeutic INR, w

31、e recommend adding aspirin, 75 to 100 mg/d (Grade 1C). For those patients unable to take aspirin, we recommend adding dipyridamole, 400 mg/d, or clopidogrel (Grade 1C).,CHEST 2019; 126:179S-187S).,In people with mitral v

32、alve prolapse (MVP) without history of systemic embolism, unexplained transient ischemic attacks (TIAs), or AF, we recommended against any antithrombotic therapy (Grade 1C). In patients with MVP and documented but unexpl

33、ained TIAs, we recommend long-term aspirin therapy, 50 to 162 mg/d (Grade 1A).,CHEST 2019; 126:179S-187S,,(房顫)This chapter about antithrombotic therapy in atrial fibrillation (AF) is part of the Seventh ACCP Conference o

34、n Antithrombotic and Thrombolytic Therapy: Evidence Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual p

35、atients' values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2019; 126:179S-187S).,Among the key recommendations in this chapter are the following (all vitamin K anta

36、gonist [VKA] recommendations have a target international normalized ratio [INR] of 2.5; range, 2.0 to 3.0): In patients with persistent or paroxysmal AF (PAF) [intermittent AF] at high risk of stroke (ie, having any of t

37、he following features: prior ischemic stroke, transient ischemic attack, or systemic embolism, age > 75 years, moderately or severely impaired left ventricular systolic function and/or congestive heart failure, histor

38、y of hypertension, or diabetes mellitus), we recommend anticoagulation with an oral VKA, such as warfarin (Grade 1A).,In patients with persistent AF or PAF, age 65 to 75 years, in the absence of other risk factors, we re

39、commend antithrombotic therapy with either an oral VKA or aspirin, 325 mg/d, in this group of patients who are at intermediate risk of stroke (Grade 1A). In patients with persistent AF or PAF < 65 years old and with n

40、o other risk factors, we recommend aspirin, 325 mg/d (Grade 1B). For patients with AF and mitral stenosis, we recommend anticoagulation with an oral VKA (Grade 1C+).,CHEST 2019; 126:179S-187S).,Requiring Lower Warfain D

41、osages to Achieve Therapeutic Anticoagulation is a Strong Risk Factor for Bleeding Event Accumulating evidence suggests some genotypes of enzymes are associated with low maintenance dose requirement and increased risk

42、of major bleeding .,Supplement circulation vol 114,no 18 october 31 ,2019,METHODS In a prospective cohort from 550 consecutive patients with mechanical valve replacement were studied . Patients were divided into thr

43、ee groups (lower dosages group , warfarin maintenance dose 0.2mg/day/BM).results over 4000 patient-years of follow-up, PT-INR values fell within target range range for 90.2% of the time on treatment .,Supplement circulat

44、ion vol 114,no 18 october 31 ,2019,There was no difference between three groups about patient characteristics including anticoagulant intensity . low dosage group have significantly increased risk of bleeding (figure

45、),Supplement circulation vol 114,no 18 october 31 ,2019,,,5,10,15,0,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,0.00,0.25,0.50,0.75,1.00,,,,,,,,,,,,,,,Not singnificant,p=0.0001,p=0.0019,,,high dose group,,Intermediate dose group,

46、,Low dose group,Analysis time (years),Bleeding event free survival by warfarin dose,關于老年瓣膜病合并房顫抗血栓治療,1.注意合并癥的情況 2.注意各種危險因素 3.年齡界限對治療的影響 4.多種藥物的相互作用 5.出血在老年中的不同表現(xiàn)和不同后果,老年瓣膜病合并心功能不全,SDHVD 者年齡均偏大,由于瓣膜狹窄或反流造成

47、血流動力學的改變,最后可導致心臟擴大 ,可單一左心房擴大或左房、左 室擴大。加之心律失常、左室?guī)缀涡螒B(tài)學的變形而影響心室收縮導致心功能不全的發(fā)生,一旦出現(xiàn)癥狀,病情會加快發(fā)展、加重。,廣東葉氏,2000 年1 月至2019 年1 月收治的40 例老年退行性心臟瓣膜病合并心力衰竭與同期收治的40 例年齡、性別相匹配的、無瓣膜鈣化合并心力衰竭的冠心病患者進行臨床對比研究,旨在揭示其潛在危險,提請臨床重視。,臨床和實驗醫(yī)學雜志　2019

