复杂性感染性心内膜炎的外科治疗

目的评价瓣周脓肿、心肌脓肿以及瓣膜严重毁损等复杂性感染性心内膜炎手术治疗的近、远期疗效.方法回顾性分析1988年12月至2002年6月手术治疗的复杂性心内膜炎患者57例临床资料,均为原发性心内膜炎,其中感染侵犯主动脉瓣25例、二尖瓣16例、二尖瓣和主动脉瓣16例.术中发现瓣叶严重毁损32例、主动脉瓣周脓肿19例、主动脉根部环形脓肿导致左心室-主动脉连接破坏4例、二尖瓣后瓣环脓肿11例、心肌脓肿6例、瓣膜赘生物形成55例.脓肿清除后遗留残腔采用间断褥式缝合6例、自体心包片修补19例、牛心包片修补6例、聚四氟乙烯膨体补片修补4例;施行以带瓣管道作升主动脉根部替换和左、右冠状动脉移植术4例,主动脉瓣替换术21例,二尖瓣替换术16例,主动脉瓣及二尖瓣双瓣替换术16例.结果早期死亡6例(11%),死亡主要原因为低心输出量综合征、人造心脏瓣膜性心内膜炎和多脏器功能衰竭.随访4个月至14年,平均(5.93±0.20)年.晚期死亡5例,晚期主要并发症为人造瓣膜性心内膜炎.术后1年心功能恢复NYHA分组Ⅰ～Ⅱ级占96%(44/46);5年再手术免除率为(84±3)%,5年实际生存率为(61±9)%.结论复杂性心内膜炎局部组织破坏较多,应限期手术或急症手术,清创后残腔的处理是影响手术本身能否成功以及术后近、远期效果的关键.     

严重主动脉瓣感染性心内膜炎患者主动脉根部置换的方法与疗效

目的总结严重主动脉瓣感染性心内膜炎患者行主动脉根部置换术治疗的临床经验,探讨其手术适应证和手术方法,以期提高外科治疗效果。方法1995年9月～2008年6月间手术治疗11例严重主动脉瓣或人工瓣膜感染性心内膜炎患者,其中活动期6例,静止期5例;术前动脉血细菌培养阳性6例。术前心脏超声心动图提示均有不同程度的主动脉瓣反流或瓣周漏,左心室收缩期末内径（LVESD）6．0±0．7cm,其中≥5．5cm 7例;左心室射血分数（LVEF）47．8％±11．2％,其中≤509／8例。手术均在彻底清创后应用人工带瓣管道（9例）或同种带瓣管道（2例）行主动脉根部置换术,同期行冠状动脉旁路移植术4例,二尖瓣环缩术3例,室间隔缺损修补术1例。结果术后心脏骤停死亡1例。发生Ⅲ°房室传导阻滞1例,后期植入永久性起搏器。术后随访10例,随访时间3个月～13．2年,术后32d因感染性心内膜炎复发死亡1例;其余患者均无感染复发和晚期死亡。结论当感染性心内膜炎合并主动脉根部或窦部瘤、感染累及主动脉窦壁或冠状动脉开口处、瓣环严重毁损或彻底清创后瓣环缺损广泛时,宜置换主动脉根部。手术的关键是彻底清创和防止根部出血。尽管手术较复杂,但局部清创彻底,有利于提高手术效果。     

儿童心脏瓣膜置换术

目的探讨儿童心脏瓣膜置换的有关问题。方法１９９２年３月至１９９７年１２月,对７例儿童进行了心脏瓣膜置换手术,其中二尖瓣置换术５例,主动脉瓣置换术２例,同期修补室间隔缺损３例。结果术后发生急性呼吸功能衰竭１例,急性心包填塞１例,全组无手术死亡。术后随访１～６９个月,患者发育正常,活动量增加。结论儿童换瓣应尽可能选用较大型号的双叶机械瓣,升主动脉根部心包补片加宽及改进缝合技术能使瓣环较小的患儿置入较大型号的心瓣膜。     

