保留二尖瓣装置的二尖瓣置换术

目的比较传统二尖瓣置换术(MVR)和保留二尖瓣装置的MVR治疗单纯风湿性二尖瓣狭窄的临床效果. 方法回顾性分析77例单纯风湿性二尖瓣狭窄行MVR患者的临床资料,按术式不同将其分为3组,组1:35例,保留全部二尖瓣装置;组2:19例,保留二尖瓣后瓣瓣下结构;对照组:23例,行传统MVR手术. 结果术后早期对照组和组1各死亡1例,晚期对照组死亡2例,组1和组2各死亡1例.术后3～16个月超声心动图检查显示,对照组和组2左心室舒张期末内径( LVEDD)较术前明显增大(P＜0.01),组1LVEDD 增大不明显(P＞0.01).组1、组2左心室射血分数 (EF)和短轴缩短率(FS)较术前有明显改善(P＜0.01),对照组改善不明显(P＞0.01). 结论单纯风湿性二尖瓣狭窄患者行MVR时保留二尖瓣装置有利于术后左心功能的恢复.     

自体瓣膜心内膜炎二尖瓣成形与二尖瓣置换远期疗效的病例对照研究

目的探索自体瓣膜心内膜炎(NVE)患者二尖瓣成形(MVP)和二尖瓣置换(MVR)的远期疗效差异。方法 1993年11月至2016年8月我院连续101例NVE患者行二尖瓣手术,其中MVP 52例,MVR 49例。男69例、女32例,平均年龄(38.1±14.9)岁。平均随访(99.4±75.8)个月。结果两组患者体外循环时间、主动脉阻断时间、住院死亡、术后机械通气时间、ICU滞留时间以及术后住院时间差异无统计学意义。术后1年、5年、10年、20年MVP组的生存率分别为100.0%、97.6%、97.6%、97.6%,MVR组分别为93.5%、84.3%、84.3%、66.2%(P=0.018)。术后1年、5年、10年、20年MVP组无卒中事件发生,MVR组无卒中事件生存率分别为100.0%、93.9%、89.4%、70.2%,两组差异有统计学意义(P=0.023)。两组感染复发、瓣周漏及再手术发生率差异无统计学意义。术后1年、5年、10年、20年MVP组无复合终点事件生存率分别为100.0%、97.6%、92.9%、92.9%,MVR组无复合终点事件生存率分别为91.3%、79.6%、75.8%、51.0%,MVP组不良事件明显少于MVR组,且差异有统计学意义(P=0.006)。结论对于NVE二尖瓣病变患者MVP比MVR更有优势,应积极推广MVP技术在NVE中的应用。     

冠心病合并慢性中度缺血性二尖瓣关闭不全的外科治疗

目的 探讨冠心病合并中度缺血性二尖瓣关闭不全(IMR)的外科治疗及其预后.方法 从1998年1月至2006年5月共收治冠心病合并中度IMR患者28例,均为冠状动脉病变合并单纯二尖瓣关闭不全,手术均在中度低温体外循环下行冠状动脉旁路移植术(CABG)和同期二尖瓣手术.二尖瓣成形术(MVP)24例,其中Reed法成形9例,Reed法成形同时加成形环8例,脱垂二尖瓣叶切除同时加成形环7例;二尖瓣置换术(MVR)4例,其中置换机械瓣1例,生物瓣3例.结果 术后早期无死亡患者,应用主动脉内球囊反搏(IABP)1例.术后随访26例,随访3～80个月,平均41个月,远期死亡2例(MVP 1例、MVR 1例).随访MVP患者生存22例,心功能Ⅰ级13 例,Ⅱ级6例,Ⅲ级3例,较术前明显改善;多普勒超声心动图检查二尖瓣无反流5例,微量反流7例,轻度反流6例,中度反流3例,重度反流1例,左房容积(LAV)54.1±12.7ml,左心室舒张期末容积(LVEDV)60.9±14.8 ml,左心室射血分数(LVEF)0.59±0.15,与术前比较差异均有统计学意义(P＜0.05).随访MVR患者生存2例,心功能Ⅰ级1 例,Ⅱ级1例;多普勒超声心动图检查瓣膜功能良好.结论 对冠心病合并中度IMR患者应在行CABG时同期进行处理,IMR处理的方法以MVP同时加用成形环的早期临床效果较好,但是对左室功能差和左室壁运动异常的患者远期效果需要进一步观察.     