48、 年1 月　第5 卷　第1 期,,,,瓣膜性心臟病患者,主要問題是瓣膜本身有機械性損害,而任何內科治療或藥物均不能使其消除或緩解,更不能用來替代已有肯定療效的介入或手術治療。實驗研究表明, 單純的心肌細胞牽拉刺激就可促發(fā)心肌重塑,因而治療瓣膜性心臟病的關鍵就是修復瓣膜損害。,目前國內外較一致的意見是:所有有癥狀的瓣膜性心臟病心力衰竭(NYHA Ⅱ級及以上) ,以及重度主動脈瓣病變伴有暈厥、心絞痛者,均必須進行介入治療或手術置換瓣膜或

49、修復瓣膜,因為有充分證據(jù)表明介入或手術治療是有效和有益的,可提高長期存活率。,,有癥狀的二尖瓣狹窄(MS) 和主動脈瓣狹窄(AS) 應當考慮手術,手術同樣適用于有癥狀的二尖瓣關閉不全(MR) 和主動脈瓣關閉不全(AR) 。有些反流性病變的患者在出現(xiàn)癥狀前也可考慮手術,例如左室射血分數(shù)降低或心臟明顯擴大。外科治療包括瓣膜的修補術和置換術,單純MS 可采用經皮球囊二尖瓣成形術。,,值得注意的是,如果在瓣膜病的治療中用藥不當,反而可能加重病情

50、。例如血管擴張劑以及ACEI 等具有血管擴張作用的藥物,應慎用于瓣膜狹窄的患者,以免后負荷過度降 低致心輸出量減少,引起低血壓、暈厥等。MS 患者,左心室并無壓力負荷或容量負荷過重,因此沒有任何特殊的內科治療,洋地黃類無益于單純MS 伴竇性心率的病人,但可以用于快速心室率的心房顫動治療,控制心室率效果不好時,可加用小劑量的β阻滯劑。AS 患者亦應避免應用β阻滯劑等 負性肌力藥物。β阻滯劑僅適用于心房顫動并快速室率或有竇性心動過

51、速時。,,最常受累的是主動脈瓣膜,其發(fā)生率遠高于其他瓣膜。這主要是由于主動脈瓣膜所承受的機械壓力較大,尤其在血壓增高時,易引起膠原纖維斷裂形成間隙而有利于鈣鹽沉積。老年瓣膜長期經受血流沖擊,瓣葉中糖蛋白與蛋白聚糖的丟失與營養(yǎng)不良,也是鈣化形成的可能機制 。主動脈瓣膜又以左冠瓣為多見,右冠瓣次之。因左冠瓣與主動脈 瓣環(huán)后緣相連接,此處易形成血流旋渦致瓣膜受損, 使鈣鹽沉積于此 。右冠瓣因缺少致密牢固的絹織支托,受血流沖擊較大亦易受

52、損。,,AR 的藥物治療:降低后負荷的藥物可以改善AR 患者的預后。在一項與地高辛的比較研究中,硝苯地平可以延緩嚴重無癥狀AR 患者做主動脈瓣置換術的時機,。ACEI 也可通過減輕后負荷,增加前向心輸出量而減少返流,可應用于以下情況: (1) 有癥狀的重度AR 患者,因其他心臟疾病或非心臟因素而不能手術者; (2) 重度心力衰竭患者,在換瓣手術前短期治療以改善血液動力學異常,此時不能應用負性肌力 藥; (3) 無癥狀AR 患者,已有左室

