人工腱索移植术治疗二尖瓣前叶脱垂

用ePTFE缝线作人工腱索行二尖瓣成形术8例,共做人工腱索21根,同期行冠状动脉搭桥2例、房间隔缺损修补1例、三尖瓣成形3例.术后1例出现二尖瓣中度反流,再次转机,加用edge to edge技术后,食管超声复查示轻度反流,其余患者无二尖瓣反流或轻微、轻度反流.随访1～30个月,二尖瓣反流均无明显加重.认为ePTFE作为人工腱索治疗二尖瓣前叶脱垂效果可靠,术中准确确定人工腱索的长度是关键,术中食管超声心动图检查可确定手术效果.     

瓣叶切除与人工腱索治疗单纯二尖瓣后叶脱垂的病例对照研究

目的 比较单纯二尖瓣后叶脱垂应用瓣叶切除或人工腱索技术行二尖瓣成形术的手术效果。 方法 2010年12月至2013年12月, 384例患者病因单纯二尖瓣后叶脱垂导致的二尖瓣反流于我科行二尖瓣成形术,其中单纯人工腱索者33例（8.6%）、单纯瓣叶切除者258例（67.2%）。应用倾向评分匹配进行配对,分为人工腱索组（n=32）与瓣叶切除组（n=32）,并进行比较。回顾性分析两组围手术期情况及术后随访结果。结果 倾向评分匹配后人工腱索组和瓣叶切除组的各项术前指标无统计学差异。两组均顺利完成手术,无围手术期死亡。两组体外循环时间、主动脉阻断时间均有统计学差异（P=0.009、0.013）。人工腱索组使用较大二尖瓣成形环更多（P=0.019）。两组出院前左室射血分数（LVEF）、舒张期二尖瓣跨瓣峰值压差（TMG）均无统计学差异。平均随访（31.8±11.9）个月,两组患者生存、再次手术、≥中度二尖瓣反流、舒张期二尖瓣跨瓣峰值压差、再次手术均无统计学差异,但人工腱索组LVEF为（66.0±4.1）%,瓣叶切除组LVEF为（61.5±5.9）%,两组间有统计学差异（P=0.007）。 结论 人工腱索技术和瓣叶切除技术都可以有效地修复二尖瓣后叶脱垂。人工腱索技术与瓣叶切除技术相比更有利于术后左室功能,但两种技术在术后生存及二尖瓣反流情况上并无差异。     

改良人工腱索技术在右胸微创切口二尖瓣成形术中的应用及效果评价

目的 探讨改良人工腱索技术在右胸微创切口二尖瓣成形术中的应用技巧,并评价其治疗效果。 方法 2009年6月至2015年1月,经右胸微创切口应用改良人工腱索技术修复二尖瓣前叶或/和后叶脱垂引起的重度二尖瓣关闭不全58例,术中在脱垂瓣叶对应的乳头肌上将不带垫片的ePTFE缝线作“U”型缝合,两头的针线则均在距缘3~5mm处缝合于脱垂瓣叶的游离缘,先将每根线在脱垂的瓣缘缝两针,在置入“C”型二尖瓣成形环后,通过左心室的反复注水试验,调整人工腱索的长度至最佳位置,直至完全纠正瓣叶脱垂和二尖瓣反流,最后每根针线再在瓣缘缝一针,打结固定。术中常规应用经食道超声(TEE)评价成形效果。 结果 全部患者均成功接受二尖瓣成形术,每例患者平均植入2.1 ± 0.7根ePTFE人工腱索(1~3根)。术中平均体外循环时间约85.7 ± 9.5 min(72~123 min),平均主动脉阻断时间约61.9 ± 9.3 min(48~95 min)。二尖瓣成形术后,术中TEE显示二尖瓣无反流或微量反流47例,轻度反流11例。出院时,复查经胸超声心动图显示二尖瓣无反流或微量反流41例,轻度反流15例,轻中度反流2例。术后随访6~73个月(平均29.4 ± 18.9个月),无远期死亡;无反流或微量反流36例,轻度反流18例,中度反流2例,重度反流2例。术后1年、3年、5年时,中度以上二尖瓣关闭不全免除率为96.6 ± 2.4%、93.9 ± 3.5%、90.1 ± 5.0%。 结论 改良人工腱索技术可安全、有效地应用于右胸微创切口二尖瓣成形术中,操作简单易行,人工腱索的调整、固定方便,早、中期效果满意。术中根据二尖瓣的病变情况选用个体化的成形方法,适当的腱索数量、准确的腱索缝合部位及适宜的腱索长度是治疗成功的关键。     

