自体心包材料二尖瓣环成形术的中期结果

目的 回顾性分析自体心包材料二尖瓣环成形术的中期效果.方法 采用自体心包材料行二尖瓣环成形术48例.Carpentier分型：Ⅰ型5例,Ⅱ型41例,Ⅲ型2例.瓣叶及瓣下结构成形包括后叶四边形切除30例,瓣叶修补7例,腱索转移4例,“缘对缘”技术2例,人工腱索3例.伴随手术包括主动脉瓣替换1例,三尖瓣成形11例,冠状动脉旁路移植术9例,冠状动脉肌桥松解1例,永久性起搏器植入1例.自体心包条的长度为（51.9 ±2.8）cm.术后随访15～96（62.2 ±21.3）个月.采用门诊随访及电话随访方式,随访内容包括临床症状、心功能、超声心动图检查等.结果 术后左心室舒张末期内径[（45.1±1.3） mm vs（58.6±1.7）mm,t=12.85,P＜0.01]、左心房内径[（38.0±1.4）mm vs （50.6±1.6） mm,t=9.58,P＜0.01]明显缩小.全组早期术后无明显反流.术后30 d内死亡1例.远期无死亡,术后发生脑梗死1例,远期出现中度反流1例.无溶血并发症,无再次手术.结论 自体心包材料二尖瓣环成形是一种抗凝并发症发生率低、耐久性可、心功能维护好、廉价的成形方法.     

二尖瓣人工腱索移植术105例手术分析

目的 总结二尖瓣人工腱索移植术的手术治疗经验.方法 选择应用二尖瓣人工腱索移植术治疗的退行性二尖瓣脱垂并关闭不全患者105例.其中,单纯人工腱索移植25例,人工腱索移植＋后叶楔形切除67例,人工腱索移植＋后叶楔形切除＋Sliding 13例.结果 术后早期无死亡病例.术后并发症：窦性心动过缓8例、室上性心动过速20例、延迟性心包填塞1例、术前心房颤动伴快-慢综合征患者永久起搏器置入l例,均治愈出院.住院时间9～21 （14±4）d.术后随访96例,随访率91.4％（96/105）.随访3个月至5年.96例随访患者中,l例术后13个月死于脑梗死,1例死于交通事故,余94例均存活.NYHA心功能分级Ⅰ级74例,Ⅱ级20例.复查心脏彩超示微量及以下反流92例,轻度反流2例,未发现人工腱索断裂或劈裂.结论 严格选择病例,掌握恰当的手术技巧,同时做好术中成形效果的评估和体外循环期间的心肌保护,是提高二尖瓣人工腱索移植术疗效的关键.     

经食道超声心动图在二尖瓣成形术中的应用

目的：评价经食道超声心动图（TEE）在二尖瓣瓣膜成形术中的应用价值。方法：选择二尖瓣脱垂并伴有中度以上的反流拟行二尖瓣成形术患者21例。术中应用经食道超声心动图评价二尖瓣病变部位,二尖瓣的解剖定位采用Carpentier命名法,将前叶分为A1、A2及A3,后叶分为P1、P2及P3,与术中所见进行对照,术后即刻评价成形效果。结果：本组21例共30处病变部位,28处病变部位与术中所见相符,2处为TEE未发现。18例1次性手术实施成功,2例术中监测发现反流2级,再次行成形术,最终获成功,1例术中监测发现反流3级,改行二尖瓣人工瓣置换术。结论：经食道超声心动图在二尖瓣成形术中判断病变部位、术后即刻评价成形效果具有重要的临床应用价值。     

双孔成形术治疗二尖瓣前叶病变的临床研究

目的 探讨双孔成形术在治疗二尖瓣前叶病变中的临床可行性.方法 对35例二尖瓣前叶病变患者行双孔成形术,在术前、术中、术后利用超声心动图对瓣膜进行评价,并对手术患者进行随访观察.结果 术前瓣口面积为(5.41± 1.50) cm2,术后瓣口面积为(3.01±0.70) cm2,两者比较差异有统计学意义(P＜0.05).术后28例患者无明显反流,5例可探及轻度反流信号,2例中度反流信号.随访1～12个月,除1例失访外,所有患者随访期间美国纽约心脏病协会(NYHA)分级均为Ⅰ级;超声心动图显示双孔成形瓣膜活动良好,无瓣口狭窄.除1例发生心房颤动、1例发生胸腔积液、2例发生心包积液外,其余患者没有发生明显的并发症.结论 双孔成形术治疗二尖瓣前叶病变,疗效稳定,并发症少,早、中期疗效满意.     

