预制人工腱索环和二尖瓣成形环置入术治疗二尖瓣脱垂

目的:回顾预制人工腱索环和二尖瓣成形环置入术治疗二尖瓣脱垂,探讨此手术对二尖瓣脱垂的治疗效果。方法:2008年1月至2012年12月间,回顾性分析北京安贞医院收治的15例二尖瓣脱垂患者,其中男性10例,女性5例,年龄(48.5±3.2)岁,SBE后腱索断裂导致关闭不全2例,单纯腱索断裂导致关闭不全8例,腱索延长导致关闭不全5例。术前超声心动图(TEE)显示:根据Carpentier标准,前叶脱垂10例,后叶脱垂3例,前叶合并后叶脱垂2例。所有患者二尖瓣均为重度关闭不全,反流面积(11.0±0.9)cm2,1例合并三尖瓣重度反流。术前射血分数(EF)平均(64.9±1.9)%,左心室舒张末直径(LVDD)平均(54.9±1.4)mm,左心房直径(LA)平均(42.9±1.7)mm。所有患者均经胸正中切口,体外循环下行预制人工腱索环移植,移植腱索数量为(3.6±0.3)根,腱索长度(15.4±1.5)mm,平均体外循环时间(113±11.7)min,平均主动脉阻断时间(86±9.8)min。3例患者置入SJ成形环,12例患者置入爱德华成形环,1例患者同时行三尖瓣成形术。结果:术后无死亡,无恶性心律失常及其他严重并发症。术后复查TEE显示少量反流3例,微量反流8例,未见反流4例。术后EF平均(60.2±2.9)%,未见明显改变。LVDD平均(46.5±1.1)mm,LA平均(32.9±1.2)mm,均较术前明显改善。随访12~57个月,平均(35.7±4.3)个月,少量反流3例,无或微量反流12例。结论:预制人工腱索环和二尖瓣成形环置入术治疗二尖瓣脱垂近中期效果确切,但是远期预后尚需进一步观察。     

三步标准化儿童二尖瓣成形手术在儿童容量负荷型二尖瓣反流中的应用

目的：探索儿童容量负荷型二尖瓣反流的最佳外科成形策略。方法：回顾2020年4月至2022年3月期间在中国医学科学院阜外医院接受初次二尖瓣成形术的110例容量负荷型二尖瓣反流患者,平均年龄（14.5±15.1）个月,男性42例（38.2%）。其中69例患者接受三步标准化儿童二尖瓣成形手术（标准化组）,41例患者接受单纯瓣环环缩术（单纯环缩组）。倾向性评分匹配后,共纳入38对患者。比较两组主要终点事件（二尖瓣功能衰竭和术后心力衰竭）发生率。结果：在26.3(19.8,32.9)个月的电话随访及11.9(7.5,14.8)个月的超声心动图随访期间未发生全因死亡,共有1例（0.8%）患者发生院内计划外的二次成形手术,7例患者（单纯环缩组：标准化组=3:4）在术后6个月及以后的超声心动图随访提示中到大量二尖瓣反流复发,9例患者（单纯环缩组：标准化组=5:4）出院1个月后超声心动图提示心力衰竭,两组间差异无统计学意义。倾向性评分匹配后,标准化组体外循环时间[113(90,132)min vs. 90(77,114) min]和主动脉阻断时间[80(61,92) min vs. 62(49,83)m...     

人工腱索加二尖瓣成形环治疗非风湿性二尖瓣关闭不全

目的:评估二尖瓣修补治疗非风湿性二尖瓣反流患者的效果。方法:1997-06至2007-06,本组为301例非风湿性二尖瓣关闭不全的患者施行了二尖瓣成形手术,其中162人为男性,139人为女性,117人为中度关闭不全,184人为重度关闭不全。平均年龄为(53.2±16.4)岁(15～72岁)。术前NYHA心功能Ⅱ级55例,Ⅲ级187例,Ⅳ级59例。99例前瓣脱垂(腱索断裂64例,腱索延长35例),后瓣脱垂139例(腱索断裂88例,腱索延长51例),前、后瓣都脱垂63例。患者中7例合并冠心病,1例合并主动脉瓣关闭不全,12例合并三尖瓣关闭不全,11例合并房间隔缺损(继发孔型)。手术均使用可膨胀聚四氟乙烯缝线替换腱索(4CVGore-Tex缝线)。所有患者都有不同程度的二尖瓣环扩张,都常规使用二尖瓣瓣环成形环施行瓣环成形。所有手术都在全麻、中度低温(28℃～31℃)及体外循环下进行。平均主动脉阻断时间为(76.2±12.3)min。结果:1例术后早期死于多脏器功能衰竭,1例患者术后因重度二尖瓣反流导致溶血而施行了机械瓣置换。除死亡和换瓣者以外,所有患者术后都予以随访(2个月～10年)。除1例外,其余的患者术后心功能...     

