二尖瓣成形术在婴幼儿先天性心脏病中的应用

目的：总结二尖瓣成形术在婴幼儿先天性心脏病（先心病）中的应用.方法：自2007年10月至2012年10月,108例二尖瓣关闭不全（不包括完全性或部分性房室通道）婴幼儿行二尖瓣成形手术,所有婴幼儿中有3例（2.7％）行再次二尖瓣成形术.术中根据瓣膜病变情况选择合适的成形方法,包括二尖瓣瓣环环缩、Wooler瓣环成形术、瓣裂修补、乳头肌缩短技术及复合技术.对所有患者均行临床和超声心动图检查评估二尖瓣功能.结果：全组婴幼儿无死亡病例,所有婴幼儿复查超声心动图提示：二尖瓣残留少量反流23例（21.3％）,中度反流12例（11.1％）,重度反流3例（2.7％）,3例重度反流患几分别于术后2年、2年9个月及4年行再次手术,再次手术后1例无反流,2例少量反流.结论：二尖瓣成形术是婴幼儿先心病中二尖瓣关闭不全手术的首选术式,均能取得良好的治疗效果     

经食管二维与实时三维超声结合在风湿性二尖瓣病变成形术中的应用

目的:研究经食管二维与实时三维超声结合在风湿性二尖瓣病变成形术中的作用。方法:26例临床诊断为风湿性二尖瓣病变拟行二尖瓣成形术患者,术前联合应用经食管二维超声与实时三维超声,对二尖瓣功能不全进行分类,详细定位病变部位,测量二尖瓣前后叶厚度、长度及瓣环径。术后即刻评价疗效。结果:术前超声诊断单纯风湿性二尖瓣关闭不全10例(38.5%),单纯二尖瓣狭窄4例(15.4%),二尖瓣关闭不全重度伴狭窄轻度9例(34.6%),二尖瓣关闭不全重度伴狭窄中度3例(11.5%);瓣膜功能不全Ⅱ型4例(15.4%),ⅡAⅢa-P型18例(69.2%),Ⅲa-AⅢa-P型4例(15.4%)。术后即刻超声评价疗效,3例在超声指导下2次成形,其中2例最终选择瓣膜置换术。结论:经食管二维和实时三维超声心动图结合,在风湿性二尖瓣病变成形术前对瓣膜功能不全进行分类诊断,能准确评估二尖瓣叶厚度和长度,指导术式和人工瓣环的选择。术后即刻评价疗效,在风湿性二尖瓣成形术中有重要的应用价值。     

经食管超声心动图在二尖瓣成形术中的应用价值

目的探讨经食管超声心动图在二尖瓣成形术中的应用价值。方法术前18例二尖瓣关闭不全患者均常规经胸超声心动图检查,术中经食管超声心动图监测,并即刻评价二尖瓣成形术的效果。结果本组18例中16例一次性手术实施成功。1例术中监测发现反流2级后再次实施成形后成功,1例术中监测发现反流3级后改行二尖瓣置换术。结论经食管超声心动图在二尖瓣成形术中具有非常重要的临床应用价值。     

非风湿性二尖瓣关闭不全的外科治疗

目的 评价二尖瓣瓣膜成形术(MVP)对非风湿性二尖瓣关闭不全的疗效.方法 2001年1月至2005年12月我院非风湿二尖瓣关闭不全心脏患者23例接受手术治疗,男性13例,女性10例,年龄16～71(49.4±5.7)岁.非风湿性二尖瓣关闭不全病因中,其中先天性5例,退行性改变12例,缺血性改变4例,感染性病变2例.术前超声心动图示二尖瓣均为大量返流,术前患者心功能Ⅲ级19例,Ⅳ级4例.瓣环成形13例,腱索短缩3例,裂修补1例,腱索转移1例,后瓣环成形 裂修补4例,部分瓣膜切除 裂修补1例.同期冠状动脉搭桥术5例,主动脉瓣膜置换术3例.结果 早期死亡率4.3%(1例),术后超声心动图示无或少量二尖瓣反流13例,少量到中量反流8例,大量反流1例.随访6～60个月(平均27个月),出院后2例患者死亡,再次手术1例.存活20例,心功能Ⅰ～Ⅱ级.结论 应用二尖瓣膜成形术治疗非风湿性二尖瓣关闭不全是可行的,可以取得良好的效果,外科技术值得进一步推广.     

