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。     

二尖瓣置换术保留后瓣及瓣下结构28例

目的　了解保留后瓣及瓣下结构对二尖瓣置换术后心功能恢复的影响。方法　 5 2例病人分为两组 ,A组 (对照组 ) 1996年 12月至 1998年 8月共行二尖瓣置换 2 4例 ,切除全部瓣叶及瓣下结构 ;B组 (实验组 ) 1998年 12月至 2 0 0 0年 12月共行二尖瓣置换 2 8例 ,保留全部或大部分后瓣及瓣下结构。术后 1周均用彩色超声多谱勒测定心脏射血指数 (CI) ,每搏量 (SV ) ,射血分数(EF)。结果　B组各项观察指标均优于A组。结论　二尖瓣置换保留全部或大部分后瓣及瓣下结构有利于术后心功能的恢复。     

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。     

保留瓣下结构二尖瓣置换术的临床效果

随着对二尖瓣装置的生理作用及其与左心室功能关系的深入研究，Lillehei等在切除瓣下结构的传统二尖瓣置换术(conventional mitral valve replacement，MVRC)基础上提出了保留瓣下结构的二尖瓣置换术(mitral valve replacement with preservation of subvalvular apparatus，MVRP)。我们选择了各方面因素差异不大的近10年作为观察时限，从心功能恢复和术后生存两个方面对MVRP及MVRC病人进行回顾性研究，以探讨两种术式的临床效果．     

保留后瓣及瓣下结构的二尖瓣置换术

目的 探讨二尖瓣置换术保留后瓣及瓣下结构对术后左以功能的保护作用。方法 二尖瓣置找术保留后瓣及瓣下结构３５例,其中５例同时行主动脉瓣置换术。术后２周和６个月和超声惊动国图复查,对３５例行保留腱索和民的二尖瓣置换术患者（观察组）与同期未保留后瓣及瓣下结构的二法瓣置换术２０例患者（对照组）的心功能恢复情况进行比较分析。结果 术后２周两组左心室舒张期末径（ＬＶＥＤＤ）、左心室收缩期末径（ＬＶＥＳＤ）、射     

保留瓣下结构的二尖瓣置换术

二尖瓣瓣膜置换手术时，保留整个及部分二尖瓣瓣下结构对患者术后保持左心室功能、降低远期生存率及减少术后低心排出量综合征并发症有显著作用。2002年6月，2005年9月，我们共完成23例保留二尖瓣后瓣及瓣下结构的瓣膜置换手术（占我院二尖瓣置换术的68％），取得了良好的临床效果，现报告如下。     

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.     

二尖瓣替换术保留瓣叶及瓣下结构37例

二尖瓣替换术保留瓣叶及瓣下结构３７例梁智星，李大奇，孙长恩，高南翔，郭建军，梁法禹行二尖瓣替换术时保留瓣叶和瓣下结构对维护左室张力环、维持心肌收缩功能和防止左心室破裂有重要作用［１～３］。我们自１９９０年１２月至１９９２年１０月连续行保留瓣叶及瓣下结...     

二尖瓣置换术保留与不保留瓣下结构对术后早期血流动力学的影响

目的比较常规二尖瓣置换术（ＭＶＲ）与保留瓣下结构的二尖瓣置换术（ＭＶＲＰ）对术后早期血流动力学的影响。方法根据术中是否保留瓣下结构分为３组。Ⅰ组：常规ＭＶＲ，切除全部二尖瓣瓣叶及其瓣下结构；Ⅱ组：保留后瓣及其瓣下组织；Ⅲ组：全部保留二尖瓣装置。术后４小时、２４小时和４８小时分别采用Ｓｗａｎ－Ｇａｎｚ导管测定血流动力学指标：平均肺动脉压（ＭＰＡＰ）、肺毛细血管嵌压（ＰＣＷＰ）、肺血管阻力（ＰＶＲ）、外周血管阻力（ＳＶＲ）、心脏指数（ＣＩ）和左心室每搏作功指数（ＬＶＳＷＩ）。结果术后Ⅰ组ＭＰＡＰ，ＰＶＲ和ＰＣＷＰ均明显高于Ⅱ组和Ⅲ组；而ＣＩ和ＬＶＳＷＩ则低于Ⅱ组和Ⅲ组。结论保留瓣下结构可改善ＭＶＲ术后早期血流动力学，有利于心功能恢复     

Mitral valve repair for degenerative disease with leaflet prolapse: to improve long-term outcomes