38例二尖瓣成形术临床分析

目的总结38例二尖瓣成形术的临床经验.方法实施二尖瓣成形术38例,其中,后叶矩形切除9例,"双孔法"13例,后叶腱索转移3例,后叶矩形切除 "双孔法"2例,后叶腱索转移 "双孔法"3例,前、后交界环缩2例,单纯放人工瓣环4例,瓣叶穿孔修补2例.本组35例植入人工瓣环.结果术后经食管超声心动图(TEE)检查二尖瓣反流消失或微量反流32例,少量反流6例.1例术后第一天发生瓣膜撕裂,行二尖瓣替换术后痊愈.1例术后第九天因消化道出血,继发肾功能衰竭死亡.36例术后早期超声复查,二尖瓣舒张期流速0～1.9m/s,平均(1.23±0.39)m/s.跨瓣压差0～14.4mmHg,平均(6.61±3.56)mmHg.36例随访2～70个月,心功能Ⅰ级31例,Ⅱ级5例.结论对于二尖瓣关闭不全的患者,术中准确判断二尖瓣的病变,采用相应的成形技术,可以取得良好的早、中期治疗效果.     

右心瓣膜感染性心内膜炎的外科治疗

目的：总结右心系统瓣膜心内膜炎的特点和手术处理经验。方法：回顾性分析右心系统瓣膜感染性心内膜炎１７例,其侵犯三尖瓣６例、肺动脉瓣４例,同时侵犯三尖瓣＋肺动脉瓣３例,肺动脉瓣＋主动脉瓣３例,主动脉瓣、二尖瓣、三尖瓣与肺动脉瓣同时受累１例。合并心脏畸形１４例,室间隔缺损修补术后、主动脉窦瘤破裂修补术后、起博器安置术后各１例。施行三尖瓣瓣膜游离缘或瓣膜赘生物切除直接缝合５例、三尖瓣瓣膜赘生物切除用自体心包片修补２例、部分瓣叶和瓣下结构切除缝合瓣叶并行人工腱索成形术１例,施行三尖瓣置换术２例;单纯行肺动脉瓣瓣叶赘生物切除４例,部分肺动脉瓣切除用自体心包片瓣叶成形术６例,切除肺动脉瓣用自体心包瓣置换１例。结果：术后早期死亡２例,病死率为１２％,术后早期并发急性肾功能不全３例,肝功能不全１例。术后随访５个月～１８年,平均随     

二尖瓣成形术在二尖瓣反流治疗中的疗效评价

目的探讨二尖瓣成形术在二尖瓣反流治疗中的疗效。方法选取2011年1月至2014年7月在成都市第三人民医院行二尖瓣成形术的二尖瓣反流患者42例。手术方式包括人工瓣环置入,瓣叶部分切除,腱索修复、转移,人工腱索置入,缘对缘缝合技术等。术中左心室注水试验及经食道超声心动图检查评估即时效果,术后超声心动图随访二尖瓣反流、左心大小及左心室功能。结果 42例成功行二尖瓣成形术患者中1例围术期死亡。术后1个月、1年与术前相比,左心房内径(LAD)、左心室舒张末期内径(LVEDD)、左心室收缩末期内径(LVESD)均差异有统计学意义(P0.05);左心室射血分数(LVEF)在术后1个月变化不明显,但在术后1年监测中比术前增高,差异有统计学意义(P0.05)。二尖瓣无明显反流33例,微量反流5例,轻度反流3例。结论二尖瓣成形术是治疗二尖瓣反流的可靠方法 ,改善了左心结构重构及功能。     

巨大心脏患者二尖瓣成形手术疗效评价

目的：总结巨大心脏患者单纯二尖瓣关闭不全施行二尖瓣成形手术的疗效。讨论影响手术疗效的主要危险因素及手术适应证的选择原则。方法：以左心室扩大指数将扩大的心脏分级，结合患者病理改变的类型，对３３例巨大心脏单纯二尖瓣关闭不全的患者行二尖瓣成形术，并对其近、远期结果进行回顾性总结。结果：病理改变为单纯瓣环扩大５例；合并瓣叶脱垂２２例，其中腱索过长１８例，腱索断裂５例，腱索缺如１例，瓣叶裂隙４例；合并瓣叶增厚、腱索乳头肌融合６例。成形方法为单纯瓣环成形９例，合并腱索缩短１１例，脱垂部分切除缝合７例，腱索移植１例，乳头肌切开腱索松解３例，瓣叶裂隙缝合４例，放置人工成形环１４例。术后早期死亡８例（２４．２％）。结论：左心室扩大的程度、二尖瓣病变的类型及手术技术是决定手术疗效的主要因素。左心室扩大指数小于１．５者成形效果较好，１．５～２．０者可成形但应控制其他危险因素的程度，２．０以上者成形手术的疗效较差，应慎重选择手术适应证。     