术中经食管超声心动图对心脏瓣膜置换术后即刻人工瓣膜功能异常的诊断价值

目的:探讨术中经食管超声心动图对心脏瓣膜置换术后即刻人工瓣膜功能异常的诊断价值。方法:回顾性分析2011年4月至2016年9月我院心脏瓣膜置换术后即刻急性人工瓣膜功能异常患者11例资料,总结术中经食管超声心动图结果,并与手术结果进行对照分析。结果:11例患者中,机械瓣置换术8例,生物瓣置换术3例。术中经食管超声心动图显示,瓣膜功能异常包括人工瓣膜梗阻(7例)及瓣膜关闭不全(4例)。术中经手术证实,人工瓣膜梗阻原因包括:残留血栓、残留腱索、保留二尖瓣后叶、主动脉瓣下隔膜、机械瓣离体瓣叶开放受限;人工瓣膜关闭不全原因包括:生物瓣瓣叶脱垂、缝线勒住生物瓣瓣脚及瓣膜内源性因素。11例患者再次接受手术,其中6例更换新的人工瓣膜,其余5例去除梗阻原因,所有患者均未再次出现人工瓣膜功能异常,住院期间无患者死亡。结论:经食管超声心动图可及时确认心脏瓣膜置换术后即刻人工瓣膜功能异常,协助判别内源性因素并指导外科补救。     

自体三尖瓣后叶材料在主动脉瓣和二尖瓣成形术中的初步临床应用

目的:探索利用患者自体三尖瓣后叶进行二尖瓣和主动脉瓣成形术的技术可行性.方法:2002年7月～2004年7月,13例患者接受了用自体三尖瓣后叶瓣膜成形手术.二尖瓣成形术6例,主动脉瓣成形术7例,男9例,女4例,平均年龄(29.7±11.3)岁.体外循环下剪除并修整三尖瓣后叶,作为成形材料进行二尖瓣或主动脉瓣成形.结果:术后1周复查超声心动图,二尖瓣成形患者的左心房前后径、左心室舒张末期内径及射血分数值较术前均显著减小(P＜0.05).平均随访(11.4±1.6)月后,主动脉瓣成形患者的左心室舒张末期内径较术前显著减小(P＜0.05),术中食道超声及术后随访超声心动图均未探及三尖瓣狭窄和关闭不全的存在.结论:自体三尖瓣后叶装置作为重建材料进行主动脉瓣或二尖瓣成形术,近期效果良好,取材后的三尖瓣功能完好,为瓣膜成形术提供了一种新的术式.     

综合应用二尖瓣成形术治疗复杂二尖瓣关闭不全的中远期效果

目的:回顾性分析综合应用二尖瓣成形术矫治复杂二尖瓣关闭不全的中远期临床效果。方法:2003年1月2014年3月,综合应用多项成形技术修复23例复杂二尖瓣关闭不全患者瓣膜,患者年龄14~71(45±23)岁。术前超声心动图提示二尖瓣关闭不全:中度6例,重度17例,均存在2个以上的反流点;联合应用后瓣矩形切除、前叶三角形切除、腱索缩短、腱索转移、缘对缘二孔化、置入人工腱索、置入人工瓣环等技术修复二尖瓣。术中采用注水试验和经食管超声心动图检查评估成形效果。手术后每年进行1次超声心动图检查,采用Kaplan-Meier方法评估术后随访期死亡率和无二尖瓣反流发生率。结果:全组患者无手术死亡和住院死亡,随访时间为(71±37)个月,2例患者失访(9%),1例患者于术后3年死于心力衰竭,预计11年总体生存率为95%。根据最近一次超声心动图随访结果,22例存活患者中,3例患者分别于术后9个月、72个月和96个月发生中度二尖瓣反流,免于中度以上二尖瓣反流的预计发生率为76.4%。无患者因为二尖瓣反流复发或者其它原因进行二次心脏手术。结论:正确判断二尖瓣闭锁不全的病理改变,综合应用多种成形技术可以取得良好的二尖瓣成形中远期效果。     