保留后瓣及瓣下结构的二尖瓣置换术

目的总结保留后瓣及瓣下结构的二尖瓣置换术(MVR)的临床经验,并观察其与常规MVR比较的临床效果。方法风湿性心瓣膜病患者54例,其中行保留后瓣及瓣下结构的MVR24例(保留二尖瓣后瓣组),行常规MVR30例(常规手术组),观察两组患者术前、术后3个月的左心室舒张期末内径(LVEDD)、左心室射血分数(LVEF)、左心室短轴缩短率(LVFS)等指标。结果保留二尖瓣后瓣组无死亡患者,常规手术组死亡1例;保留二尖瓣后瓣组术后血管活性药物的用量、种类和呼吸机使用时间较常规手术组减少;术后3个月保留二尖瓣后瓣组LVEDD较常规手术组减小,LVEF较常规手术组增大(P<0.05)。结论保留后瓣及瓣下结构的MVR手术操作不复杂,不增加心内手术时间,有可能减少左心室破裂的危险,术中操作仔细可以避免卡瓣,术后心功能恢复较好,更适用于心功能较差、左心室较大的以二尖瓣关闭不全为主的患者。     

保留后瓣及瓣下结构的二尖瓣置换术临床分析

目的总结保留二尖瓣后瓣及瓣下结构二尖瓣置换术(MVR)的经验,评价其临床效果。方法回顾性分析首都医科大学北京安贞医院2006年1月至2011年3月行MVR患者1 035例的临床资料,其中男562例,女473例;年龄37～78(53.84±13.13)岁。风湿性心脏瓣膜病712例,退行性瓣膜病323例;二尖瓣狭窄为主389例,二尖瓣关闭不全为主646例;均排除冠状动脉疾病。不保留后瓣及瓣下结构的MVR(不保留组)457例,保留后瓣及瓣下结构的MVR(保留组)578例,两组患者术前情况差异无统计学意义。分析比较两组患者手术后并发症、死亡率,以及左心室大小与功能。结果不保留组与保留组患者的死亡率(2.63%vs.1.21%,P=0.091)及并发症发生率(8.53%vs.7.44%,P=0.519)差异无统计学意义,但不保留组左心室破裂发生率高于保留组(1.09%vs.0.00%,P=0.012);术后6个月心脏超声心动图提示左心室舒张期末内径(LVEDD)较术前缩小,但两组差异无统计学意义;两组患者左心室射血分数(LVEF)均较术前提高,保留组中二尖瓣关闭不全为主患者的LVEF优于不保留组(56.00%±3.47%vs.53.00%±3.13%,P=0.000),两组二尖瓣狭窄为主的患者中LVEF差异无统计学意义(57.00%±5.58%vs.56.00%±4.79%,P=0.066)。结论保留二尖瓣后瓣及瓣下结构的MVR安全有效,可以减少术后左心室破裂的发生并改善术后心功能。     