人工腱索在修复先天性三尖瓣畸形中的应用

先天性三尖瓣畸形是累及三尖瓣瓣叶及其下结构的一系列疾病。此类病人中,其腱索常粗短或缺如,传统的三尖瓣成形术效果并不理想。事实证明,在二尖瓣修复中,应用聚四氟乙烯(ePTFE)增长或替换腱索是行之有效的方法。在三尖瓣修复术中却鲜有报道。该文着重阐述了人工腱索在三尖瓣修复中应用的方法和疗效。     

二尖瓣关闭不全的外科治疗

目的 总结二尖瓣关闭不全外科治疗的经验.方法 2001年1月至2007年7月共治疗二尖瓣关闭不全56例,男性25例,女性31例.先天性11例,风湿性3例,非风湿性42例,合并先天性心脏病19例.中度关闭不全18例,中度-重度关闭不全17例,重度关闭不全21例.病变类型腱索异常37例,如腱索断裂,缺如,一根或多根腱索延长;腱索和乳头肌异常11例;瓣叶发育异常16例;感染性心内膜炎造成的二尖瓣关闭不全3例;瓣环扩大54例.手术方式单纯腱索短缩13例,乳头肌劈开腱索包埋短缩8例,瓣叶和腱索移植5例,人工腱索再造2例.前瓣叶楔形切除或折叠9例,后叶矩形切除与sliding技术8例,缘对缘技术1例,感染性心内膜炎造成的二尖瓣损害局部修复3例.自制涤纶带环缩2例,二尖瓣环部分环缩38例,置入Duran环16例.结果 全组没有手术死亡病例.有2例在手术后8个月和15个月发生二尖瓣返流行二尖瓣瓣膜置换术;二尖瓣功能正常29例(51.79%),残留轻度关闭不全14例(25.00%),残留轻-中度关闭不全11例(19.64%).随访1～6年(2.3年),结果良好.结论 外科修复是治疗二尖瓣关闭不全的主要方法,该方法是安全,有效的,早期效果良好.     

Carpentier-Edwards生理环在退行性二尖瓣关闭不全二尖瓣成形术中的应用

【摘要】 目的 评价Carpentier-Edwards生理环在退行性二尖瓣关闭不全二尖瓣成形术中的应用效果。方法 2010年1月～2013年12月间,我院应用应用Carpentier-Edwards生理环在二尖瓣成形术中治疗退行性二尖瓣关闭不全的患者60例。结果 围术期无死亡。应用的手术方法：人工腱索23例、后瓣叶楔形切除34例、滑行切开技术2例、前叶三角形切除11例、瓣叶折叠5例、单纯人工瓣环置入13例。住院时间：14±3 d。并发症情况：室上性心动过速10例、窦性心动过缓2例,均治愈出院。术后均获随访。随访时间：1～4年。均存活。所有患者均无明显症状,NYHA心功能正常。最后一次复查超声指标左房内径、左室舒张末期内径、左室收缩末期内径、肺动脉收缩压均显著减小(P <0.01),左室射血分数、心输出量与术前比较均显著升高(P <0.01),二尖瓣反流程度明显减轻(P <0.01),跨瓣压差均<3mmHg。结论 严格掌握手术适应证、选择个体化手术方法处理瓣叶和瓣下结构和正确的瓣环置入技术,应用Carpentier-Edwards生理环治疗退行性二尖瓣关闭不全近中期疗效满意。     

Recurrent mitral regurgitation due to ruptured artificial chordae: case report and review of the literature