房室间隔缺损二尖瓣反流的手术治疗

目的总结先天性心脏病房室间隔缺损二尖瓣关闭不全的二尖瓣成形手术方法和临床效果。方法84例房室间隔缺损患者中,完全性房室间隔缺损9例、过度性房室间隔缺损21例、部分性房室间隔缺损54例。二尖瓣关闭不全的主要病理改变为瓣叶裂隙84例、瓣环扩大41例。二尖瓣成形方法为瓣叶裂隙缝合78例、交界环缩26例、瓣环环缩7例、双孔法2例等。术中左心室注水观察、评价成形后二尖瓣反流程度,脱离体外循环后食管超声心动图观察成形结果。结果全组死亡1例,1例因术后血尿行二尖瓣置换术。术后门诊随访,二尖瓣反流0￣Ⅰ级反流58例,Ⅱ级11例;术后随访,左心房、左心室缩小,与术前比较差别有统计学意义。结论房室间隔缺损二尖瓣关闭不全除瓣叶裂隙需要缝合外,还要矫正扩大的瓣环,术中注水试验和食管超声能为判断手术效果提供帮助。     

二尖瓣成形术46例临床分析

目的：总结二尖瓣成形术的治疗经验。方法：回顾近2年我科46例行二尖瓣成形术患的临床资料。瓣膜病变：风湿性7例、退行性变5例、先天性33例、缺血性1例。手术在中低温体外循环心内直视下进行，二尖瓣按瓣下、瓣叶和瓣环的顺序成形，同时矫治合并的心血管畸形。结果：全组无围术期死亡，并发症包括：心包积液2例，胸腔积液3例，低心排综合征1例。术后超声心动图提示二尖瓣未见返流41例，残留反流5例，其余患恢复良好，心功能较术前明显改善。结论：在严格掌握手术适应症的前提下，二尖瓣成形术可取得良好的效果。     

术中经食管超声心动图监测行二尖瓣成形术

目的　评价术中经食管超声心动图在二尖瓣成形术中的作用。方法　 1993年 3月至 2 0 0 3年 3月 ,6 2例二尖瓣关闭不全病人在经食管超声心动图监测下行二尖瓣成形术 ,男 2 4例 ,女 38例 ,平均年龄 (31 3± 7 5 )岁。病因为退行性变 4 2例 ,先天性 2 0例。重度二尖瓣关闭不全 5 9例 ,中度 3例。根据二尖瓣病变的特征进行相应的成形手术。结果　全组无一例手术死亡 ,8例改行二尖瓣替换术。术后超声心动图检查二尖瓣无返流 3例 ,轻度返流 4 9例 ,中度返流 2例。结论　经食管超声心动图在术中能即时判断二尖瓣成形术的效果 ,并找出失败原因 ,从而指导进一步成形术。     

先天性二尖瓣关闭不全患儿成形手术近中期结果分析

目的:总结先天性二尖瓣关闭不全患儿成形手术治疗的近中期结果。方法:选择自2016年1月至2018年1月因中重度二尖瓣关闭不全于我院行“三步法”二尖瓣成形术治疗的患儿70例。研究分析患者二尖瓣病变特征,术中操作要点,手术安全性和有效性,术后并发症及近中期随访结果。结果:70例患儿中男性31例,女性39例;年龄中位数23.83(四分位间距7.58,52.39)个月;身高85.50(67.75,105.25)cm;体重11.75(6.48,16.88)kg。手术均采用胸骨正中切口,均在全麻低温体外循环下进行。体外循环时间(102.10±40.65)min,主动脉阻断时间(67.76±32.97)min。术后住院15.50(11.75,25.75)天,术后早期死亡率为2.86%。术后二尖瓣中度以上关闭不全患者比例较术前显著降低(术前100%,术后7.14%;P<0.01)。术后随访20(17.45~26.30)个月。随访期间死亡率为1.5%,再次手术发生率为7.35%,二尖瓣中量以上反流发生率为14.71%。结论:“三步法”二尖瓣成形术是一种安全、有效的治疗方法,近中期结果良好,为二尖瓣关闭不全患儿提供了一种可靠的手术选择。     

