Perioperative Management of Heart Valve Replacement in the Elderly With the continuous improvement of cardiac surgical techniques, myocardial protection and perioperative management, the mortality rate of heart valve replacement has been decreasing year by year, and the age of valve replacement has been increasing year by year. From January 1990 to December 1995, we performed 43 cases of prosthetic valve replacement for patients over 60 years old, accounting for 4% of heart valve replacements in the same period. The experience of perioperative treatment is reported as follows: 1. Clinical data There were 43 cases in this group, 26 male and 17 female. The age of this group was 60~67 years old. Body weight ranged from 44 to 75 kg. 28 cases of rheumatic heart disease, 2 cases of congenital heart disease, 10 cases of degenerative heart valves, 3 cases of infective endocarditis. There were 29 cases of hypertension, 2 cases of coronary atherosclerotic heart disease (CHD), 1 case of pre-excitation syndrome, 3 cases of diabetes mellitus and 1 case of cerebral thrombosis. The duration of the disease ranged from 1 to 43 years. There were 11 cases of mitral junction closed dilatation. There were 11 cases with history of heart failure and 2 cases of cardiogenic malignancy. 2, perioperative treatment 2.1 preoperative treatment: preoperative preparation should be based on the nature of heart valve lesions, the degree of myocardial damage, as well as hemodynamic changes in the characteristics of cardiac, diuretic, vasodilator drug therapy. Sedimentary liver dysfunction can be operated after 1 week of normal liver function. If the liver function is still not normalized after prolonged hepatoprotective therapy, but the heart failure is corrected, surgery can be performed. Gastrointestinal stasis caused by malnutrition, hypoproteinemia or anemia patients are given preoperative elements or special diets, a small amount of oral hormones, and a small number of intravenous drip plasma, albumin or fresh blood. 2.2 Surgical methods: Surgery is performed under general anesthesia, hypothermia and extracorporeal circulation. Myocardial protection is performed by intermittent or continuous perfusion of blood-containing cardiac arrest fluid in a downstream or retrograde manner. Controlled reperfusion was performed with low-potassium warm blood containing mannitol (37. C) before opening the aorta in severe patients. In our group, 21 cases of mitral valve replacement (MVR), 5 cases of aortic valve replacement (AVR) and 17 cases of double valve replacement (DVR) were performed. Tricuspid valvuloplasty was performed in 30 cases. There were 5 cases of left atrial folding, 4 cases of left atrial thrombectomy, 2 cases of oval foramen closure, and 1 case each of coronary artery bypass grafting (CABG) and anomalous conduction bundle severance. 2.3 Postoperative treatment: dopamine and dobutamine were started after extracorporeal circulation was stopped. Blood volume and colloid fluid were supplemented under monitoring central venous pressure (CVP), pulmonary capillary wedge pressure (PCWP), left atrial pressure (LAP), and erythrocyte pressure product (HCT). And vasodilation with nitroglycerin or sodium nitroprusside. Amrinone or epinephrine was added to enhance myocardial contractility in those with low cardiac output syndrome. Strictly limit the amount of crystal fluid intake, intermittent injection or intravenous drip infusion of fast urine, as soon as possible to discharge excess water in the body. 3. Results: 39 cases (90.7%) survived early in this group; 17 cases had various complications and 4 cases (9.3%) died; early complications and causes of death are shown in the table. There were no late deaths in this group. 39 cases were followed up for 7 months to 6 years, 1 case was given a permanent pacemaker due to pathological sinus node syndrome, and 2 cases of right cardiac insufficiency improved after cardiac tonicity and diuretic treatment. 39 cases had their central functions restored to class I in 28 cases and class II in 11 cases. 4, Discussion 4.1 Preoperative examination: patients over 60 years of age began to decline in function of all organs of the body. In addition to heart valve lesions, often combined with other cardiac, cerebrovascular, hepatic, renal and respiratory diseases. In this group, there were 25 cases of combining more than 2 diseases, accounting for 58.14%. In addition, the long course of the disease, together with the second operation, increased the surgical risk and the difficulty of postoperative management. Therefore, preoperative history should be asked carefully and physical examination should be done carefully. In addition to routine examination, coronary angiography should be performed in all elderly patients before surgery when available. Coronary angiography should be performed for those who have been diagnosed with CHD or those who suffer from hypertension, hyperlipidemia, diabetes mellitus without chest pain symptoms but with ischemic changes of ST segment and T wave on electrocardiogram, and those who have angina pectoris symptoms clinically but with bundle branch block on electrocardiogram without obvious ischemic changes. 