特发性二尖瓣腱索断裂手术治疗的临床分析

目的 探讨特发性二尖瓣腱索断裂的临床特征、发病规律、治疗方法及术后康复情况.方法 对188例经手术治疗的特发性二尖瓣腱断裂住院患者的临床资料及随访情况进行回顾性分析.结果 前叶腱索断裂49例,后叶腱索断裂129例,前后叶腱索断裂10例.腱索部分断裂172例,完全断裂16例.72例患者术前伴有心房颤动,26例术后自动转...     

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.     

腱索断裂:病因与自然病史

最近报告认为腱索断裂是单纯性二尖瓣回流第二位常见原因。本文对英国Brompto医院1970～1981年二尖瓣手术所见213例腱索断裂进行分析。患者男性107例,女性106例。年龄:4～78岁,平均56岁。病因:自发性或原发性断裂159例(74.6％);继发性断裂54例,其中继发于慢性风湿性二尖瓣病19例(8.9％),15例曾做过二尖瓣闭式切开术,继发于亚急性细菌性心内膜炎28例(13.2％),缺血性心脏病5例(2.3％),急性风湿热1例(0.47％),成骨不全1例(0.47％)。     

特发性二尖瓣腱索断裂患者心血管病危险因素与冠状动脉造影结果的相关性分析

目的探讨特发性二尖瓣腱索断裂患者心血管病危险因素与冠状动脉(冠脉)造影结果的相关性。方法入选行冠脉造影的特发性二尖瓣腱索断裂患者195例,其中冠脉造影正常组143例(占74.33%),冠脉造影异常组(即确诊合并有冠心病)52例(占26.67%)。危险因素包括性别、年龄、吸烟史、高血压病、2型糖尿病、缺血性心血管病家族史、血脂异常、高尿酸血症、血红蛋白、总胆红素、体重指数。采用单因素和多因素分析。结果 (1)单因素分析显示,合并冠心病组发病年龄较冠脉造影正常组大,合并冠心病组吸烟比例、高血压病史比例、缺血性心血管病家族史比例、总胆固醇水平、甘油三酯水平、低密度脂蛋白胆固醇水平、尿酸水平均显著高于冠脉造影正常组。(2)多因素Logistic回归分析显示,缺血性心血管病家族史是特发性二尖瓣腱索断裂患者合并冠心病最显著的独立相关危险因素(OR=29.628,95%可信区间8.234-106.604,P=0.001),其它危险因素依次为高血压病史、高尿酸血症。结论缺血性心血管病家族史是特发性二尖瓣腱索断裂患者合并冠心病的独立相关危险因素,对于合并有冠心病高危因素(如高龄、有高血压病史、高尿酸、吸烟史、高脂血症)的特发性...     

闭合性心内结构损伤的治疗体会(摘要)

心脏闭合伤致心内结构损伤临床较少见,我院1995年5月～1999年4月收治6例,均为男性。1　临床资料(附表)附表　6例闭合性心内结构损伤的临床资料序号年龄(岁)伤因受伤至入院时间心脏伤情入院时合并伤既往史手术方式结果139车祸4天二尖瓣人工机械瓣瓣钩断裂无8年前行二尖瓣置换术无死亡243坠落45天二尖瓣后叶腱索断裂无健康二尖瓣置换术愈353车祸210天二尖瓣后叶腱索断裂无健康二尖瓣成形术愈420车祸20天二尖瓣后叶撕裂2.0cm,并赘生物附着左股动脉假性动脉瘤,破口直径0.5cm　　健康赘生物清除、二尖瓣成形、左股动脉修补术愈556拳击180天二尖瓣…     

非风湿性二尖瓣瓣膜下关闭不全综合征:病因及临床表现

非风湿性二尖瓣瓣膜下关闭不全综合征是指由于腱索或乳头肌畸形、断裂或功能失调所产生的一系列症状,瓣叶或瓣环无原发性病变。这类患者占作者一组进行二尖瓣关闭不全手术212例的16％。本文介绍了这33例患者的临床及血液动力学等方面的表现。分类:(1)腱索异常;31例,分为4组。有心肌梗塞史:6例,平均61岁,其中3例示二尖瓣前叶(亦称二尖瓣的“主动脉瓣叶”)腱索伸长,2例示该腱索断裂,1例示二尖瓣后叶腱索断裂。有心内膜炎史:3例,均为女性,平均31岁,均示二尖瓣前叶腱索断裂。     

以自体心包卷制的腱索替代断裂的二尖瓣腱索

二尖瓣腱索断裂所致的严重二尖瓣关闭不全.可造成严重病残,病程进展较快,许多病人不能活过一年,因此早期手术十分必要。本文介绍10例用自体心包修补断裂的二尖瓣腱索。病人年龄为48～75岁(平均61岁),其中男性6例,女性4例。5例症状突然发生(2～5月),另5例症状较持久(12～48月)。所有病例在体检时均于心尖区闻及响亮的收缩期杂     