慢性中重度缺血陛二尖瓣关闭不全的外科治疗及中期随访

目的 比较二尖瓣成形术和瓣膜置换术治疗慢性中重度缺血性二尖瓣关闭不全的手术效果及中期随访结果 .方法 自2002年6月至2008年5月,83例慢性缺血性二尖瓣关闭不全(中度35例,重度48例)接受冠状动脉旁路移植术同期行二尖瓣成形术或二尖瓣置换术.男49例,女34例;年龄51～77岁,平均(59.3±7.5)岁.43例二尖瓣成形术包括使用Dacron补片条或自体心包条环缩后瓣环21例,交界处环缩9例,后叶矩形切除9例,St.Jude成形环环缩4例.40例二尖瓣置换术包括机械瓣28例,生物瓣12例.结果 住院死亡3例,二尖瓣成形术组和二尖瓣置换术组住院死亡分别占2.3%(1/43例)、5.0%(2/40例),差异无统计学意义(P>0.05).术后瓣膜置换组机械通气时间长于二尖瓣成形组(P<0.05),二尖瓣成形组术后6例残余轻度二尖瓣反流(P<0.05)但不影响心功能,两组其他住院并发症无统计学差异(P>0.05).76例通过门诊或电话随访,随访3～60个月,平均(20.2±4.9)个月.随访期间二尖瓣成形术7例轻度二尖瓣反流.瓣膜置换组人工瓣功能均良好,3例出现抗凝相关并发症.随访远期死亡7例,冠状动脉旁路移植术同期二尖瓣成形术和二尖瓣置换术5年生存率分别为90%和61%.结论 对于慢性中重度缺血性二尖瓣关闭不全病人,二尖瓣成形术后近期和远期效果好,可作为优先选择的术式.     

全保留二尖瓣及瓣下结构在重症二尖瓣关闭不全患者二尖瓣置换术中的应用

目的探讨全保留二尖瓣及瓣下结构在重症二尖瓣关闭不全患者二尖瓣置换术中的应用经验,评价其临床效果。方法回顾性分析2011年6月至2013年1月在广东省人民医院心血管外科因重症二尖瓣关闭不全行全保留二尖瓣及瓣下结构二尖瓣置换术17例患者的临床资料,其中男14例,女3例;年龄38~82（63.41±11.82）岁;合并心房颤动13例;术前纽约心脏学会（NYHA）心功能分级Ⅲ级5例,Ⅳ级12例;缺血性二尖瓣关闭不全7例,退行性二尖瓣关闭不全9例,风湿性二尖瓣关闭不全1例。结果所有患者均行全保留二尖瓣及瓣下结构的二尖瓣置换术,同期行冠状动脉旁路移植术4例;其中生物瓣11例,机械瓣6例。全组患者住院期间无死亡,均顺利出院,住院期间未并发低心排血量综合征,无左心室破裂。17例患者均随访,随访时间2~25（16.44±5.02）个月。随访期间1例患者因术后2个月发生二尖瓣重度瓣周漏死亡。其余患者人工二尖瓣功能良好,无抗凝和瓣膜引起的并发症,心功能较术前明显改善,心功能NYHA分级恢复至Ⅰ级11例,Ⅱ级4例,Ⅲ级1例。术后早期及随访期间心胸比率、左心房内径、左心室舒张期末内径及收缩期末内径与术前相比均明显减小。而术后早期左心室射血分数（LVEF）与术前相比有所降低[（50.94%±8.78%）vs.（55.31%±10.44%）,P=0.04],术前LVEF与随访期间的差异无统计学意义[（55.31%±10.44%）vs.（56.13%±9.67%）,P=0.73],随访期间LVEF与术后早期相比显著增加[（56.13%±9.67%）vs.（50.94%±8.78%）,P=0.02]。术后早期与随访期间人工二尖瓣压力减半时间（PHT）差异无统计学意义[（95.06±19.00）ms vs.（94.56±19.19）ms,P=0.91]。结论全保留二尖瓣及瓣下结构在重症二尖瓣关闭不全患者二尖瓣置换术中应用安全有效,可以改善左心室重构及术后心功能。     