Purpose  Residual mitral regurgitation (MR) is a risk factor of reoperation. Here we report the midterm results of mitral valve repair for degenerative disease with mitral valve prolapse and identify important factors for durable repair. Methods  From April 1999 to September 2007, 116 patients with leaflet prolapse (59 men; mean age 63 years) underwent mitral valve repair; they consisted of 19 anterior, 67 posterior, 23 bileaflet, and 7 isolated commissures. The mean clinical and echocardiographic follow-ups were at 4.1 ± 2.3 and 3.3 ± 2.4 years, respectively. Results  Altogether, 12 patients showed recurrent moderate or severe MR during the follow-up period; and 10 of the 12 patients (83.8%) had recurrent moderate or severe MR within 1.5 years. Causes of early MR recurrence were dehiscence of sutured segments and ineffectiveness of the artificial chords. The rates of freedom from reoperation at 3 and 7 years were 95.3% ± 2.0% and 91.0% ± 4.7%, respectively. The rates of freedom from recurrent moderate or severe MR at 3 and 7 years were 90.5% ± 2.9% and 83.8% ± 5.9%, respectively. Conclusions  The prevention of dehiscence of the sutured segment and reestablishment of coaptation using artifi- cial chords are imperative to maintain the durability of mitral valve repair for patients with degenerative disease. This study was presented at the 60th annual scientific meeting of the Japanese Association for Thoracic Surgery.     

二尖瓣成形术临床应用542例及随访

目的回顾性总结542例二尖瓣成形术病人的手术疗效和20年随访结果。方法1985年至2006年，542例二尖瓣病变的病人接受二尖瓣成形术，男306例，女236例。474例随访1-240个月，平均（41．03±40．40）个月，随访率90．8％。结果手术死亡20例（3．7％），出院时病人心功能均为Ⅰ级或Ⅱ级。随访死亡20例，再次手术23例；7年、10年和15年生存率分别为91％、88％和70％；7年和10年二次手术免除率分别为94％和86％。结论二尖瓣成形治疗二尖瓣病变，死亡率低，远期效果好。     

"缘对缘"二尖瓣成形术治疗二尖瓣前叶脱垂的早中期随访

目的 回顾性分析"缘对缘"二尖瓣成形术的早、中期效果.方法 1999年8月至2007年7月完成了128例"缘对缘"(edge to edge)二尖瓣成形术,分析其围术期及随访结果.结果 全组无手术死亡.平均随访46.8个月(1～97个月),无二次手术率96.9%,生存率98.4%.5例(3.9%)复发二尖瓣中、重度反流,其中4例(3.1%)行二尖瓣置换,1例早期缝线撕脱二次手术后死亡,1例拒绝二次手术而死亡.3例(2.3%)轻度二尖瓣狭窄,心功能Ⅰ级,仍在随访中.其余120例二尖瓣反流明显减轻(术前3.4对术后1.1,P＜0.05),心功能(NYHA)级别明显改善(术前2.4级对术后1.1级,P＜0.05).术后二尖瓣口面积平均为(2.45±0.70)cm2.左室舒张末径显著缩小[术前(57.9±9.0)mm对术后(48.6±7.6)mm,P＜0.05].术后左心室射血分数无明显改变(术前0.61±0.08对术后0.60±0.06,P=0.03).结论 "缘对缘"二尖瓣成形术是治疗二尖瓣前叶脱垂的安全、有效方法,早、中期效果良好.远期效果尚有待于进一步观察.     

Limited right anterolateral thoracotomy for mitral valve surgery

Objective: There has been great enthusiasm in recent years to perform mitral valve surgery through small multiple incisions with the use of the Port Access technique. The procedure is costly, involves a relatively long training curve and leaves the patient with multiple scars in the chest and groin. We used a mini-thoracotomy technique for mitral valve patients and compared our results with the conventional technique. Methods: We randomized 100 consecutive patients presenting to our practice for mitral valve surgery between two groups. The first group (test group) consisted of 50 patients in which mitral valve surgery was performed via mini-right anterolateral thoracotomy approach. The control group (50 patients) underwent classical mitral valve surgery through median sternotomy. Standard aortic and bicaval cannulation with antegrade blood cardioplegia was adopted in both groups. Results: There was no statistical difference between the two groups preoperatively regarding their age, pathology, LV function and male/female ratio. Most of the patients had valve replacement except four in the test group and three in the control group. The incision in the test group was 12–15 cm long in the right submammary groove. Direct aortic cannulation, clamping and cardioplegia administration was achieved in all patients easily. The mean bypass time was slightly longer in the test group (64±12 min) when compared with the test group (59±11 min). The cross-clamp time was lower in the test group (27±8 min) when compared with the control group (31±9 min). There was no hospital mortality in both groups and there was one morbidity in the form of sternal infection in the control group. The mean hospital stay was similar for both groups (7±2 days). Conclusion: The cosmetic appearance in the test group was excellent and the patients’ wounds were scarcely apparent in the female patients. The study demonstrates the efficacy and safety of this older technique, with excellent cosmetic results and no additional cost or risk to the patients.     