经胸与经食管超声心动图诊断二尖瓣脱垂并腱索断裂准确性的比较

目的:比较经胸与经食管超声心动图诊断二尖瓣脱垂并腱索断裂的准确性.方法:选择经胸与经食管超声心动图检查诊断为二尖瓣脱垂伴或不伴腱索断裂并行手术治疗的患者21例,以术中所见为标准,明确两者诊断二尖瓣脱垂并腱索断裂的准确性,同时比较它们在判断病因及病变部位等方面的作用.结果:术前检查21例二尖瓣脱垂的患者中,经胸超声心动图诊断有8例患者发生腱索断裂,经食管超声心动图诊断为15例患者发生腱索断裂,与手术结果比较,两者的诊断准确率分别为71%和95%,差异有统计学意义(P＜0.05).结论:经食管超声心动图较经胸超声心动图能更准确地诊断二尖瓣脱垂并腱索断裂,从而为术式的选择提供更可靠的依据.     

腱索断裂引起的二尖瓣反流:瓣膜修补的近期与远期结果

约1/5有临床重要性的二尖瓣膜关闭不全是由于腱索断裂引起的。腱索断裂可由细菌性心内膜炎、风湿性瓣膜炎和偶尔因胸部外伤所致。本文报道腱索断裂导致二尖瓣反流患者瓣膜修补术后的近期及远期结果。方法:自1958年至1980年,131名患者由于腱索断裂导致二尖瓣反流作二尖瓣瓣膜修补,其中男性82例,女性49例,年龄5～70岁(平均57岁)。所     

二尖瓣腱索断裂(附10例报告及文献复习)

本文报告10例二尖瓣腱索断裂病例并复习近年国内文献。综合分析36例患者资料表明:二尖瓣腱索断裂以后叶常见,后、前叶累及比例为1.8:1。病因以自发性断裂常见,尤其是老年患者。青少年患者风湿性心脏炎是常见原因。感染性心内膜炎已不是二尖瓣腱索断裂的主要原因。     

Incidence of ruptured chordae tendineae in the mitral valvular prolapse syndrome: an echocardiographic study.

Echocardiographic studies were performed in 190 consecutive patients with mitral valvular prolapse. All patients had either midsystolic posterior motion of the mitral valve or holosystolic hammock-like movement of the valve in systole. Thirteen patients (7 percent) were noted to have ruptured chordae tendineae. In four patients, a combination of abnormalities was observed. Five patients had clinical and bacteriologic evidence of infective endocarditis, two of whom had severe intractable pulmonary edema consequent to acute mitral regurgitation which required mitral valvular replacement. At surgery, one of these patients had ruptured chordae tendineae to both leaflets, and the other had chordal rupture of the posterior leaflet. The other patients probably had spontaneous rupture of the chordae tendineae. A spectrum of clinical findings was noted. Six patients had marked mitral regurgitation, while two had isolated systolic clicks. Thus, chordal rupture does not always result in severe hemodynamic deterioration. Serial echocardiographic studies will be of value in studying the natural history and progression of disease in patients with chordal rupture.     

Failure mechanics of mitral valve chordae tendineae

BACKGROUND AND AIM OF THE STUDY: Rupture of chordae tendineae is the main cause of mitral valve insufficiency, and often requires corrective surgery. The precise mechanisms of chordal rupture, however, are unknown. METHODS: Failure mechanics were measured in porcine mitral valve chordae (37 anterior marginal, 40 anterior basal, 35 posterior marginal, and 38 posterior basal). Full-length chordae were weighed, measured, and stretched to failure in an Instron tensile testing machine. The ruptured ends were characterized under a dissecting microscope. RESULTS: Marginal chordae had 68% thinner cross-sectional areas and failed at 68% less load and 28% less strain than basal chordae. Chordae from the posterior leaflet were 35% thinner and failed at 43% less load and 22% less strain than anterior leaflet chordae. Failure strength was lowest for posterior marginal chordae. Chordae most frequently tore just below the leaflet insertion, in what was often their narrowest section. CONCLUSION: Overall, the marginal chordae and posterior leaflet chordae were thinner and required less strain and load to fail than basal chordae and anterior leaflet chordae, respectively. These results support previous reports of decreased extensibility in marginal chordae. The high incidence of ruptures in the posterior marginal chordae of diseased mitral valves may be due to an inherent weakness in these chordae.     

