全保留二尖瓣及瓣下结构在重症二尖瓣关闭不全患者二尖瓣置换术中的应用

目的探讨全保留二尖瓣及瓣下结构在重症二尖瓣关闭不全患者二尖瓣置换术中的应用经验,评价其临床效果。方法回顾性分析2011年6月至2013年1月在广东省人民医院心血管外科因重症二尖瓣关闭不全行全保留二尖瓣及瓣下结构二尖瓣置换术17例患者的临床资料,其中男14例,女3例;年龄38~82（63.41±11.82）岁;合并心房颤动13例;术前纽约心脏学会（NYHA）心功能分级Ⅲ级5例,Ⅳ级12例;缺血性二尖瓣关闭不全7例,退行性二尖瓣关闭不全9例,风湿性二尖瓣关闭不全1例。结果所有患者均行全保留二尖瓣及瓣下结构的二尖瓣置换术,同期行冠状动脉旁路移植术4例;其中生物瓣11例,机械瓣6例。全组患者住院期间无死亡,均顺利出院,住院期间未并发低心排血量综合征,无左心室破裂。17例患者均随访,随访时间2~25（16.44±5.02）个月。随访期间1例患者因术后2个月发生二尖瓣重度瓣周漏死亡。其余患者人工二尖瓣功能良好,无抗凝和瓣膜引起的并发症,心功能较术前明显改善,心功能NYHA分级恢复至Ⅰ级11例,Ⅱ级4例,Ⅲ级1例。术后早期及随访期间心胸比率、左心房内径、左心室舒张期末内径及收缩期末内径与术前相比均明显减小。而术后早期左心室射血分数（LVEF）与术前相比有所降低[（50.94%±8.78%）vs.（55.31%±10.44%）,P=0.04],术前LVEF与随访期间的差异无统计学意义[（55.31%±10.44%）vs.（56.13%±9.67%）,P=0.73],随访期间LVEF与术后早期相比显著增加[（56.13%±9.67%）vs.（50.94%±8.78%）,P=0.02]。术后早期与随访期间人工二尖瓣压力减半时间（PHT）差异无统计学意义[（95.06±19.00）ms vs.（94.56±19.19）ms,P=0.91]。结论全保留二尖瓣及瓣下结构在重症二尖瓣关闭不全患者二尖瓣置换术中应用安全有效,可以改善左心室重构及术后心功能。     

Surgical Treatment of Mitral Valve Regurgitation in Dilated Cardiomyopathy

Abstract Background: Mitral valve (MV) surgery for dilated cardiomyopathy (DCM) was proposed at the beginning of the 1990s, and its effectiveness has been confirmed by many studies. The aim of this study is to evaluate long-term survival and the functional results of our experience with MV surgery for DCM. Methods: From January 1990 to October 2002, MV surgery for DCM was performed in 91 patients (64 ischemic, 27 idiopathic). DCM was defined as in our previous reports. Patients with organic MV disease, severe right ventricle dilatation with impaired function, or severe renal or hepatic failure were excluded from the study. MV annuloplasty was performed in 64 patients, and 27 patients underwent a MV replacement. Results: The 30-day mortality rate was 4.4% (4 patients). The probability of being alive at 5 years was 78.4% +/- 4.3% and was higher in patients who underwent MV repair (81.4% +/- 4.5%) than in patients who underwent replacement operation (66.7% +/- 9.1%), even if the P value was not statistically significant. After a mean follow-up period of 27 +/- 30 months, the New York Heart Association (NYHA) class decreased from 3.5 +/- 0.7 to 2.1 +/- 0.6 in the 69 survivors ( P <.001). The probability of being alive 5 years after surgery with an improvement of least 1 NYHA class was 65.9% +/- 5.0% and was higher in patients with MV repair (76.6% +/- 6.0%) than in patients who underwent valve replacement (51.9% +/- 9.6%), even if the P value was not statistically significant. Fifty patients were carefully followed with serial evaluations in our echocardiographic laboratory. Volumes did not change, nor did stroke volume or ejection fraction. Some degree of functional mitral regurgitation (FMR) was present in all but 8 of the patients who underwent repair. The analysis of these patients showed that all of the patients who had no residual MR had a mitral valve coaptation depth (MVCD) of 10 mm or less and had a better functional result. Conversely, the MVCD was shorter in patients who had no or mild (1/4) residual MR than in patients who had a residual MR >1/4. NYHA class was lower in patients with no or up to 1/4 residual MR, showing that the purpose of the procedure is the reduction or elimination of FMR, which is the determinant of the clinical result. Conclusions: Long-term results in our patients are satisfying. FMR can be crucial for achieving a higher effectiveness of a combined strategy to improve the global outcome of these patients.     