Long-term experience with the Sorin Bicarbon and Edwards Mira mechanical valve prostheses in the mitral position

OBJECTIVE: Sorin Bicarbon (SB) and Edwards Mira (EM) valves have an identical mechanical design but different sewing cuffs. The purpose of this retrospective study was to analyze the long-term clinical and echocardiographic outcomes after mitral valve replacement with these two valves in a combined population of patients. METHODS: We retrospectively reviewed records of 73 patients who underwent mitral valve replacement using SB (n = 19) or EM (n = 54) valves. Preoperatively, 49 patients (68.1%) were in New York Heart Association (NYHA) functional class III or IV. Concomitant procedures were performed in 52 patients (71.2%). Early and late postoperative echocardiography was performed in 69 and 57 patients, respectively. RESULTS: Operative mortality was 4.1%, and early morbidity was 9.6%. Overall patient survival at 9 years was 85.1% +/- 4.8%. Actuarial freedom from valve-related death was 95.4% +/- 2.6% at 9 years. As shown by Doppler echocardiography, the early and late mean transprosthetic pressure gradients were 3.4 +/- 1.4 mmHg and 3.8 +/- 2.1 mmHg, respectively. At the end of follow-up, 98.4% of survivors were in NYHA class I or II. CONCLUSION: The Sorin Bicarbon and, Edwards Mira mechanical valves in the mitral position provide satisfactory long-term clinical and echocardiographic performance.     

老年患者二尖瓣置换术265例分析

目的回顾性研究老年心脏瓣膜病的治疗效果. 方法对1991年6月～2003年6月期间收治的265例老年二尖瓣病变患者的一般情况、术式、合并疾病、手术过程和手术结果等临床资料,完成系统随访,分析其影响手术预后的众多高危因素. 结果生存252例,早期死亡13例,手术死亡率4.9%,主要死于心力衰竭和肾功能衰竭;随访236例,随访率93.7%.与同期60岁以下二尖瓣置换患者比较,术后5年和10年生存率均较低,分别为87.52%和96.84%,81.23%和94.87%.晚期死亡15例(0.17%病人*月),主要死亡原因是心力衰竭、恶性肿瘤和肺部感染.影响手术预后的因素有术前心功能Ⅳ级、糖尿病和肺功能不全. 结论老年心脏瓣膜病患者合并疾病多,手术死亡率和并发症发生率均较高.     

Combined anterior mitral valve leaflet retention plasty and septal myectomy in patients with hypertrophic obstructive cardiomyopathy

Objectives: Septal myectomy is the treatment of choice for patients with hypertrophic obstructive cardiomyopathy (HOCM) with significant left-ventricular outflow tract (LVOT) obstruction. In some HOCM patients, however, systolic anterior motion (SAM) of the anterior mitral leaflet significantly contributes to LVOT obstruction, resulting in mitral regurgitation and insufficient release of the obstruction after myectomy. We, therefore, developed a strategy of combined myectomy and anterior leaflet retention plasty (ALRP), and investigated its results in adult HOCM patients with manifest SAM. Methods: Subaortic septal myectomy and ALRP were performed in 25 adult HOCM patients with significant SAM, as assessed by echocardiography (mean age = 48.5 ± 15 years). All patients received cardiac catheterization and echocardiography evaluation prior to the operation, before discharge, and at follow-up. Follow-up ranged between 0.8 and 14 years (median = 2.5 years). Results: All patients survived the operation, and the Kaplan–Meier estimated survival was 100% at 1 year and 82 ± 6% at 5 years. Freedom from re-operation at 5 years was 83 ± 8%. The mean LVOT pressure gradient decreased from 84 ± 32 to 19 ± 11 mmHg postoperatively (p < 0.001), and only two patients had mild residual or recurrent SAM at follow-up. Mitral regurgitation and New York Heart Association classification were also markedly improved at follow-up. Conclusions: Combined subaortic septal myectomy and ALRP is a safe and effective therapy in HOCM patients with significant SAM. ALRP can help prevent residual or recurrent LVOT obstruction and improves mitral regurgitation.     

An alternative valve for mitral valve replacement in young children: using an NO-REACT® INJECTABLE BIOPULMONIC™ prosthesis as a mitral valve replacement in a 14-month-old child

Mitral valve replacement in infants is challenging and there are limited alternative valves available. Since the Boston group published their first report on alternative valves for mitral valve replacement in infants, there has been a growth in the literature on the topic, mostly based on the use of a stented bovine jugular vein graft (Melody^® valve). The challenges of the Melody valve are firstly in its length of 28 mm unexpanded, which has the potential to cause left ventricular outflow tract obstruction, and secondly, the valve needs mechanical dilatation, which is laborious. A modified No-React^® Injectable Biopulmonic™ Prosthesis (Bio Integral Surgical, Inc., Mississauga, ON, Canada) which is shorter (19 mm) and simpler in that it is self-expanding was implanted in a 14-month-old child to replace her mitral valve. The operation was successful and the short-term function of the prosthesis is good.