经房间隔或经主动脉切口治疗二尖瓣反流合并主动脉根部瘤的疗效比较

目的:回顾性分析采用经房间隔切口,或者经主动脉切口对主动脉根部瘤合并二尖瓣病变进行二尖瓣置换的病例,对比两种二尖瓣手术入路的临床效果,探讨最佳的手术方式。方法:2011年1月至2014年12月,首都医科大学附属北京安贞医院50例主动脉根部瘤合并二尖瓣病变的患者接受Bentall+二尖瓣置换术,其中经主动脉切口置换二尖瓣的患者25例(主动脉切口组),经右心房和房间隔切口置换二尖瓣的患者有25例(房间隔切口组)。主动脉切口组中,男性22例,女性3例,平均年龄(37.8±3.0)岁,二次开胸手术1例;房间隔切口组中,男性18例,女性7例,平均年龄(49.6±3.5)岁。结果:主动脉切口组患者手术后ICU停留时间为(27.5±4.5)h,与房间隔切口组(36.3±10.78)h,差异无统计学意义(P0.05)。两组患者均无术后死亡,无恶性心律失常及其他严重并发症的发生,均顺利出院。主动脉切口组随访8~56个月,平均(34.3±18.6)个月,有1例出现二尖瓣瓣周漏和左冠状动脉吻合口漏;房间隔切口组随访8~56个月,平均(31.6±14.4)个月,有1例出现二尖瓣瓣周漏。结论:经主动脉切口对主动脉根部瘤合并二尖瓣病变行二尖瓣置换术在手术时间、心脏损伤,二尖瓣暴露以及二次开胸手术等方面较之房间隔切口有不可比拟的优势。足够的主动脉窦部内径及主动脉瓣环径是对主动脉根部瘤合并二尖瓣病变的患者应用这一技术行二尖瓣置换的前提条件。     

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.     

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。     

应用自体心包条行二尖瓣瓣环成形的疗效评价

【摘要】目的 总结自体心包成形条在二尖瓣成形术中的应用及临床疗效。方法 回顾性分析2011年11月至2015年9月我院采用二尖瓣成形术治疗169例二尖瓣关闭不全患者的临床资料,其中男102例,女67例;年龄20～79(47．5±10．5)岁;术前超声心动图发现二尖瓣中度反流(Ⅲ级)32例,重度反流(IV级)137例。手术方法为体外循环下修复二尖瓣瓣叶及瓣下结构,同时所有病例均使用心包条环缩瓣环。手术中注水试验和经食管超声心动图评价成形效果。 结果 平均体外循环时间(120．6±30．3)min,主动脉阻断时间(65．6±15．5)min,围术期死亡3例,死亡原因为低心排综合征、多器官功能衰竭和败血症。术后心脏超声心动图提示：二尖瓣无反流(0级)99例,微量反流(Ⅰ级)43例,轻度反流(Ⅱ级)22例,轻至中度反流(Ⅲ级)2例。所有患者均无二尖瓣狭窄和二尖瓣收缩期前向运动（SAM）。术后随访150例(90.3％),随访时间12～40个月。随访期间2例死亡,其中1例死因与心脏疾病无关;3例行二尖瓣置换术。随访期超声心动图显示左房直径、左室舒张末直径明显减小(P<0．05)。NYHA心功能分级I级119例、Ⅱ级26例。结论 二尖瓣成形术中应用自体心包条环缩成形是简单、安全、有效的,能较好的维持左心功能,早期疗效满意。     

二尖瓣成形环瓣环环缩术在缺血性二尖瓣返流中的应用

目的 研究应用二尖瓣成形环行瓣环环缩术治疗缺血性二尖瓣返流的手术效果。方法 选择2000年1月~2015年12月在我院行二尖瓣成形术的缺血性二尖瓣返流并发室壁瘤的患者72例,根据二尖瓣病变部位及性质选择成形方案,其中33例使用二尖瓣成形环进行瓣环环缩术。回顾性分析手术的近期、远期治疗效果。结果 围手术期死亡4例（6%）。术后二尖瓣返流程度较术前明显改善,中度及中度以上二尖瓣返流1例（1%）。术后随访(5±3)年,随访期死亡11例（16%）,出现中度及中度以上二尖瓣返流12例（18%）。是否使用成形环进行瓣环环缩术后早期二尖瓣返流程度无统计学差异,但远期成形环环缩组较对照组二尖瓣返流程度有显著改善（P<0.05）。结论 缺血性二尖瓣返流并发室壁瘤的患者中,二尖瓣成形术可安全、有效地重建二尖瓣功能。使用成形环进行瓣环环缩可改善远期效果。     