冠心病合并二尖瓣关闭不全的外科治疗

目的　探讨冠心病合并二尖瓣关闭不全 (MR)的外科治疗方法。方法　 1994年 4月至2 0 0 0年 10月 ,同期手术治疗冠心病合并MR病人 34例 ,其中二尖瓣轻度反流 1例 ,中度反流 2 5例 ,重度反流 8例。二尖瓣的病理改变主要表现为单纯瓣环扩大、瓣叶脱垂或二尖瓣腱索断裂。手术均在低温体外循环下进行。二尖瓣成形 (MVP) 2 7例 ;单纯二尖瓣前交界或双交界折叠环缩 15例 ;脱垂瓣叶切除后再缝合 9例 ;二尖瓣前叶脱垂部分直接缝合到相应的后叶形成双孔二尖瓣 3例 ;应用二尖瓣瓣环 2 0例 ;二尖瓣置换 (MVR) 7例 ,均选择机械瓣。结果　无手术或住院死亡和严重并发症。超声心动图检查提示平均左室舒张末径为 (5 3 0± 6 3)mm ,与术前比较差异有显著性 (P <0 0 1)。 31例平均随访 2 9个月。无远期死亡。病人生活质量均明显提高。心功能I～II级 2 8例 ,III级 3例。超声心动图检查提示微量二尖瓣反流 6例 ,少至中度反流 3例。机械瓣功能正常。结论　冠心病合并中度以上MR应积极处理 ,二尖瓣成形应为首选     

二尖瓣成形术治疗感染性心内膜炎二尖瓣关闭不全

目的 评估二尖瓣成形术治疗感染性心内膜炎的可行性和疗效.方法 1990年10月至2007年7月,83例感染性心内膜炎致二尖瓣关闭不全的病人接受二尖瓣手术.男62例,女21例.41例(49.4%)行二尖瓣成形术(MVP),42例(50.60%)行二尖瓣置换术(MVR).同时行主动脉瓣置换术37例,三尖瓣成形术12例,室间隔缺损修补术4例,冠状动脉旁路移植术2例,主动脉瓣成形术1例,房间隔缺损修补术1例,股动脉取栓术1例.术中18例行食管超声检查评估二尖瓣反流情况.结果 MVP与MVR组病人比较,术前左室收缩末内径(41.63±8.60)mm对(37.69±6.38)mm,P＜0.05;术前射血分数0.62±0.07对0.66±0.76,P＜0.05;术前心功能分级平均(2.88±0.61)级对(2.45±0.71)级,P＜0.01.体外循环47～265min,平均(117.06±46.77)min;主动脉阻断26～210min,平均(86.95±39.07)min;呼吸机辅助呼吸5～120h,平均(21.49±16.06)h.MVP与MVR组病人体外循环和主动脉阻断时间均差异无统计学意义,MVP组气管插管和住ICU时间均显著低于MVR组(P＜0.05).MVR组病人瓣叶赘生物明显多于.MVP组病人(P＜0.05).MVP组术者相对固定.住院死亡3例(3.6%),均为二尖瓣置换病人.出院时病人心功能均为Ⅰ级或Ⅱ级.随访1～165个月,平均(39.33±39.76)个月,随访率95%.MVR组发生瓣周漏1例,反复胸腔积液1例,脑出血2例,其中1例死亡,10年生存率75%.MVP组无死亡,10年生存率100%.结论 感染性心内膜炎二尖瓣病变的病人瓣叶毁损不严重,如术者临床经验丰富,大多可行二尖瓣成形术,并取得良好手术结果.