二尖瓣成形术治疗二尖瓣关闭不全的疗效分析

目的分析二尖瓣瓣膜成形术(MVP)治疗中重度二尖瓣关闭不全(MR)患者的临床疗效。 方法以2013年6月至2017年6月徐州医科大学附属沭阳医院心胸外科收治的28例行MVP的MR患者为研究对象行回顾性分析,其中男性17例,女性11例;年龄50～72岁,平均(61.5±10.6)岁。所有患者术前均存在中重度MR。术前根据患者的合并症、病变部位的定位和合并腱索断裂与否,评估选择可行的MVP术式及合并手术：所有患者均采用正中切口、体外循环下手术治疗,术中行二尖瓣楔形切除、矩形切除及缘对缘缝合方法修补二尖瓣,合并腱索断裂或腱索冗长的行e-PTFE线人工腱索植入,常规行二尖瓣成型环植入,术中注水观察评估瓣膜成行效果。术中采取的二尖瓣成形方法统计：7例(25.0%)植入1～3根腱索,行二尖瓣矩切除术9例(32.1%),二尖瓣楔形切除术8例(28.6%),二尖瓣缘对缘缝合4例(14.3%),所有患者均置入鞍形二尖瓣成形环。对于合并心房颤动的患者同期行单纯左心耳切除术(LAA),或心房颤动射频消融术(AB)＋LAA;合并冠心病,则同期行冠状动脉搭桥术(CABG);合并中度及以上的三尖瓣关闭不全,则同期行三尖瓣成形环植入手术(TVP)。1例(3.6%)患者行MVP＋CABG,1例(3.6%)行MVP＋TVP＋LAA;3例(10.7%)行MVP＋TVP＋AB＋LAA;5例(17.9%)行MVP＋TVP;18例(64.3%)行单纯MVP。术后予华法林抗凝治疗3～6个月,合并心房颤动者终身抗凝治疗。统计所有患者采取的手术方式,包括合并手术、二尖瓣成形方法;对比患者术前及术后2年的返流、心功能改善情况以及LAD、左心室舒张末内径(LVEDD)、左心室射血分数(LVEF)水平的差异。 结果所有患者术前均为中重度返流,术后2年复查心脏彩超：21例(75.0%)无明显二尖瓣返流,6例(21.4%)二尖瓣轻度返流,1例(3.6%)二尖瓣中度返流。且所有患者的心功能较术前均提升1 ～ 2级。术前LAD[(49.42±12.58)mm],术后2年LAD[(38.17±9.84)mm],术前LVEDD[(50.91±7.93)mm],术后LVEDD[(44.37±7.42)mm],术后均较术前明显缩小;术前LVEF(51.69±9.71)%,术后LVEF(62.79±8.53)%,术后LVEF较术前明显增加。 结论MVP治疗MR安全有效、疗效显著,但远期效果还待进一步研究随访。     

"瓣中瓣"二尖瓣置换手术对左室功能的影响

目的 探讨"瓣中瓣"二尖瓣置换手术(保留二尖瓣和瓣下结构的瓣膜置换手术)对患者术后左室功能恢复的影响.方法 2009年4月至2010年12月收治64例二尖瓣关闭不全并左室增大(直径≥50 mm)的患者,其中施行"瓣中瓣"二尖瓣置换手术32例(研究组),行剪除二尖瓣及腱索的瓣膜置换手术32例(对照组).超声心动图检测并计算两组患者术后左室舒张末期直径(LVED)、左室射血分数(LVEF)、左室短轴缩短率(LVFS),并进行统计学比较.结果 术后随访2～14个月,无死亡病例.研究组术后2周、术后6个月LVED[(49.6±33.3)、(46.9±38.6)mm]小于对照组[(61.4±34.6)、(57.6±29.8)mm](P＜0.05),同时LVEF[(55±20)%、(59±25)%]高于对照组[(50±19)%、(51±21)%](P＜0.05).结论 "瓣中瓣"二尖瓣置换手术较剪除二尖瓣及腱索的瓣膜置换手术更有助于提高左室功能和改善心室重构.     