Results of video-assisted mitral surgery in a non-selected population

A prospective 'analysis of operative risk and results in video-assisted mitral valve surgery performed in a non selected population is reported. Seventy two consecutive patients (1997-2004) with mean age 60 +/- 12 years underwent a video-assisted mitral valve procedure using a femoral CPB. A transthoracic direct aortic clamping was done in 28 patients (TT) and an endo-aortic occlusion balloon was used in 44 patients (Endo). The surgical approach was a right lateral minithoracotomy in all cases; 16 patients had a previous cardiac surgery. The expected mitral operation (39 repairs, 33 replacements) was done in all cases, without conversion. There were 4 early deaths (1 st month), all in Endo group: 1 aortic dissection, 1 heart failure and 2 sudden deaths. Postoperative complication occurred in 17 patients with 5 reoperations for hemostasis of the thoracic wall. Cumulative rate of mortality and morbidity was 29% in Endo and 28% in TT (ns). Hospital stay was 8 +/- 2 days. At discharge, 4 patients had a residual grade 2 echocardiographic mitral regurgitation after valve repair. In January 2005, with a 1.8 years follow-up, there were 4 late deaths, 3 patients underwent a valve reoperation, 2 patients were still in NYHA class 3 and 5 patients had a residual grade 1 or 2 mitral regurgitation. The 3-year actuarial survival was 86 +/- 10% and the 3-year probability to be free of reoperation was 95 +/- 6%. In mitral valve surgery, video-assisted approach is reliable, the operative risk is controlled and midterm results are not compromised. Video-assisted mitral valve surgery is a new less invasive standard; it is the procedure of choice in valve replacement, in reoperation and in non complex valve repair with good cosmetic results.     

Mitral valve repair for nonrheumatic mitral regurgitation

BACKGROUND: We studied the results of mitral valve repair in patients with severe mitral regurgitation of nonrheumatic etiology. METHODS AND RESULTS: Between January 1988 and April 2002, 116 patients, of which 59 were male and 57 female, with severe mitral regurgitation of nonrheumatic etiology, underwent mitral valve repair using a variety of techniques. Their mean age was 26.4 years (range 2-67 years). The cause of mitral regurgitation was congenital in 56 patients, myxomatous in 44, infective endocarditis in 7, and ischemic in 9. Ninety patients were in preoperative New York Heart Association class III, and 26 in class IV. Reparative procedures included posterior teflon felt collar annuloplasty (modified Cooley's) in 80 patients, chordal shortening in 37, cusp excision in 34, cleft closure in 8, chordal transfer in 6, and neochordae in 3. The early mortality was 3.4% (4 patients). Follow-up ranged from 1 to 167 months (mean 47 months), and was 95% complete. There were 2 late deaths (1.7%). Six patients (5.2%) underwent reoperation for severe mitral regurgitation post-repair. Of the remaining 104 patients, 90 (86.5%) had no or trivial mitral regurgitation at the last follow-up. Actuarial, reoperation-free, and event-free survival at 130 months was 93%+/-3.6%, 89.9%+/-6%, and 69.7%+/-13.7%, respectively. Ninety-two patients (88.5%) were in New York Heart Association class I at the last follow-up. CONCLUSIONS: Mitral valve repair in nonrheumatic mitral regurgitation patients provides satisfactory results with current surgical techniques, and is the preferred option in this subset of patients.     

Results of the Ross operation in rheumatic versus non-rheumatic aortic valve disease