Abstract：

Objective Valve replacement is a conventional therapy for the mitral insufficiency caused by IE. Mitral valve repair as an optional procedure for the disease has become feasible in recent years. However, concerns from surgeons about the recurrence of endocarditis after mitral valve repair remained. in this study we evaluated the long-term clinical outcomes of patients treated with surgery for the mitral insufficiency caused by infective endocarditis (IE). Methods Between July 1990 and July 2007, 83 consecutive patients (male 62, female 21) with mitral valve IE were enrolled in this study. Forty-one (49.4% )patients received mitral valve repair ( MVP,group A) and 42(50. 6% ) patients received mitral valve replacement ( MVR, group B). Thirty-seven cases had concomitant aortic valve replacement; 1 patient had aortic valve repair; 4 cases had ventricular septal defect repair; 1 case had atrial septal defect repair, 12 cases had bicuspid valve repair; 2 cases had coronary artery bypass graft and 1 case had femoral artery thrombus. Intraoperative transesophageal echocardiography were performed in 18 cases for the evaluation of mitral valve regurgitation. Mean cardiopulmonary bypass time, aortic clamping time and postoperative ventilation time were recorded and analyzed. Mid- and long-term clinical and echocardiographic outcomes were assessed.Results Preoperative left ventricular end systolic diameter, left ventricular ejection fraction and the classification of New York Heart Association in group A were significantly lower than those in group B (P ＜ 0. 05), but no difference was observed between the 2 groups in the cardiopulmonary bypass time and the crossclamping time. However, the intubation time and ICU time were shorter in group A than those in group B ( P ＜ 0.05 ). More vegetations were seen in the MVR group than in the MVP group. Three (3.6% ) patients died after the operation in group B. All patients were assessed as in NYHA Ⅰ-Ⅱ at discharge.A follow-up was done between 1 to 165 months (mean 39 months) with a mean follow-up rate of 95%. In the MVR group, peri-valvular leakage happened in 1 case, cerebral hemorrhage happened in 2 cases and repetitive pleura! effusion in 1 case. One death happened in the MVR group and none in the MVP group. The 10-year survival rate (100% ) in group A was nonsignificantly higher in group A than that (75% ) in group B(P =0.081). Conclusion Mitral valve repair is feasible for treating mitral valve lesions caused by endocarditis, and may provide an optimistic long-term outcome to the patients. The indication for mitral valve repair is mild to moderate mitral valve lesion. Experienced cardiac surgeons, use of antibiotics before and after the operations based on drug-sensitivity test and blood test, as well as follow-up the patients yearly, are important factors for the favorite outcomes.     

保留瓣下结构对二尖瓣置换术后机械瓣血流动力学的影响

目的探讨保留瓣下结构对二尖瓣置换术(MVR)后机械瓣血流动力学的影响. 方法对100例二尖瓣狭窄为主的患者施行MVR,根据术中对自体瓣膜处理的方式不同分为全部保留瓣下结构组(Ⅰ组、23例),全部切除瓣下结构组(Ⅱ组、27例),保留前瓣组(Ⅲ组、22例),保留后瓣组(Ⅳ组、28例),20例健康志愿者作为正常组.均采用二维超声心动图、彩色多普勒技术,对各组患者随访,以正常人作为对照,测量二尖瓣口血流动力学参数,比较各组间的差别. 结果Ⅰ～Ⅳ组二尖瓣口血流动力学的各种参数与正常组比较差别具有显著性意义(P＜0.05),而各种参数在Ⅰ～Ⅳ组之间比较差别无显著性意义(P＞0.05). 结论在慢性二尖瓣狭窄为主的患者中,研究涉及的各种保留瓣下结构方法之间,保留与不保留瓣下结构之间,术后中期的机械瓣血流动力学无明显差别.     

Surgical results of active infective native mitral valve endocarditis: repair versus replacement