The use of expanded polytetrafluoroethylene (ePTFE) sutures has become an established method to correct mitral regurgitation due to elongated or ruptured mitral chordae. Mitral valve repair using artificial chordae has demonstrated excellent long-term results, particularly as ePTFE retains its flexibility with time and is highly resistant to mechanical stress. On conducting a literature review, four cases were found of recurrent mitral regurgitation due to the late (6-14 years postoperatively) rupture of ePTFE chordae. Herein, the case is described of artificial chordal rupture that required reoperation at 11 years after the initial mitral valve repair. In all previously reported cases, chordal rupture was related to the calcification of ePTFE, whereas in the present case only minimal calcification was observed at histology, and chordal rupture was most likely due to ePTFE fatigue-induced lesion. Although rare, rupture of the artificial chordae may cause recurrent mitral regurgitation; hence, the continuous monitoring of these patients, especially when the follow up extends beyond 10 years, appears mandatory.     

ePTFE人工腱索在二尖瓣成形修复术中的应用

目的评价使用ePTFE人工腱索治疗二尖瓣关闭不全的近期疗效。方法对15例接受ePTFE人丁腱索进行二尖瓣成形患者手术前后心功能,二尖瓣反流程度,左心室、左心房内径大小,左室射血分数进行对比。结果患者手术后心功能明显改善,心腔明显缩小。左室舒张末径从术前（59．70±6．23）mm减少为（47．30±5．54）mm,左室收缩末径从术前（39．60±5．46）mm减少为（33．40±5．33）mm,左房内径从手术前（50．20±8．19）mm减少为（39．00±5．23）mm,二尖瓣反流程度从术前3．5±0．5减少为1．1±0．3。结论ePTFE作为二尖瓣腱索的人工替代物近期疗效满意。     

Mitral valve repair: an in-vitro comparison of the effect of surgical repair on the pressure required to cause mitral valve regurgitation

BACKGROUND AND AIM OF THE STUDY: The study aim was to compare mitral valve repair techniques in vitro. Rupture or elongation of the mitral valve chordae tendineae is a known cause of mitral regurgitation, and can be corrected by edge-to-edge repair, chordal replacement, or chordal transposition. METHODS: A test apparatus was used to apply pressure to porcine mitral valves. Mitral valve specimens were tested intact (n = 50), after they had been experimentally damaged, and after repair. Each test was repeated ten times. Experimental damage consisted of severing either the anterior leaflet strut, and attached marginal chordae (n = 30) or posterior leaflet chordae (n = 20). Valves with damaged anterior leaflets were repaired by either: (i) edge-to-edge repair; (ii) chordal replacement; or (iii) chordal transposition. Valves with damaged posterior leaflets were repaired by the first two techniques. Each repair method was repeated on ten specimens. RESULTS: Mitral valves repaired using the edge-to-edge repair (p = 0.002) and chordal replacement (p = 0.038), after rupture to anterior leaflet chordae, recovered significantly better than specimens repaired by chordal transposition. There was no statistical difference in recovery between edge-to-edge repair and chordal replacement (p > 0.05). There was no statistical difference (p > 0.05) in the recovery of the pressure withstood by valves repaired by edge-to-edge repair and chordal replacement, after rupture of posterior leaflet chordae. CONCLUSION: These results showed that edge-to-edge repair and chordal replacement are well suited for the repair of both the anterior and posterior leaflets.     

Repair of a dysplastic tricuspid valve using artificial chordae: case report

Atrioventricular valve repair with artificial chordal replacement has been widely used for congenital and acquired mitral valve abnormalities, but not for tricuspid valve abnormalities. A case is presented of dysplastic tricuspid valve that was successfully repaired using artificial chordae. A 2-year-old female presented with poor weight gain. Echocardiography revealed severe tricuspid regurgitation due to dysplastic tricuspid valve, poor coaptation by prolapse of the anterior leaflet, and tethering of the septal leaflet by short chordae. The prolapsed anterior leaflet was repaired with three pairs of 6-0 expanded polytetrafluoroethylene sutures. The short chordae of the septal leaflet were detached, and the septal and posterior leaflets were sutured together. Trivial tricuspid regurgitation was noted postoperatively. There was no tricuspid regurgitation during the follow up period of three years. The present case provides further evidence that artificial chordal replacement is a useful technique even for small children with congenitally abnormal tricuspid valves.     