Manouguian法瓣环增宽加主动脉瓣置换术治疗成人小主动脉瓣环

目的总结成人主动脉瓣狭窄伴小主动脉瓣环行瓣环增宽并替换主动脉瓣的经验。方法 12例病人行主动脉瓣环增宽并替换主动脉瓣。手术径路均采用Manouguian法：将主动脉斜切口下延伸,经无冠瓣与左冠瓣交界处向下,垂直切开瓣环至二尖瓣基部。采用绦纶片内衬自体心包片作为增宽材料,替换23 mm或25 mm主动脉瓣;同期行二尖瓣替换4例。结果 1例同期行二尖瓣置换者因严重低心排死于手术当晚;1例术后第7 d因心包填塞经剑突下引流后痊愈;肺部感染并发呼吸功能不全1例,经气管切开及呼吸机支持1周后痊愈;1例主动脉根部明胶海绵物填充后感染于术后12 d再次开胸清除腐烂明胶海绵,并留管冲洗引流而愈。本组术后住院13~20 d,平均（16.2±1.5）d;11例患者均获随访,时间5~84个月,平均（36.7±21.2）个月,心功能恢复至Ⅰ级5例,Ⅱ级6例,无远期死亡。结论对大多数小主动脉瓣环,采用Manouguian术式简单易行,不需切开二尖瓣基部,已能满足替换23 mm或25 mm瓣膜,增宽材料易得,效果可靠。     

先天性心脏病合并感染性心内膜炎的外科治疗

目的总结先天性心脏病（congenital heart disease,CHD）合并感染性心内膜炎（infective endocarditis,IE）的外科治疗经验,以提高诊断、治疗效果。方法回顾性分析我院73例CHD合并IE患者行瓣膜手术的临床资料,对30例主动脉瓣感染性心内膜炎者行主动脉瓣置换术,另3例行Ross手术。在IE累及二尖瓣21例患者中,行二尖瓣成形术5例,二尖瓣置换术16例;10例主动脉瓣、二尖瓣IE行双瓣膜置换术;对6例肺动脉瓣IE患者行单瓣法做肺动脉瓣成形术2例,肺动脉瓣置换术4例,其中1例同期行主动脉弓置换;3例三尖瓣IE均行三尖瓣置换术。结果主动脉瓣感染33例（45．2％）,二尖瓣感染21例（28．8％）,肺动脉瓣感染6例（8．2％）,双瓣膜感染10例（13．7％）,三尖瓣感染3例（4．1％）。血培养及赘生物培养总阳性率为23．3％,其中链球菌8例（47．1％）,葡萄球菌3例（17．6％）。本组无手术死亡,除1例二尖瓣置换术后1年再次发生IE,拒绝手术治疗外,其余72例患者随访1年均治愈。结论CHD应尽早行根治性手术,以避免远期并发IE,损坏心脏瓣膜。对CHD合并IE出现瓣膜关闭不全者应尽快手术,如IE累及二尖瓣、三尖瓣且无瓣膜结构的严重损毁者,施行瓣膜成形术是较好的方法。     