Objective: The current study compared clinical outcomes after mitral valve repair or replacement in patients with active infective endocarditis involving only the native mitral valve. Methods: From January 1994 to December 2009, 102 patients were identified with active infective native mitral valve endocarditis. Mitral valve repair (MVP) was performed in 41 patients and mitral valve replacement (MVR) in 61 patients. The mean age was 34.4 ± 16.9 years in the MVP group and 43.1 ± 14.9 years in the MVR group (p = 0.007). The composite end points of cardiac death and cardiac-related morbidities were compared in these two groups using the inverse-probability-of-treatment-weighted method. The median follow-up time was 4.7 years (range, 0.1–15.8) and follow-up was possible in 100 (98%) patients. Results: There were three in-hospital deaths (2.9%), all in MVR patients (p = 0.272). The mean cardiopulmonary bypass time and aortic cross-clamping time were 111.4 ± 34.7 min and 72.7 ± 23.7 min in the MVP group and 101.1 ± 42.9 min and 62.9 ± 26.9 min in the MVR group (p = 0.204, p = 0.062). The 1-, 5-, and 10-year survival rates were 97.5%, 97.5%, and 81.1%, respectively, in the MVP group and 90%, 85.8%, and 85.8%, respectively, in the MVR group (p = 0.316). Actuarial event-free survival at 1, 5, and 10 years was 92.7%, 89.5%, and 72.2% in the MVP group, and 94.8%, 81.0%, and 77.3% in the MVR group (p = 0.787), respectively. Conclusions: The present study showed that postoperative long-term survival and event-free survival in patients with active infective endocarditis of the native mitral valve were not statistically significantly different regardless of whether patients underwent MVP or MVR.     

Mitral valve replacement in the pediatric age group- a single institution experience

Background  Mitral valve replacement in pediatric patient is a difficult surgical task, with many intraoperative and post-operative considerations. We conducted this study to evaluate the indications and early results of mitral valve replacement in children. Methods  From January 2003 to July 2008, fifty-four children under the age of fifteen years underwent mitral valve replacement at our institution. All children received a mechanical bi-leaflet or tilting disc prosthetic valve. All of them underwent valve replacement on the basis of preoperative echocardiography and intraoperative assessment of valve pathology. Results  Preoperatively 65% of the children were in New York Heart Association (NYHA) class III and 35% of them were in NYHA class IV. The cause of mitral valve disease was chronic rheumatic valve disease in 97% of cases and congenital in 3% of the cases. In the rheumatic group 66% of them had severe mitral regurgitation as predominant lesion. The mean diameter of the implanted valve was 27.17mm. There was no hospital or 30 day mortality. The mean follow-up period was 3.6 years. One patient died after 2 years from a stuck valve. Two other patients required thrombolysis for stuck valves. 53 patients are doing well at last follow up. Conclusions  Mitral valve replacement in children is a safe alternative to valve repair when the morphology is not suitable for repair, with acceptable immediate and early outcomes.     

Impact of MitraClip™ therapy on secondary mitral valve surgery in patients at high surgical risk

Objective: Conventional or minimally invasive surgical mitral valve repair (MVR) is the gold-standard treatment for severe mitral regurgitation (MR) of any etiology. Given its good safety profile, trans-catheter MVR with the MitraClip™ device is used increasingly for high-risk or inoperable patients. We report our experience with failed MitraClip™ therapy and its impact on subsequent surgical strategies, such as the feasibility of MVR in high-risk patients. Methods: During a follow-up of 344 ± 227 days from the first 215 consecutive patients treated with the MitraClip™ device, six patients required surgical re-intervention due to failed repair (n = 3) or recurrent severe MR (n = 3) at 35.8 ± 47.7 (range 0–117) days after trans-catheter MVR. Feasibility of secondary surgical MVR was assessed with regard to prior clip therapy. Results: In three patients, secondary surgical MVR was successfully performed following the surgical strategy deemed optimal before trans-catheter treatment. Injury of the mitral leaflets caused by prior clip treatment was present in three other patients and influenced the surgical strategy toward more complex surgical techniques in one case and MV replacement in two others. One patient died 6 days after MV replacement. All other patients are alive with adequate valve function at the latest follow-up of 12.4 ± 7.4 months (range 4–22). Conclusions: Secondary surgical MVR was feasible in some patients after prior clip treatment, but led to valve replacement in others. At present, patient selection criteria for trans-catheter MVR should not be expanded toward more healthy patients, as primary trans-catheter MVR may complicate secondary surgery in certain cases and may even preclude reconstructive valve surgery.     