BACKGROUND AND AIM OF THE STUDY: A total of 213 patients underwent the Ross operation at our institution between January 1990 and January 1999. Outcome was assessed in rheumatic (RH) patients and compared with that in patients with other etiology (non-RH). METHODS: After exclusion of 69 patients with a follow up of <18 months, the study group comprised 144 patients (119 RH, 25 non-RH). Patients were studied clinically and by echo-Doppler cardiography preoperatively, within 2 months and 6-8 months after surgery, and yearly afterwards. Preoperative assessment included age, gender, body surface area (BSA), type of aortic valve lesion and additional valve disease, left and right ventricular outflow tract (LVOT, RVOT) dimensions, and left ventricular (LV) size, function and mass. Postoperatively, patients were studied for presence and severity of autograft regurgitation, mitral regurgitation, LV size, function and mass, and incidence and timing of reoperation. RESULTS: On average, RH patients were older and had higher BSA, more aortic regurgitation than stenosis, more additional mitral valve disease (mostly regurgitation), larger LV size and poorer LV function. Mitral valve repair was performed in 24% of RH patients versus 0% of non-RH patients. Postoperatively, differences in LV size, function and mass remained present, but diminished during follow up. The autograft reoperation incidence was 22% (26/119) in RH patients versus 8% (2/25) in non-RH patients (p = NS). Preoperative predictors for reoperation in the RH group were severe concomitant mitral regurgitation (MR), followed by male gender and large indexed LVOT (all p<0.001 by discriminant analysis). CONCLUSION: Marked differences were present in patient characteristics between rheumatic and nonrheumatic patients who underwent the Ross operation. Rheumatic patients had a higher incidence of autograft reoperation. Severe concomitant MR was the most important predictor for reoperation in rheumatic patients.     

The place of closed mitral valvotomy in the modern cardiac surgery era

BACKGROUND AND AIM OF THE STUDY: The study aim was to investigate the long-term efficacy of closed mitral valvotomy (CMV). METHODS: Data obtained over a 36-year period from 1,134 patients who underwent CMV were analyzed. The analysis was carried out retrospectively from hospital records, with follow up examinations being conducted mainly at the outpatient clinic. RESULTS: In-hospital mortality (< or = 30 days after surgery) was 0.4% (n = 5, all closed procedures). Cardiac failure was the main cause of early death, and postoperative peripheral embolism occurred in five cases (0.5%). Freedom from thromboembolism was 99.0 +/- 0.5% at 36 years. Operative results were satisfactory in most patients, and severe mitral incompetence was seen only in three cases. Post-valvotomy mitral regurgitation occurred in 88 patients (7.7%) during the first year after CMV. Reoperation was performed in 500 patients (44.1%). The mean interval between CMV and reoperation was 141.1 +/- 80.8 months (range: 1-436 months). Fourteen patients were reoperated on for mitral regurgitation, 485 for mitral restenosis, and five for mixed mitral valve disease (stenosis and regurgitation). Freedom from reoperation after CMV was 81.4 +/- 1.3% at 10 years, 16.4 +/- 2.1% at 20 years, 3.1 +/- 1.2% at 20 years, and 0% at 36 years. Cox regression analysis indicated that impaired functional capacity, reduced mitral valve area, gradual increase in left atrial diameter and postoperative mitral insufficiency increased the reoperation rate after CMV. CONCLUSION: When compared with percutaneous balloon or surgical open valvotomy, CMV represents a satisfactory technique in terms of simplicity, high efficacy and lower cost.     

Mitral valve repair in patients with infective endocarditis.

BACKGROUND: The goal of the present study was to investigate the feasibility of mitral valvle repair in patients with infective endocarditis (IE). METHODS AND RESULTS: Twenty-one patients who had undergone mitral valve surgery for IE were reviewed. Valve repair was performed in 8 patients with active and in 6 patients with healed endocarditis: 6 of these 14 patients were New York Heart Association (NYHA) functional class III or IV preoperatively. Valve replacement was performed in 5 patients with active endocarditis and in 2 with healed endocarditis: 6 of these 7 patients were NYHA functional class III or IV preoperatively. Repair techniques included annuloplasty (n=13), resection-suture (n=13), chordal transfer (n=2), and closure of the perforation (n=3). In the valve replacement group, 6 patients required concomitant aortic valve replacement. In the valve repair group, 1 patient died and 1 patient required reoperation for recurrent mitral regurgitation. Postoperative echocardiography demonstrated no (n=8) or mild (n=4) mitral regurgitation at the last follow-up examination. In the valve replacement group, 1 patient died and 1 patient required reoperation because of a paravalvular leak. No cases of recurrent infection occurred in either group. CONCLUSIONS: Mitral valve repair in patients with IE is feasible and has low morbidity.     