胸腔镜下二尖瓣生物瓣置换术32例分析

目的探讨胸腔镜下二尖瓣生物瓣置换的经验,评价其临床效果。方法回顾性分析2013年3～12月在广东省人民医院心血管外科行胸腔镜下二尖瓣生物瓣置换术32例患者的临床资料。其中男14例、女18例,年龄19～80（55.6±17.3）岁,体重37～78（55.7±9.7）kg,体表面积1.30～1.95（1.67±0.16）m^2;合并心房颤动5例,术前心功能分级（NYHA）Ⅱ级20例,Ⅲ级11例,Ⅳ级1例;二尖瓣风湿性病变16例,二尖瓣退行性病变11例,感染性心内膜炎4例,合并先天性心脏病1例。结果所有患者均行胸腔镜下二尖瓣生物瓣置换术,其中采用Medtronic HancockⅡ人工生物瓣27例,Medtronic Mosaic生物瓣5例。同期行三尖瓣成形术13例,房间隔缺损修补术1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及左心室破裂。术后复查心脏彩色超声心动图提示,所有患者人工二尖瓣功能良好,无瓣周漏发生。术后患者心功能较术前明显改善,心功能恢复至Ⅰ级9例,Ⅱ级17例,Ⅲ级6例。术后早期及术后3个月左心房内径及左心室舒张期末内径与术前相比均明显减小。而术后早期及术后3个月左心室射血分数（LVEF）与术前相比有所降低。结论胸腔镜下二尖瓣生物瓣置换术创伤小,并发症少,安全可行,使用特殊类型生物瓣可明显减小手术切口大小。     

非缺血性心脏瓣膜疾病合并冠心病同期手术治疗的临床分析

目的 总结非缺血性心脏瓣膜疾病合并冠心病同期手术患者的临床特征和手术效果,以提高手术疗效. 方法 2000年1月至2007年6月同期手术治疗105例非缺血性心脏瓣膜疾病合并冠心病患者,年龄36～79岁(61.96±7.61岁),其中风湿性心瓣膜疾病59例,退行性二尖瓣病变24例,老年性钙化性主动脉瓣病变13例;其它主动脉瓣病变9例.术前行冠状动脉造影明确诊断98例,术中探查发现冠心病7例.全组均行冠状动脉旁路移植术,共移植血管216支(2.06支/例),同期行二尖瓣置换术36例,二尖瓣成形术15例,主动脉瓣置换术43例,双瓣膜置换术11例. 结果 术后住院死亡6例(5.7%,6/105).死于严重低心排血量3例,肾功能衰竭2例,术后心脏骤停并发多器官功能衰竭1例.术后随访93例,随访时间1个月至7年,失访6例.无晚期死亡患者.心功能分级(NYHA)Ⅰ级25例,Ⅱ级53例,Ⅲ级10例,Ⅳ级5例.1例患者活动后仍有心绞痛存在. 结论 非缺血性心脏瓣膜疾病合并冠心病患者绝大多数无典型的心绞痛症状,50岁以上的患者必须行冠状动脉造影检查,对有冠心病易患因素者,应积极作冠状动脉造影检查;冠心病所致的心肌缺血可明显加重心脏瓣膜疾病所引起的心肌损害,术中心肌保护尤为重要;正确评价术前左心功能低下的患者是选择手术治疗的难点,更是影响手术效果的关键因素.     

右心房房间隔和左心房顶联合切口置换二尖瓣技术

1997年 10月至 1999年 12月 ,我们采用经右心房房间隔和左心房顶联合切口 ,对 2 3例再次二尖瓣手术或左、右心房均较小的病人进行二尖瓣置换术 ,效果满意 ,现报道如下。临床资料　 2 3例中男 12例 ,女 11例 ;年龄 2 6～ 6 5岁。原发疾病为风湿性心脏瓣膜病 2 1例、退行性瓣膜病变和冠心病所致二尖瓣关闭不全各 1例。本次手术包括二尖瓣闭式扩张术后 9例、二尖瓣置换术后 4例、二尖瓣和主动脉瓣双瓣置换术后和心室间隔缺损修补术后二尖瓣狭窄各 1例 ;单纯二尖瓣狭窄 6例、二尖瓣狭窄并主动脉瓣狭窄和冠心病合并二尖瓣腱索断裂各 1例。心功能…     