The prevalence of ruptured chordae tendineae in the mitral valve prolapse syndrome

Echocardiographic studies were performed on 134 consecutive patients with idiopathic mitral valve prolapse syndrome. Fifteen patients (11.2%) were noted to have ruptured chordae tendineae on M-mode examination and in 12 of them the diagnosis was confirmed by bidimensional studies. Only four patients were referred for surgery as a result of severe mitral regurgitation. At operation one patient was found to have rupture of the anterior mitral chorda and the other three had posterior mitral chordal rupture. Eleven patients with chordal rupture had either mild symptoms or were completely asymptomatic. It is concluded that chordal rupture in patients with the mitral valve prolapse syndrome does not always result in severe hemodynamic deterioration and may go undetected unless a high index of suspicion is maintained. Serial echocardiographic studies may reveal the natural history of this condition in asymptomatic patients.     

Mechanisms of severe mitral regurgitation in mitral valve prolapse determined from analysis of operatively excised valves

Certain clinical and mitral valvular morphologic findings are described in 83 patients (age 26 to 79 years [mean, 60]; 26 women [31%] and 57 men [69%]) with mitral valve prolapse (MVP) and mitral regurgitation (MR) severe enough to warrant mitral valve replacement. All 83 operatively excised valves were examined by the same person, and all excised valves had been purely regurgitant (no element of stenosis). No patients had hemodynamic evidence of dysfunction of the aortic valve. In each valve a portion of the posterior mitral leaflet was elongated such that the distance from the distal margin to basal attachment of this leaflet was similar to the distance from the distal margin of the anterior leaflet to its basal attachment to the left atrial wall. Two major mechanisms for the severe MR were found: dilatation of the mitral anulus with or without rupture of chordae tendineae and rupture of chordae tendineae with or without dilatation of the mitral anulus. Of the 83 patients, 48 (58%) had both dilated anuli (greater than 11 cm in circumference) and ruptured chordae tendineae; 16 (19%) had dilated anuli without ruptured chordae, and 16 (19%) had ruptured chordae without significant anular dilatation. In three patients the anulus was not dilated, nor were chordae ruptured, and therefore the mechanism of the MR is uncertain. Mitral chordal rupture was nearly as frequent in the 64 patients with clearly dilated anular circumferences as in the 19 patients with normal or insignificantly dilated anular circumferences (less than or equal to 11 cm).     

Congenital aortic valve disease with rupture of mitral chordae tendineae.

A new clinical entity is described in which free aortic regurgitation from congenital aortic valve disease caused rupture of the chordae to the anterior leaflet of the mitral valve in 7 men aged 45 to 63 years (mean 52 years); 2 of the patients also had rupture of chordae to the posterior leaflet. Comparing these patients with those with ruptured mitral chordae in association with rheumatic heart disease and patients with spontaneous chordal rupture, differences were evident. No patient had a history of rheumatic fever and none had active infection. The typical clinical presentation was of acute mitral regurgitation into a small left atrium, with severe pulmonary oedema which was often resistant to medical treatment. The cause of chordal rupture in these patients was in part the result of progressive left ventricular dilatation, of direct trauma to the anterior cusp of the mitral valve, and possibly of a genetic factor. The anatomical features of both aortic and mitral valves are described, and in 3 histology of the mitral valve was available; 2 had myxomatous degeneration similar to that seen in patients with spontaneous chordal rupture, and in 1 there was degeneration of collagen tissue. All patients were treated surgically but the mortality was high (5 out of 7,70%). Early operation with replacement of the aortic and mitral valves is recommended if this high mortality is to be reduced.     

Ruptured mitral chordae tendineae may be a frequent and insignificant complication in the mitral valve prolapse syndrome

In this study, we performed 512 echocardiographic studies on264 consecutive, unselected patients with the idiopathic mitralvalve prolapse syndrome. Twenty-eight patients (10.6%) had evidenceof ruptured chordae tendineae of the mitral valve on M-modeexamination and in 24 the diagnosis was confirmed by two-dimensionalechocardiography. Mild to severe mitral insufficiency was provenin all of them by left ventriculography during cardiac catheterization.Eight patients underwent surgery to relieve symptomatic severemitral regurgitation. At operation all had myxomatous degenerationof the mitral valve, two patients were found to have ruptureof anterior mitral chordae, and six had rupture of posteriormitral chordae. Twenty (71%) patients with chordal rupture hadeither mild symptoms or were completely asymptomatic. It isconcluded that chordal rupture in patients with the mitral valveprolapse syndrome may be present in asymptomatic patients andgo undetected clinically in a substantial number of patientsunless a high index of suspicion is maintained. Serial M-modeand two-dimensional echocardiographic studies are of importancein identifying the progression of prolapse findings and mayreveal the natural history of this pathologic condition in asymptomaticpatients.     

Differentiating clinical and echocardiographic characteristics of chordal rupture detected in patients with rheumatic mitral valve disease and floppy mitral valve: impact of the infective endocarditis on chordal rupture.