4.2 Surgery and precautions: Due to the patient’s age and osteoporosis, the chest opener should be used to open the sternum slowly to avoid sternal fracture, which may cause postoperative bleeding and difficulty in healing the sternum. For patients with thickened aorta and thin aortic wall, heparinization can be given first, and after preparation for endocardial suction, the vena cava drainage tube can be inserted first, and then the ascending aortic supply vessel can be inserted. When blocking the ascending aorta, cardiopulmonary diversion temporarily reduces the flow rate and slowly blocks the aorta to prevent damage to the aortic wall causing hemorrhage. There is still debate about the choice of prosthetic heart valves. Biologic valves do not require long-term anticoagulation and have a low incidence of bleeding and thromboembolic complications. However, the durability of biologic valves is only 10-15 years, and the rate of reoperation after valve replacement is high, and the difficulty of surgery and surgical mortality have increased for the elderly. Therefore, many scholars have recently advocated the use of mechanical valves, and follow-up results suggest that there is no significant difference between the long-term survival rates of mechanical and biologic valves. The thromboembolic rate of mechanical flaps is similar to that of biologic flaps. In our group, all mechanical valves were selected, and no bleeding or thromboembolism occurred after surgery due to anticoagulation. Their anticoagulation was administered after removal of pericardial and mediastinal drains at 48 hours postoperatively, and anticoagulation could be delayed in case of tracheotomy and peritoneal dialysis. The first dose of warfarin is 0.05 to 0.1.mg/kg, and the dose is later adjusted according to the prothrombin time (PT) measurement so that the PT is 1.5 to 2 times the control value. After discharge, the dose of anticoagulant drugs is adjusted according to diet, the presence of gingival bleeding or PT rechecked in 3~6 months. 4.3 Tricuspid valvuloplasty in left atrial folding : Pulmonary hypertension and right ventricular hypertension both cause right ventricular dilatation, so that the tricuspid valve can not be closed. Therefore, correction of tricuspid valve closure insufficiency has a significant impact on the recovery of cardiac function in the early and late stages after valve replacement. We chose kay plasty for patients with predominant regurgitation at the junction of the posterior valve HO septal valve. In contrast, DeVega annuloplasty was used for tricuspid valve closure insufficiency due to enlarged anterior and posterior valve attachment rings. For severe left atrial enlargement (left atrial volume) 300 ml) Kawazoe’s left atrial folding is used to reduce respiratory and circulatory complications. 4.4 Management of combined CHD: Patients over 60 years of age undergoing heart valve replacement surgery should first be excluded if they have combined CHD. Intraoperative further exploration of the coronary arteries, stenosis and nodules, has decided whether the same period of CABG. surgery should be carried out first heart valve replacement, and then the saphenous vein or internal mammary artery for the ascending aorta and coronary artery bypass grafting. 5. Postoperative treatment: According to the characteristics of the elderly, attention should be paid to the treatment of combined cardiac, cerebrovascular, hepatic, renal and respiratory diseases in the perioperative period. Strengthen cardiotonic, diuretic and vasodilator treatment to improve heart and lung function. Monitor the changes of liver and kidney function, blood creatinine for 2 consecutive days>200umol/d, should be actively peritoneal dialysis to prevent the occurrence of renal failure. For patients with diabetes mellitus, blood glucose should be controlled in the normal range as far as possible during the operation period, and glucose-lowering drugs can be used; glucose intake should be strictly limited in the postoperative period, or 4~5g of glucose plus 1 unit of insulin should be injected intravenously. Antibiotics should be given regularly and in sufficient quantity to prevent postoperative infection.