超声与手术结果诊断二尖瓣腱索断裂的临床对比研究

目的将超声诊断二尖瓣腱索断裂（MCTR）与手术结果进行对比。方法回顾性分析152例MCTR患者的超声心动图结果,并与手术结果进行对比。结果二尖瓣腱索断裂的特征较明显,对比结果发现本组152例中,145例术前超声与术后诊断结果相符,符合率为95.4%,准确判断前后叶脱垂和腱索断裂的符合率为92.8%（141/150）,判断完全和部分腱索断裂的符合率为88.2%（134/152）。结论超声心动图诊断二尖瓣腱索断裂准确率较高,可为手术治疗提供重要资料,值得在临床中推广应用。     

二尖瓣成形术在感染性心内膜炎二尖瓣关闭不全中的应用研究

目的评估二尖瓣成形术治疗自体感染性心内膜炎(infective endocarditis,IE)的可行性及中远期疗效。方法选取2011年1月-2015年6月医院收治的因感染性心内膜炎单纯累及二尖瓣并致二尖瓣关闭不全患者68例为研究对象,其中二尖瓣成形术(mitral valve plasty,MVP)19例为MVP组,二尖瓣置换术(mitral valve replacement,MVR)49例为MVR组。比较两组患者的一般资料及手术结局和随访情况。结果术前两组左心室舒张末内径(left ventricular diastolic diameter,LVDD)、射血分数(ejection fraction,EF)和心功能分级(New York Heart Association,NYHA)差异无统计学意义;MVP组手术方法采用彻底清除赘生物后,行瓣膜穿孔直接修补5例,心包修补5例,人工腱索5例(前叶3例,后叶2例),前叶三角形或楔形切除2例,后叶三角形或楔形切除9例,全组均植入二尖瓣成形环。MVR组植入机械瓣28例,生物瓣21例;手术后两组各死亡1例,MVP组死因呼吸衰竭,MVR组死因顽固性人工瓣心内膜炎;MVP组术中心脏复跳后经食道心脏超声(transesophageal echocardiography,TEE)显示15例无明显返流,3例轻度返流,1例轻中度返流,1例中度以上返流重新转流行MVR术;MVP组主动脉阻断时间长于MVR组(P<0.05);术后MVR组失访2例,共64例(MVP18例,MVR46例)进入随访,平均随访时间(41.5±25.6)个月,MVP组无二次手术,经胸超声心动图随访显示轻度返流4例,轻中度返流2例,中度返流1例;MVR组1例因瓣周漏二次手术,术后痊愈出院,余无死亡,无重大心血管事件。结论选择性应用MVP治疗IE所致的二尖瓣关闭不全手术安全可行,中远期疗效满意。     

二尖瓣脱垂返流的超声心动图量化评价

目的采用超声心动图连续方程法量化评价二尖瓣脱垂所致返流的严重程度。方法二尖瓣脱垂返流患者26例,采用Simpson方程获得左室心功能参数及二尖瓣返流的返流量(RV)和返流分数(RF)。结果连续方程法测得RV为(51.47±17.46)mL,RF为(43.23±9.13)%,ROA为(1.39±0.63)cm2,并获得了心功能量化参数。结论超声心动图连续方程法能精确量化二尖瓣脱垂所致偏心性返流的严重程度。     