二尖瓣手术后重度三尖瓣反流患者的临床特征及治疗

目的 总结二尖瓣手术后重度三尖瓣反流(TR)的临床特征及治疗体会,以提高对该类患者的治疗效果.方法 30例重度TR患者,其中男1例,女29例;年龄32～65岁(47.1±9.2岁),窦性心律2例,心房颤动28例.第一次手术时:轻度TR 13例,中度TR 10例,重度TR 7例;5例在第一次手术时接受三尖瓣De Vega成形术,2例患者在第1次手术时接受三尖瓣Kay成形术.患者主要临床表现:腹胀28例(93.3%,28/30),下肢水肿20例(66.7%、20/30),活动后心悸17例(56.7%、17/30),腹水6例(20%、6/30).结果 9例患者接受了第二次手术,其中三尖瓣置换术6例,二尖瓣、三尖瓣置换术2例,三尖瓣Kay成形术1例.9例患者中8例术后康复出院,1例因术后右心房切口出血和低心排血量死亡.21例患者目前仍继续保守治疗.随访期间失访1例.结论 对二尖瓣手术后重度TR患者的治疗应根据患者具体的临床特征考虑手术或保守治疗,手术方式的选择亦应根据患者三尖瓣的具体情况及手术者的经验考虑三尖瓣成形术或三尖瓣置换术.     

二尖瓣成形术治疗二尖瓣关闭不全

二尖瓣成形术与二尖瓣置换术相比有较多优点，因此，近年来二尖瓣成形术治疗二尖瓣关闭不全越来越受到临床医生的重视。针对二尖瓣关闭不全的不同病理改变，可以采用瓣环成形、三角形切除、四边形切除以及腱索转移、置换等方法。随着微创外科的发展，小切口二尖瓣成形和机器人辅助的二尖瓣成形技术也逐渐发展起来；另外，对二尖瓣关闭不全进行介入治疗也开始起步。相信随着手术技术的不断成熟，将会有更多二尖瓣关闭不全患者接受二尖瓣成形术的治疗。     

二尖瓣成形术中轻度功能性三尖瓣反流的处理

目的探讨中重度粘液样退行性二尖瓣关闭不全合并轻度功能性三尖瓣反流患者,二尖瓣成形术（mitralvalverepair,MVP）同期是否需行三尖瓣成形术（tricuspidvalvuloplasty,TVP）。方法根据MVP同期是否行TVP,将1993年1月至2008年3月第二军医大学附属长海医院胸心外科135例中重度粘液样退行性二尖瓣关闭不全合并轻度功能性三尖瓣反流患者分成MVP组（76例）和MVP＋TVP组（59例）,观察两组患者围术期病死率和三尖瓣反流的变化,比较两组患者术后远期生存率、三尖瓣中重度反流免除率;采用多因素Coxregression分析术后远期三尖瓣中重度反流的危险因素。结果（1）所有患者围术期均无死亡,术后在院期间复查超声心动图提示两组患者三尖瓣反流程度均为轻度或轻度以下;（2）MVP组患者术后5年、10年生存率分别为98．4％和95．0％;MVP＋TVP组患者术后5年、l0年生存率分别为100．0％和93．7％,两组患者术后远期生存率差异无统计学意义（P=0．311）,但术后远期三尖瓣中重度反流免除率差异有统计学意义（P=0．040）。多因素分析显示：术前存在肺动脉压〉30mmHg（95％CI：1．127,137．487,P=0．040）,心房颤动（95％CI：1．177,23．378,P=0．030）是术后远期三尖瓣中重度反流的独立危险因子。结论中重度粘液样退行性二尖瓣关闭不全患者合并轻度功能性三尖瓣反流,特别是术前存在肺动脉压〉30mmHg、心房颤动的患者,MVP同期应积极行TVP。     

A Nationwide Survey of Surgical Treatment for Severe Ischemic Mitral Regurgitation

Objective: Mitral subvalvular procedures in addition to restrictive annuloplasty are promising for ischemic mitral regurgitation (IMR). However, the prevalence and efficacy of specific subvalvular repair in severe IMR have not been elucidated. This is the first nationwide survey regarding surgeons’ attitudes toward IMR in Japan.Methods: A questionnaire was sent to 543 institutions. From 2015 to 2019, numbers of elective first-time mitral valve replacement (MVR) with/without complete chordal preservation (CCP)/papillary muscle approximation (PMA) and mitral valvuloplasty (MVP) with/without papillary muscle relocation (PMR)/PMA in patients with severe IMR were collected. Concomitant procedures for coronary artery, tricuspid valve, and arrhythmia could be included but left ventricular reconstruction was excluded.Results: Completed questionnaires were received from 286 institutions (52.7%). The majority (90%) had less than 20 cases within 5 years. The number of MVP (1413, 61.5%) surpassed MVR (886, 38.5%). CCP was performed in half of MVR (50.0%), while PMA was included in only 1.9% of MVR. PMA and PMR were also performed infrequently, in only 7.7% and 10.9% of MVP, respectively.Conclusion: Japanese surgeons aggressively perform MVP for severe IMR. Subvalvular repair was also aggressively performed in addition to MVR, but not to MVP. A multicenter registry study is in progress.