53、擴大,而收縮功能正常,可長期應用,以延長其代償期; (4) 已經手術置換瓣膜,但仍有持續(xù)左室收縮功能異常,,AR的手術指征:與嚴重MR 一樣,AR 術前左室大小與術后射血分數(shù)的改善直接相關,但有兩點重要不同:AR 術前心室較大者術后也可以維持正常射血分數(shù)。另外,如果射血分數(shù)的降低時間小于12～14 個月,術后也可能恢復正常。,,嚴重AR患者出現(xiàn)下列情況時應當考慮瓣膜置換:出現(xiàn)癥狀、左室射血分數(shù)下降( 5.5 cm) 。 一旦出現(xiàn)

54、明顯的左室功能下降,手術結果將不會令人滿意。左室收縮末徑可以反映左室功能,并且不像射血分數(shù)那樣受前負荷的影響,AS的心導管診治:對于超聲心動圖診斷不明確的患者,可以做心導管檢查,心導管檢查的主要作用是排除伴發(fā)的冠心病,在此比其他瓣膜病更重要,因為主動脈瓣狹窄主要發(fā)生在老年人。通過心導管可做經皮球囊瓣膜成形術,但與經皮球囊二尖瓣擴張術(PBMC)治療二尖瓣狹窄不同,主動脈瓣狹窄的瓣膜成形術常常不成功,其出血和栓塞的發(fā)生率較高,6 個月的成

55、功率較低,AS的外科治療:應當認為AS 是一種外科疾病,因為沒有藥物可以代替手術治療,也沒有藥物可以改善生存率。非手術治療的預后很差。其手術指征為:超聲心動圖或心導管檢查證實嚴重的主動脈瓣狹窄并伴有心臟癥狀。有少數(shù)患者可做瓣膜修補,但瓣膜置換術的效果更好。手術風險較高的患者可考慮做心導管球囊成形術。,,MR 的藥物治療:發(fā)生MR 后,左房擴大增加了二尖瓣后葉張力,緊拉葉瓣使瓣膜功能失常加重,所以嚴重MR 常是進展性的。嚴重MR 非手術治

56、療應限制體力活動,減少鈉攝入,并通過合理應用利尿劑增加鈉排泄。血管擴張劑和洋地黃可增加左室衰竭后的前向心輸出量。靜脈應用硝普鈉或硝酸甘油可減少后負荷,減少返流,有助于穩(wěn)定急性或重度MR 患者病情。,,無癥狀慢性MR 且射血分數(shù)正常時,并無后負荷增加,尚不清楚應用降低后負荷藥物是否有利。ACEI治療慢性MR 可能有益,特別是有癥狀或左室增大者,可減少MR 并使左室腔減小,但要注意ACEI 降低后負荷可能掩 蓋左室功能不全,而有癥狀MR

57、 患者則適用于手術治療。與MS 一樣,MR 患者近期心房顫動應考慮轉為竇性心律。心力衰竭晚期患者應用抗凝藥和下肢繃帶,可減少靜脈血栓形成和肺栓塞。,MR 的手術治療:必須全面考慮疾病緩慢進展的性質和瓣膜修復以及瓣膜置換所帶來的遠期及近期風險。沒有癥狀或只在強體力活動受限者病情可穩(wěn)定多年,不宜外科治療。左室功能受損者手術治療風險驟增,遠期存活下降,但其保守治療幾乎沒有有效的辦法,即使在病情晚期,仍可考慮手術治療。如果臨床表現(xiàn)與超聲心動圖檢

58、查不一致時,左心導管檢查和心血管造影可能有助于確認嚴重MR 的存在,還有助于發(fā)現(xiàn)相關瓣膜病變、病變嚴重程度以及發(fā)現(xiàn)需同時血管重建的病人,手術的最佳時機:是慢性代償期到失代償期 的轉變階段。左室射血分數(shù)> 60 % ,左室收縮末徑< 4.5 cm時手術效果最好。選擇手術時機還要考慮肺動脈高壓和心房顫動的情況,關于老年瓣膜病合并心功能不全治療,1.正確判斷瓣膜的受損部位、程度、范圍2.把臨床癥狀與病變情況結合考慮3.牢