三尖瓣隔瓣重建术在心内膜垫缺损矫治术中的应用

目的:探讨一种新的心内膜垫缺损合并三尖瓣隔瓣发育不良患者的三尖瓣隔瓣重建术,并探讨此术式的临床效果。方法:根据三尖瓣隔瓣和前瓣瓣叶及腱索的发育情况,采取不同的三尖瓣隔瓣重建方法,并于术前、术后(出院前)进行超声心动图检查,评价此术式的临床效果。结果:全组病例于三尖瓣成形术后,反流面积均较术前明显较少,其中87.5%的病例为轻度以下反流,未出现重度反流者。结论:改良三尖瓣重建手术方法既能达到三尖瓣环缩手术法的效果,又能保证有效的三尖瓣面积,且操作简单,取材方便,临床效果满意。     

Left ventricular outflow tract obstruction due to mitral annulus calcification in patient with mild concentric left ventricular hypertrophy

The combination of the systolic anterior motion of the anterior leaflet of the mitral valve and/or the mitral annular calcification in the case of asymmetrical septal hypertrophy has been fully recognized. However, in concentric left ventricular hypertrophy the systolic anterior motion of the anterior mitral valve and the massive posterior submitral calcification have not been commonly reported. We present a case with mild concentric left ventricular hypertrophy and massive posterior submitral calcification which displace the entire mitral ring anteriorly, namely, toward the left ventricular outflow tract. In this case, typical left ventricular outflow obstruction with systolic anterior motion of the anterior mitral valve was seen. Thus, we considered that this rare condition may have contributed to the formation of the systolic anterior motion of the anterior mitral leaflet in this case. We have provided additional information regarding the possible causes of systolic outflow obstruction in hypertrophic obstructive cardiomyopathy.     

Surgical treatment of mitral insufficiency using annuloplasty suture technic

In 1991 a simple and cheap technique was introduced for mitral valve repair at our department. After repairing the mitral leaflets, where indicated a posterior leaflet annuloplasty was performed with a semicircular suture and the annulus fixed for the appropriate size by tying the stitch. Between July 1991 and December 1995 86 patients underwent the above procedure (average age 56.8 +/- 10.4 years). 45 patients had primary mitral valve disease (myxomatous degeneration, rheumatoid disease, endocarditis), the other 41 had functional mitral regurgitation secondary to severe aortic valve or coronary artery disease. Echocardiography showed severe mitral regurgitation in 77% of the patients. In 45 cases the mitral valve itself was also repaired (valvotomy, quadrangular resection, wedge resection, etc.) in 29 cases the aortic valve was replaced as well, while 24 patients required additional revascularisation of the myocardium. The 30 day mortality was 3.5%. One week after surgery echocardiography was performed at all patients and showed acceptable mitral valve area (2.28 +/- 0.39 cm2). In 28 cases mild mitral regurgitation was found, the other valves were competent. All but 3 patients were followed up (96.4%). There were 6 late deaths (3 cardiac, 2 non cardiac, 1 embolic, 7.2% late mortality). During the follow up period (31.7 +/- 11.2 months) 5 patients required mitral valve replacement for severe recurrent mitral regurgitation (6.0%). In two cases new chorda rupture caused the recurrence, in an other case the suture had torn out of the annulus due to inadequate surgical technique. In the last two cases the annulus had dilated with intact Prolene annuloplasty stitch present, 86.8% of the survivors were in NYHA class I. or II. Our results suggest that mitral valve repair in selected cases can be performed without using expensive annuloplasty rings. The suture used for annuloplasty should be strong, non absorbable and non stretchable. Since 1994, when we started using GoreTex suture instead of Prolene no more patients required reoperation for annuloplasty failure.     