胸腔镜下二尖瓣生物瓣置换术32例分析

目的探讨胸腔镜下二尖瓣生物瓣置换的经验,评价其临床效果。方法回顾性分析2013年3～12月在广东省人民医院心血管外科行胸腔镜下二尖瓣生物瓣置换术32例患者的临床资料。其中男14例、女18例,年龄19～80（55.6±17.3）岁,体重37～78（55.7±9.7）kg,体表面积1.30～1.95（1.67±0.16）m^2;合并心房颤动5例,术前心功能分级（NYHA）Ⅱ级20例,Ⅲ级11例,Ⅳ级1例;二尖瓣风湿性病变16例,二尖瓣退行性病变11例,感染性心内膜炎4例,合并先天性心脏病1例。结果所有患者均行胸腔镜下二尖瓣生物瓣置换术,其中采用Medtronic HancockⅡ人工生物瓣27例,Medtronic Mosaic生物瓣5例。同期行三尖瓣成形术13例,房间隔缺损修补术1例。全组患者住院期间无死亡,均顺利出院,住院期间未并发低心排血量综合征及左心室破裂。术后复查心脏彩色超声心动图提示,所有患者人工二尖瓣功能良好,无瓣周漏发生。术后患者心功能较术前明显改善,心功能恢复至Ⅰ级9例,Ⅱ级17例,Ⅲ级6例。术后早期及术后3个月左心房内径及左心室舒张期末内径与术前相比均明显减小。而术后早期及术后3个月左心室射血分数（LVEF）与术前相比有所降低。结论胸腔镜下二尖瓣生物瓣置换术创伤小,并发症少,安全可行,使用特殊类型生物瓣可明显减小手术切口大小。     

Mitral valve repair in patients with end stage cardiomyopathy: who benefits?

Objective: Patients with end stage cardiomyopathy frequently present with additional severe mitral regurgitation. We analyzed the outcome of mitral valve reconstruction in this high risk patient group. Methods: Sixty-six patients with significant mitral regurgitation and an ejection fraction (EF) below 30% (dilated CARDIOMYOPATHY=53, ischemic cardiomyopathy (ICM)=13) were retrospectively evaluated from 07/96 and 02/02. All received annuloplasty ring implantation and additional repair (n=4) if required. Mean follow-up was 28±18 months. Results: Mitral valve repair (MVR) was technically feasible in all patients. Intraoperative transesophageal echocardiography (TEE) revealed none (n=60) or only trivial (n=6) residual mitral regurgitation. Thirty day mortality was 6.1%. Actuarial survival after 1 and 5 years was 86±4 and 66±8%, respectively. During follow-up seven patients were transplanted due to lack of clinical improvement after 10±7 months (range 1–23). Echocardiography revealed a significant improvement in EF (25±10.5% pre-op, 34±15% post-op) and a slight decrease in left ventricular end-diastolic diameter (69±10 mm pre-op, 67±13 mm follow up). Patients were in NYHA functional -class 3 (median) preoperatively and in class 2 at long term-follow-up. Gender, left ventricular enddiastolic diameter, preoperative ejection fraction or type of surgical approach (sternotomy, right lateral minithoracotomy) had no significant influence on patient outcome. Patients with ICM or patients older than 60 years showed an increased risk for clinical events both early post-operatively and at long-term follow-up. Conclusion: MVR can be performed with low perioperative morbidity and mortality even in patients with advanced heart failure, modifying selection criteria for potential candidates may further improve long term outcome.     