59、記心功能是病程的分水嶺4.對心功能不全的治療，應因病而治。,美托洛爾治療瓣膜性心臟病心力衰竭的隨機對照研究,山西葉氏,經心臟超聲確認為瓣膜性心臟病的心力衰 竭284 例中, 拒絕施行介入或手術治療, 同意參與研究的184例, 其中男性80 例, 女性104 例, 年齡31～ 73 歲(平均56. 4±8. 3 歲) , 隨機分為兩組,A 組美托洛爾組,B 組常規(guī)治療 延安大學學報(醫(yī)學科學版) Vo l14

60、No12 2019 年6 月,,所有入選患者接診后均為按慢性收縮性心力衰竭治療指南常規(guī)治療, 待心功能糾正到Ê 以上, 患者一般情況好轉后(心功能分級按美國紐約心臟病學會N YHA 分級法) , 隨機分為兩組,A 組美托洛爾組,B 組常規(guī)治療組,A 組開始口服美托洛爾12. 5mg/d, 每2w 增加1 次劑量, 最大用量75mg/d , 長期服用,A、B 兩組其他用藥均按心衰治療指南 常規(guī)處理, 觀察時間2 年。　

61、觀察指標 死亡率　統(tǒng)計兩組在觀察期內組間死亡率和總死亡率。,延安大學學報(醫(yī)學科學版) Vo l14 No12 2019 年6 月,,美托洛爾的心衰死亡率(4. 3%) , 明顯低于總死亡(9.2% ) 和常規(guī)治療組死亡率(14. 3%) , 兩組比較有統(tǒng)計學意義(P < 0. 05)。對心功能的控制與維持有良好作用,A 組心功能Ⅰ1～ 2 級者75 例(80. 6%) ,B 組心功能1～2 者32 例(35.2% ) ,

62、 兩組比較有統(tǒng)計學意義(P < 0. 05)。同時顯示美托洛爾 對心衰患者運動與靜息時心室率均有良好控制, 減少因心衰加重的住院率延安大學學報(醫(yī)學科學版) Vo l14 No12 2019 年6 月,,.青島管氏,血液透析治療老年心瓣膜病所致頑固性心力衰竭臨床療效評價,臨床醫(yī)藥（2019）04-0135-02,,對1994年--2019 年入院的36 例老年心瓣膜病頑固性心力衰竭患者，在綜合性治療無效的基礎上采用

63、血液透析( H D ) 治療,臨床醫(yī)藥（2019）04-0135-02,男性1 6 例，女性2 0 例，平均年齡69.6 ± 6.1 歲(60-79 歲)，其中聯(lián)合瓣膜病28 例，B 超檢查證 實合并腹水1 1 例，單或雙側胸腔積液1 7 例。選擇3 0 例同期未做血液透析的心瓣膜病頑固性心力衰竭患者，男性1 3 例，女性17 例，平均年齡6 9 . 5 ± 6 . 0 歲（6 1 - 7 8 歲），其中聯(lián)合瓣膜

64、病2 1 例，B 超檢查證實合并腹水1 0 例，單或雙側胸腔積液1 8 例。所有入選病人均符合頑固性心力衰竭的診斷標準，按N Y H A 心功能分級均為I I I - - I V 級充血性心力衰竭( C H F ),臨床醫(yī)藥（2019）04-0135-02,3 6 例老年心瓣膜病頑固性心力衰竭患者，經血液透析治療糾正心衰存活1 年以上的有1 7 例，其中1 0 例 于心衰糾正后做了瓣膜置換術，存活最長的已達5 年。1 個月內死亡1 9例

65、，死亡的主要原因：7 例 死于難以控制的心源性休克；7 例 死于腎功能衰竭；3 例死于致命性心律失常；2 例死于嚴重的感染, 總病死率為5 2 . 7 7 % 。同期未做血液透析的心瓣膜病頑固性心力衰竭患者，1 周內3 0 例病人死亡2 1 例，1 個月內3 0例病人全部死亡，病死率為1 0 0 % ，與透析組相比差異十分顯著,臨床醫(yī)藥（2019）04-0135-02,,血液透析治療老年心瓣膜病頑固性心力衰竭患者有效 可能與以