全胸腔镜下二尖瓣手术97例经验总结

目的:探讨经胸壁三孔完全胸腔镜下二尖瓣手术的治疗效果及安全性。方法:回顾性分析2012-02-2018-02在兰州大学第二医院心脏外科接受完全胸腔镜下二尖瓣成形或置换手术患者的临床资料。男56例,女41例;年龄20～73岁,平均(58±17)岁。所有患者患有二尖瓣中-重度狭窄和(或)关闭不全,其中鲁登巴赫综合征3例,合并心房颤动19例,合并重度肺动脉高压18例,合并三尖瓣关闭不全40例。手术采用股动脉、静脉插管建立体外循环,阻闭升主动脉,冷血心脏停跳液顺行灌注行心肌保护,完全胸腔镜下行二尖瓣成形或置换术。结果:本组97例患者均顺利完成手术,无手术死亡。全组无术后残余漏、瓣周漏,6例发生术后早期并发症,分别为肾功能不全4例,经治疗后均恢复正常,二次开胸止血1例,术中扩大切口1例,均顺利恢复。平均体外循环时间(165±45) min;平均升主动脉阻断时间(102±41) min;平均手术时间(238±57) min。平均术后呼吸机辅助时间(19±11) h,平均ICU停留时间(28±13) h,术后平均引流量(278±86) ml,平均住院时间(9.5±3.8) d。术后左室射血分数较术前无明显降低(P=0.112),术后左心房明显缩小(P=0.046);其中,二尖瓣关闭不全患者术后左心室内径明显缩小(P=0.039)。置换后的人工瓣膜和成形后的自体瓣膜均正常关闭,无瓣周漏,无狭窄或关闭不全。随访3～72个月,全部病例中,5例有轻度肾功能不全表现,余无其他并发症或死亡。结论:完全胸腔镜下二尖瓣手术的手术操作安全,创伤小,疗效确切,在二尖瓣疾病的外科治疗方面有着良好的应用价值。     

成人再次二尖瓣成形术的临床特征分析

目的分析二尖瓣成形术后复发性病变的病因,总结再次二尖瓣成形术的手术技术和效果。方法回顾分析2012年1月至2019年10月阜外医院19例行再次二尖瓣成形术的成人患者的临床资料,男12例,女7例,首次手术年龄4~66岁,平均(34.9±22.6)岁。先天性二尖瓣关闭不全7例,退行性二尖瓣关闭不全12例。再次手术时年龄18~81岁,平均(43.5±19.1)岁。两次手术间隔2~430个月,平均(118±116)个月。再次手术同期进行三尖瓣成形术5例,冠状动脉搭桥手术2例,左房血栓清除1例。术前心胸比0.56±0.07,左房内径(LA)为(49.4±8.5)mm,左室舒张末径(LV)为(56.6±5.9)mm,左室射血分数(LVEF)62.6%±7.8%。结果手术失败组包括瓣叶缝线撕脱5例,瓣叶裂未完全缝合2例、人工瓣环瓣周漏2例、人工腱索撕脱1例。病变进展或新发病变组包括新发瓣叶脱垂4例,瓣环明显扩张2例,自体腱索断裂1例,感染性心内膜炎1例,二尖瓣相对性狭窄1例。本组患者体外循环时间(109±53)min,阻断时间(70±29)min,术后呼吸机使用时间(16±5.8)h。围术期无死亡。出院时有2例二尖瓣少中量反流,LA为(42.9±6.1)mm,LV为(53.4±6.3)mm,LVEF为59.3%±3.8%。术后随访(21.0±14.9)个月。1例术后2个月出现感染性心内膜炎,二尖瓣中量反流。另有1例术后10个月发生脑梗死。无死亡、再次手术患者,心功能均为Ⅰ级或Ⅱ级。结论二尖瓣成形术后出现复发性二尖瓣病变患者,在瓣叶条件良好,反流原因明确情况下,行再次二尖瓣成形手术可以获得满意的围术期结果,近中期疗效良好。     

Floppy mitral valve, mitral valve prolapse, and mitral valvular regurgitation

Opinion statement  

Floppy mitral valve/mitral valve prolapse and genetics

Mitral valve prolapse (MVP) is a defect in the mitral valve where a redundancy of valve tissue is associated with a variety of clinical expressions, ranging from an isolated mild bulging of the mitral valve to a severe prolapse of the mitral valve with extensive mitral regurgitation. As the natural history and complications of MVP are not always benign, it seems essential to strive for the proper management of these patients. The identification of functionally related genes could provide helpful clues and increase the present understanding of the pathogenesis of MVP, with the ultimate goal of developing targeted therapies. The genetics of MVP can be divided into two parts: (i) Genetics in floppy mitral valve/MVP; and (ii) genetics in heritable connective tissue disorders (Marfan syndrome, polycystic kidney, etc.) associated with floppy mitral valve. Herein, the known genetic aspects of MVP are described, according to the above-mentioned scheme.     