Ten-year experience with the porcine bioprosthetic valve: interrelationship of valve survival and patient survival in 1,050 valve replacements

The porcine bioprosthetic valve was used in 440 patients having isolated mitral valve replacement (MVR), 522 patients having isolated aortic valve replacement (AVR), and 88 patients having MVR + AVR between 1974 and 1981. Patients with associated surgical procedures were excluded. Mean follow-up was 8.3 years. At 10 years, there was no difference in patient survival between those having AVR and those having MVR. Reoperations were performed on 192 patients. Endocarditis was the reason for reoperation in 3.7% of patients who had MVR and 10.6% of those who had AVR. Structural valve degeneration was the reason for reoperation in 89.7% of MVR patients and 78.8% of AVR patients (p = 0.04). Hospital mortality among patients having valve reoperations was 4.7%. At 10 years, the freedom from valve reoperation for all causes and from structural valve degeneration was significantly better for the AVR group than the MVR group (74% +/- 3% versus 61% +/- 4%, p = 0.004; and 79% +/- 3% versus 63% +/- 4%, p = 0.0006, respectively). For patients in their 60s, the 10-year freedom from reoperation was 92% +/- 2% for AVR and 80% +/- 6% for MVR (p = not significant). At 10 years, freedom from cardiac-related death and valve reoperation was best for both MVR and AVR patients in their 60s. Patients 70 years old or older rarely had reoperation but died before valve failure occurred. The 10-year freedom from all major valve-related events (cardiac-related death, reoperation, thromboembolism, endocarditis, and anticoagulant-related bleeding) was practically the same for both MVR and AVR patients (48% +/- 3% versus 49% +/- 3%, respectively). The porcine bioprosthetic valve is the valve of choice only for patients 60 years old or older. Patients in their 70s have an extremely low rate of reoperation but a high rate of cardiac-related death and do not outlive the prostheses.     

肥厚梗阻性心肌病合并二尖瓣病变的外科治疗

目的 分析肥厚梗阻性心肌病合并二尖瓣病变的病理特点,探讨外科治疗策略.方法 1996年10月至2009年6月,外科手术治疗62例肥厚梗阻性心肌病病人,其中男41例,女21例;年龄6～68岁,平均(34.05±15.26)岁;体重27～83 kg,平均(60.42±12.71)kg.术前超声心动图(UCG)均提示二尖瓣SAM征,50例合并不同程度的二尖瓣关闭不全(MR).手术在全麻低温体外循环下完成,按常规经主动脉切口行室间隔心肌切除术,同期完成二尖瓣置换术(MVR)12例,二尖瓣成形术(MVP)9例.围术期常规UCG、心电图及X线胸片检查,评价左心房(LA)、左心室(LV)、左窒流出道流速及压差(LVOT)、左室射血分数(EF)、二尖瓣的结构和功能.结果 全组体外循环40～290 min,平均(104.23±47.14)min,主动脉阻断20～195 min,平均(66.76±36.32)min;气管插管5～21 h,平均(13.23±11.76)h.LA术前(43.46±7.21)mm,术后(34.56±5.23)mm;左室流出道压差术前(103.84±44.04)mm Hg(1 mm Hg=0.133 kPa),术后(23.54±17.78)mm Hg;室间隔厚度术前(26.93 ±5.23)mm,术后(17.12±5.67)mm,均显著下降(P＜0.05).术后MR和SAM症基本消失或显著减轻.手术死亡4例(6.4%,4/62例),主要死因为严重低心排综合征、严重心律失常及急性肾功能衰竭.主要并发症有完全左束支传导阻滞(33例)、室内传导阻滞(7例)、完全性房室传导阻滞(6例)、左前分支阻滞(5例)、Ⅰ度房室传导阻滞(5例)、心房颤动(4例).远期随访生存者症状消失,生活质量明显改善,心功能Ⅰ～Ⅱ级,二尖瓣结构功能良好;无远期死亡、并发症或再次手术.结论 肥厚梗阻性心肌病常常合并二尖瓣病变,室间隔肥厚心肌切除术,充分的疏通左心室流出道可基本消失MR和SAM征;如二尖瓣本身有严重先天性发育异常或继发性病变,首选MVP,疗效满意,因人工心脏瓣膜及术后抗凝治疗并发症,MVR不作为常规手术方式.