AIMS: We aimed to compare the clinical and echocardiographic correlates of chordal rupture in patients with rheumatic mitral valve disease and floppy mitral valve. METHODS AND RESULTS: The study group comprised of 224 patients who underwent transthoracic and transesophageal echocardiography because of the severe mitral regurgitation. Chordal rupture was detected in 58 (25.9%) out of the 224 patients, in 33 out of the 83 (39.7%) patients with floppy mitral valve, and in 25 out of the 141 (17.7%) patients with rheumatic mitral valve disease. Chordal rupture was more frequently associated with anterior leaflet (80%) in patients with rheumatic mitral valve disease, and posterior leaflet (72.7%) in patients with floppy mitral valve (p<0.05). Univariate correlates of chordal rupture were age, male sex, posterior mitral leaflet thickening and chordal elongation in patients with floppy mitral valve (p<0.05), and chordal shortening (p<0.0001) and infective endocarditis involving mitral anterior leaflet (p<0.05) in rheumatic group. Independent predictors of chordal rupture were age (>50 years), posterior mitral leaflet thickness (> or =0.45cm), and male sex (p<0.05) in patients with floppy mitral valve while infective endocarditis involving mitral anterior leaflet (p<0.05) in patients with rheumatic mitral valve disease. Patients with chordal rupture due to floppy mitral valve had an older age (p<0.0001), a male dominance, longer mitral leaflets and chordae, and a larger mitral annulus circumference (p<0.05) as compared to those with rheumatic chordal rupture. Despite the comparable severity of mitral regurgitation and left atrial diameters between the two groups of chordal rupture (p>0.05), functional class and pulmonary artery systolic pressure were higher, and atrial fibrillation, acute deterioration, infective endocarditis, mitral leaflet rupture and need for mitral valve surgery in the 3 months were more frequent in rheumatic chordal rupture subgroup (p<0.05). CONCLUSION: Chordal rupture seems to be more frequently associated with anterior mitral leaflet in rheumatic mitral valve disease, whereas it was the posterior leaflet in floppy mitral valve. Chordal rupture was related to male sex, older age, posterior leaflet thickening, and chordal elongation in patients with floppy mitral valve. However, infective endocarditis, acute deterioration, and need for early mitral surgery were more frequent in patients with rheumatic chordal rupture.     

Comparison of accuracy of transesophageal versus transthoracic echocardiography for the detection of mitral valve prolapse with ruptured chordae tendineae (flail mitral leaflet)

The accuracy of transesophageal echocardiography was compared with that of transthoracic echocardiography in the detection of ruptured chordae tendineae (flail mitral leaflet) in 27 patients with mitral valve prolapse (MVP) who underwent valve repair or replacement for mitral regurgitation. Confirmation of the presence of ruptured chordae resulting in a flail leaflet was available at surgery in all cases. The echocardiographic studies were read blindly by 2 independent observers with any differences resolved by a third. Mean (+/- standard deviation) age was 63 +/- 13 years. Men (n = 20) outnumbered women (n = 7) (p less than 0.02), and tended to be younger (p = 0.06). Flail leaflets were identified in 20 of 27 patients. In 1 patient, both leaflets were involved and in the remaining 19 patients posterior leaflets (15 patients) were more frequently affected than anterior leaflets (4 patients). Transesophageal echocardiography correctly identified all 20 patients with flail leaflets, but 1 false positive study occurred among the 7 patients without a flail leaflet. In contrast, transthoracic echocardiography identified only 12 of 20 patients with flail leaflets, with no false positive studies. Transesophageal echocardiography was more accurate, correctly classifying 26 of 27 (96%) cases versus 19 of 27 (70%) by the transthoracic approach (p less than 0.01). This study suggests a higher incidence of chordal rupture to the posterior leaflet in patients with MVP and demonstrates improved accuracy of transesophageal over transthoracic echocardiography in the detection of flail leaflets.     

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.     

Aortic stenosis and rupture of mitral chordae tendineae

Ten patients with aortic stenosis and ruptured mitral chordae tendineae constituted 8% of 125 consecutive surgical cases of chordal rupture. Their ages ranged from 54 to 87 years (mean 68). Six patients presented with acute onset of congestive heart failure, and eight were in New York Heart Association functional class III or IV at the time of cardiac catheterization. Extensive mitral anulus calcification was observed by fluoroscopy in seven patients. The mean aortic valve area index was 0.4 cm2/m2 and nine patients had moderate to severe mitral regurgitation by angiography. Calcific aortic stenosis affected a tricuspid valve in nine cases and a bicuspid valve in one case. One patient had a rheumatic mitral valve and one a redundant myxomatous mitral valve; the remaining eight had no abnormality of the mitral apparatus commonly regarded as predisposing to chordal rupture. Mitral anulus calcification and ventricular anatomic and hemodynamic alterations in aortic stenosis may contribute to rupture of the mitral chordae tendineae.