Progression of mitral regurgitation in patients with mitral valve prolapse

Mitral valve prolapse (MVP) is a very common clinical entity which is frequently associated with mild mitral regurgitation (MR) and which most commonly becomes clinically manifest in the third and fourth decades of life. Severe MR associated with MVP, occurs much less frequently and is most commonly seen in patients above the age of 50 years. Relatively little information is available regarding the progression of mild to severe MR in patients with MVP. This report reviews a recent study which investigated the progression from mild to severe MR in patients with MVP. The study included 86 patients, average age 60 years, who presented with cardiac symptoms and severe MR. A high incidence of MVP was seen on echocardiograms (57 of 75 [75%]) and on left ventriculography (61 of 84 [73%]). Mitral valve replacement was performed in 75 patients. Pathologically all valves appeared grossly enlarged, severely floppy and had extensive myxomatous changes with collagen dissolution. 80 patients had a pre-existing heart murmur first detected at average age 34. Patients remained asymptomatic for an average of 25 years at which time clinical symptoms first appeared. After symptoms developed mitral valve surgery was necessary in most patients within one year. This rapid deterioration could partially be attributed to ruptured chordae in 39 of 76 patients (51%) or atrial fibrillation in 48 of 86 patients (56%). 28 patients had one or more serial clinical evaluations including auscultation, chest x-ray, echocardiography, and cardiac catheterization.(ABSTRACT TRUNCATED AT 250 WORDS)     

One-year outcome of percutaneous mitral valve repair in patients with severe symptomatic mitral valve regurgitation

AIM To investigate one-year outcomes after percutaneous mitral valve repair with Mitra Clip~? in patients with severe mitral regurgitation(MR). METHODS Our study investigated consecutive patients with symptomatic severe MR who underwent Mitra Clip~?implantation at the University Hospital Bergmannsheil from 2012 to 2014. The primary study end-point was all-cause mortality. Secondary end-points were degree of MR and functional status after percutaneous mitral valve repair.RESULTS The study population consisted of 46 consecutive patients(mean logistic Euro SCORE 32% ± 21%). The degree of MR decreased significantly(severe MR before Mitra Clip~? 100% vs after Mitra Clip~? 13%; P 0.001),and the NYHA functional classes improved(NYHA III/IV before Mitra Clip~? 98% vs after Mitra Clip~? 35%; P 0.001). The mortality rates 30 d and one year after percutaneous mitral valve repair were 4.3% and 19.5%,respectively. During the follow-up of 473 ± 274 d,11 patients died(90% due to cardiovascular death). A preprocedural plasma B-type natriuretic peptide level 817 pg/m L was associated with all-cause mortality(hazard ratio,6.074; 95%CI: 1.257-29.239; P = 0.012).CONCLUSION Percutaneous mitral valve repair with Mitra Clip~? has positive effects on hemodynamics and symptoms. Despite the study patients' multiple comorbidities and extremely high operative risk,one-year outcomes after Mitra Clip~? are favorable. Elevated B-type natriuretic peptide levels indicate poorer mid-term survival.     

Troublesome factors in mitral valve repair for mitral valve regurgitation

Limitations in the long-term results of medical treatment for mitral regurgitation are well recognized, but the advances in its surgical repair have produced good results. Therefore, early surgical intervention has been the focus of treatment in Europe and America. Increased surgical intervention depends on the development of technical skills in mitral reconstruction. This study investigated presurgical factors making surgical reconstruction difficult in 103 patients who underwent mitral operations performed from April 1994 to September 1997 in our hospital. Records were reviewed retrospectively for etiology, type of operation, and the immediate result of operation. The etiology of mitral regurgitation was prolapse in 65 patients (63%), restriction in 14, normal in 11, infectious endocarditis in 10, and others in 3. The type of prolapse involved the anterior leaflet in 22 patients (34%), posterior in 28 (43%), and both leaflets in 15 (23%). Valve repair was attempted in 74 patients, of which 16 were switched to valve replacement during operation. These included anterior leaflet prolapse in 9 patients, posterior leaflet in 1, both leaflets in 3, restriction in 2 and infectious endocarditis in 1. The success rate for reconstruction of anterior leaflet prolapse was not high. The cause of mitral regurgitation was mostly prolapse of the mitral valve, in our country as well as in Europe and America. Prolapsed posterior leaflet is much more common in Europe and America, and there is a high success rate reported for its valve reconstruction. In contrast, this study cannot recommend earlier surgical intervention because of difficult repair for anterior leaflet prolapse.