Correlation between anterior mitral leaflet concavity area and ischemic induced mitral regurgitation severity by echocardiography

Functional mitral regurgitation (MR) results from left ventricular remodeling, leaflet tethering or tenting. Coronary artery disease is one of the important causes of functional MR due to tethering. Detection of functional MR and its severity are important factors in patient prognosis. There are different methods for detection of functional MR and its severity, including anterior mitral leaflet concavity area (AMLCA). In this cross sectional study 32 patients, 19 male with three vessel disease (3VD) who were candidate for coronary artery bypass grafting (CABG) with or without mitral valve replacement were selected. The patients had functional MR in ventriculography. AMLCA was determined by long axis view of transthorasic echocardiography (TTE). In this study 32 patients with 3VD and MR were selected (15 mild, 15 moderate and 2 cases with severe MR). The mean age was 62 ± 12 years. In these patients AMLCA were 0.1- 0.43 cm2 in transthorasic echocardiography. The findings of this study showed strong association between anterior mitral leaflet concavity area and functional MR severity (r=0.89) in parasternal long axis (LAX) view of TTE. According to these findings the relation between functional MR and AMLCA was a linear relationship and increase in severity of functional MR was in concordance with increasing of anterior mitral leaflet concavity area (P=0.001). Mitral leaflet concavity area in the parasternal LAX view provides rapid and reliable recognition of functional MR due to coronary artery disease and is quantitatively related to the degree of such MR. We recommend further study with more subjects and ischemic functional MR and AMLCA.     

Determining factors in mitral valve reconstructive surgery. Report of 150 cases

150 patients had mitral valve repair for mitral valve incompetence. There were 57 males and 93 females with a mean age of 22 years. 60% of the patients were in Class II NYHA and 40% in Class III and IV. Type I was present in 18 patients, type II in 98 and type III in 34 cases. Mitral repair included correction of valve prolapse, valvular enlargement with pericardial patch and annuloplasty with semi-rigid ring in 128 cases and PTFE patch along the posterior leaflet in 12 cases. The perioperative mortality rate was 2.6%. All patients had early post-operative echocardiography. According to this, mitral regurgitation was absent or tiny in 135 patients, grade II in 10 cases and grade III in 2 cases. It was moderate or important in twelve patients. In the late post-operative period. All the others patients were reoperated upon for mitral dysfunction in a mean time of 37 months. The reason for reoperation was in the majority of the cases the recurrence of mitral regurgitation related to increase of valvular and sub valvular disease. The late mortality rate is 7%. Out of 126 reviewed survivors on the long run, 71 patients are asymptomatic in class I, 53 patients in class II and 2 patients in class III NYHA. The estimated mitral regurgitation by echography in those patients is absent or trivial in 96 cases. grade II in 29 cases and grade III in one case. Mitral valvuloplasty is the preferred procedure in mitral insufficiency surgical management. It is associated to a low early mortality and morbidity rate. Despite the need for reoperation in about 10% of the cases in the long follow-up, mitral repair offers a good quality of life without anticoagulant treatment.     

Relevant factors in mitral valve reconstructive surgery. Report of 150 cases

150 patients had mitral valve repair for mitral valve incompetence. There were 57 males and 93 females with a mean age of 22 years, 39% were less than 15 years of age. 60% of the patients were in Class II NYHA and 40% in Class III and IV. According to Carpentier's classification, isolated type I was present in 18 patients (12%), type II in 98 patients (64%) and type III in 34 cases (24%). Mitral repair included correction of valve prolapse, valvular enlargement with pericardial patch and annuloplasty with semi-rigid ring in 128 cases and PTFE patch along the posterior leaflet in 12 cases. The perioperative mortality rate was 2.6% (4 patients). All patients had early post-operative echocardiography. According to this, mitral regurgitation was absent or tiny in 135 patients (92%), grade II in 10 cases and grade III in 2 cases. It was moderate or important in twelve patients (8%). In the late post-operative period, three patients were lost to follow-up. All the others patients were reoperated upon for mitral dysfunction in a mean time of 37 months. The reason for reoperation was in the majority of the cases the recurrence of mitral regurgitation related to increase of valvular and sub valvular disease. The late mortality rate is 7% (10 patients). Out of 126 reviewed survivors on the long run, 71 patients (56%) are asymptomatic in class I, 53 patients (42%) in class II and 2 patients in class III NYHA. Mitral valvuloplasty is the preferred procedure in mitral insufficiency surgical management. It is associated to a low early mortality and morbidity rate. Despite the need for reoperation in about 10% of the cases in the long follow-up, mitral repair offers a good quality of life without anticoagulant treatment.