Artificial chordae for mitral valve repair: mid-term clinical and echocardiographic results

BACKGROUND: This paper reports on the mid-term clinical and echocardiographic results of mitral valve repair with chordal replacement. METHODS: Sixty-nine patients (mean age 61 +/- 14 years) underwent mitral valve repair with chordal replacement. The etiology was degenerative in 53 (77 %), rheumatic in 7 (10 %), ischemic in 6 (9 %) and infective in 3 (4 %). Mean ejection fraction was 58 +/- 14. In 35 patients (51 %), a minimally invasive approach was used. Mean follow-up time was 45 +/- 27 months. RESULTS: Anterior leaflet chordae were replaced in 58 (84 %) patients. There were 3 operative deaths. Freedom from non-trivial recurrent mitral regurgitation (MR) was 81.3 +/- 8.7 % at 97 months. Follow-up echocardiographic controls showed mild recurrent MR in 5 (8 %) patients and moderate in 2 (3.2 %). These two patients required reoperation due to mitral annulus redilation after suture annuloplasty. Competent neochordae were found at reoperation. Freedom from reoperation at 97 months was 96.6 +/- 2.4 %. Four patients died during follow-up resulting in an actuarial survival of 87 +/- 6.2 %. CONCLUSION: The replacement of chordae tendineae with ePTFE sutures during mitral valve repair has shown good mid-term results. The implantation of the neochordae can be also performed safely using minimally invasive procedures.     

Mitral valve repair for severe mitral regurgitation caused by endomyocardial biopsy

Mitral regurgitation (MR) following endomyocardial biopsy is a rare and severe complication. A 70-year-old man with severe MR due to chordal injury caused by left ventricular endomyocardial biopsy is described. In this patient, a few chordae tendineae of the posterior-median papillary muscle were injured by the biopsy forceps. Due to the chordal rupture, both anterior and posterior leaflets were prolapsed and severe MR developed. MR was successfully treated by artificial chordal replacement using extended polytetrafluoroethylene sutures and ring annuloplasty. This mitral valve repair with artificial chordal replacement was considered suitable to treat MR resulting from iatrogenic chordal injury as the leaflets were not involved in the degenerative process and papillary muscle function was preserved. To avoid MR, the transvenous approach should be used routinely for endomyocardial biopsies; biopsy from the left ventricle is not justified.     

Acute mitral regurgitation due to ruptured ePTFE neo-chordae

Chordal replacement with expanded polytetrafluoroethylene (ePTFE) sutures has proven to be a simple, versatile, and durable technique for the treatment of prolapsed cusps causing mitral valve regurgitation. ePTFE is known for its strong resistance to tension, and is judged to be unbreakable under physiological conditions. Herein are reported two cases of rupture of synthetic chordae tendineae; the possible causes of this extremely rare finding are analyzed.     

Long-term pathological changes of expanded polytetrafluoroethylene (ePTFE) suture in the human heart

Expanded PTFE (ePTFE) sutures have been used widely as a mitral chordal substitute. We present a structural analysis of ePTFE sutures implanted as artificial chordae for 7.5 years and 8.6 years in patients with mitral regurgitation. No calcification was found either macroscopically or microscopically, and the ePTFE suture retained its normal flexibility. The suture was totally encapsulated with host tissues composed of dense fibrous tissue covered with endothelial cells.     

Preservation of left ventricular function in mitral valve surgery.

Surgery for degenerative mitral regurgitation has become complex. Preservation of annulo-ventricular continuity through the chordae tendineae is an important determinant of operative survival, postoperative left ventricular function, long-term survival, and quality of life. Some cardiologists believe that NYHA I function is never achieved after conventional mitral replacement with chordal transection. Valve repair is the procedure of choice but when valve replacement is inevitable every effort should be made to preserve the posterior leaflet and its chordal attachments. Valve replacement with preservation of the subvalvar apparatus provides a functional outcome similar to that after valve repair but usually leads to life long anti-coagulation.     

Tricuspid valve repair with artificial chordae in a 72-year-old woman

Expanded polytetrafluoroethylene sutures have been used for the replacement of chordae tendineae since 1985, especially for mitral valve prolapse. There are only a few reports of artificial chordae tendineae to treat tricuspid valve regurgitation. We report on a 72-year-old woman in NYHA class III preoperatively, who underwent successful tricuspid valve repair after preoperative echocardiography revealed tricuspid valve regurgitation grade IV, caused by prolapse of the anterior leaflet (A1-A2) and annular dilatation. Tricuspid valve repair was performed using artificial chords consisting of two polytetrafluoroethylene sutures and a ring annuloplasty. Postoperative echocardiography revealed mild tricuspid valve regurgitation of less than 1°, even after three years. Gore-Tex? sutures as used in mitral valve repair are an excellent option to replace chordae tendineae in tricuspid valve prolapse. This approach represents a safe and effective technique for tricuspid valve repair.