室间隔缺损合并二尖瓣关闭不全15例的外科治疗

目的总结室间隔缺损合并中度二尖瓣关闭不全的手术治疗经验。方法15例室间隔缺损合并中度二尖瓣关闭不全,在行室间隔缺损修补术后,根据二尖瓣病变作相应处理,行交界折叠术7例,环缩后瓣瓣环6例,2例未加处理。结果15例患无手术并发症,无早期死亡。术后心脏超声检查发现3例二尖瓣有微一少量反流,余12例处理无反流,恢复顺利。结论室间隔缺损合并中度二尖瓣关闭不全进行相应处理可改善术后近期恢复及远期效果,避免再次手术。     

Aspekte der Mitralklappenrekonstruktion bei der chirurgischen Therapie der Mitralklappeninsuffizienz

Mitral valve repair (MVR) is the golden standard for the surgical treatment of mitral valve regurgitation and is superior to mitral valve replacement in terms of perioperative and long-term morbidity and mortality. However, the underlying disease has a significant impact on the functional long-term result of the repair. To evaluate the results of MVR, patients have to be divided by the underlying disease, degenerative mitral valve regurgitation, rheumatic mitral valve regurgitation, ischemic mitral valve regurgitation, and mitral valve regurgitation due to advanced cardiomyopathy. The best functional result for MVR can be achieved for degenerative mitral valve regurgitation (10-year freedom from reoperation for recurrent mitral regurgitation up to 94%) followed by patients with rheumatic mitral valve regurgitation (10-year freedom from reoperation for recurrent mitral regurgitation up to 82%). The progress in the underlying disease of the mitral valve is responsible for recurrent mitral valve regurgitation in these patients. For both underlying disease the 10-year survival rate is > 75%. For patients with ischemic mitral valve regurgitation the functional and survival rates are worse with a 5-year survival rate < 60% and recurrent mitral valve regurgitation > MI (mitral valve insufficiency) II degrees in 28% of patients within 6 months. However, ischemic mitral valve regurgitation is not a disease of the valve, it is a disease of the myocardium; thus, the myocardium is the key factor influencing the functional results of MVR and not pathologic changes in the mitral valve per se. There are no long-term results on patients operated on MI in conjunction with advanced cardiomyopathy; however, the initial mid-term results are encouraging with improved survival.Besides the underlying disease the timing of surgery is of utmost importance for the long-term survival; patients with preoperative NYHA functional class III/IV have a significantly worse short-term and long-term outcome compared to patients operated on for significant mitral valve regurgitation who have only minor or even no symptoms (NYHA class I/II). However, the compliance to undergo complex open-heart surgery via a median sternotomy in asymptomatic patients is very low. Minimally invasive endoscopic mitral valve repair may be an option to increase compliance in these patients, which will result in improved long-term survival with a normal life expectancy.     

Intraoperative Doppler color flow mapping for decision-making in valve repair for mitral regurgitation. Technique and results in 100 patients

Mitral valve repair provides substantial advantages over mitral valve replacement in patients with severe mitral regurgitation. However, because of the possibility of persistent regurgitation, an intraoperative technique is needed to provide an immediate and accurate assessment of the adequacy of the repair before closure of the chest. One hundred patients with pure mitral regurgitation were studied with intraoperative epicardial Doppler color flow mapping immediately before and after valve repair. Intraoperative assessment of the severity of mitral regurgitation showed good agreement with preoperative left ventriculography and with standard precordial Doppler echocardiography before and after surgery. Postrepair intraoperative Doppler studies showed satisfactory surgical results in 92 patients. Postrepair intraoperative Doppler studies in the remaining eight patients demonstrated unsatisfactory results: persistent significant regurgitation in four, systolic anterior motion of the mitral valve with dynamic left ventricular outflow tract obstruction in three, and a persistent flail leaflet in one. In six of the eight patients, further surgery was performed during the same thoracotomy. In two patients, the intraoperative postrepair Doppler findings of persistent regurgitation were confirmed on precordial Doppler studies within 5 days, and mitral reoperation was required. Intraoperative epicardial Doppler color flow mapping provided a "safety net" that ensured a successful outcome in all 100 patients by providing the surgeon with a direct means to assess the success of the operation and the need for further surgery.