二尖瓣成形术在感染性心内膜炎二尖瓣关闭不全治疗中的应用

目的评价二尖瓣成形术治疗感染性心内膜炎二尖瓣关闭不全的疗效。方法自2002年3月至2012年1月共有33例感染性心内膜炎二尖瓣关闭不全患者在北京阜外心血管病医院接受二尖瓣成形术,其中男23例、女10例,年龄10～67（35.7±17.8）岁。13例有心脏基础解剖病变。术前二尖瓣轻度反流5例,中度反流15例,重度反流13例。心功能分级（NYHA）Ⅰ级5例,Ⅱ级23,Ⅲ级4例,Ⅳ级1例。所有患者均行二尖瓣成形术,活动期手术14例。同期行主动脉瓣置换术6例,三尖瓣成形术5例,冠状动脉旁路移植术1例,左心房粘液瘤切除术1例,主动脉窦瘤修补术1例。成形方法包括心包修补穿孔5例,瓣叶切除缝合17例,双孔法成形3例,腱索转移及人工腱索5例,15例使用人工成形环。结果围术期死亡1例,于术后7 d并发急性心肌梗死死亡。32例存活患者均康复出院。出院前超声心动图提示：左心室舒张期末内径、左心房内径分别为（48.9±7.6）mm及（31.7±7.4）mm,较术前有明显改善（P=0.000）。32例患者完成随访,随访时间6～125（73.0±38.6）个月。随访期间无死亡,无心内膜炎复发及出血栓塞等并发症。1例术后3年因二尖瓣狭窄而行二尖瓣机械瓣置换术。心功能分级（NYHA）Ⅰ级25例,Ⅱ级5例,Ⅲ级2例。二尖瓣有少量反流4例,中量反流1例,无反流26例;舒张期二尖瓣流速偏快（1.7 m/s）1例,主动脉瓣中量反流1例。左心室舒张期末内径及左心房内径与术后早期比较差异无统计学意义,射血分数较术后早期改善（60.9%±6.6%vs.57.5%±6.7%;P=0.043）。结论二尖瓣成形术治疗感染性心内膜炎二尖瓣关闭不全疗效可靠,左心房、左心室内径显著减小,心功能改善明显。     

二尖瓣置换术后左心室后壁破裂3例

198 9年 1月至 1999年 12月 ,我们共为 840例病人施行了二尖瓣置换术。术中、术后共发生左心室后壁破裂 3例 ,现道告如下。资料与方法　例 1　女 ,42例。风湿性心脏病 ,重度主动脉瓣狭窄并关闭不全 ,中度二尖瓣狭窄并关闭不全 ,重度三尖瓣关闭不全 ,心功能ＩＶ级。 1989年 8月行二尖瓣及主动脉瓣置换术。术中见主动脉瓣严重纤维化、钙化 ,二尖瓣纤维化 ,瓣下结构挛缩。二尖瓣置换 2 7号、主动脉瓣置换 2 1号单叶机械瓣。心脏复跳后发现左心室后壁近左房室瓣环处有 1ｃｍ裂口 ,可见人工瓣环 ,遂立即建立体外循环 ,取 1 5ｃｍ× 1 0ｃｍ涤纶片…     

Prophylactic mitral reconstruction for mitral regurgitation

BACKGROUND: Mitral regurgitation (MR) will produce myocardial dysfunction. The goal of this study was to review outcomes of mitral valve reconstruction in asymptomatic patients with severe MR. METHODS: From 1992 to 2000, 93 asymptomatic patients with degenerative disease and severe MR underwent mitral valve reconstruction. Mean preoperative left ventricular internal diameter diastole was 56 +/- 8 mm and ejection fraction was 60% +/- 6%. Mean age was 47 +/- 10 years and mean follow-up 23 +/- 27 months. All patients underwent complex reconstruction. RESULTS: There were no deaths and two late reoperations. One was for systolic anterior motion of the anterior leaflet of the mitral valve requiring valve replacement and one for hemolysis requiring re-repair. There was one perioperative transient ischemic attack and no late thromboembolic events. At follow-up all but 1 patient remains in NYHA class I and all had no MR except in 2 patients at 63 and 89 months. CONCLUSIONS: Mitral valve reconstruction for "asymptomatic" MR can be performed with no mortality and low morbidity before development of left ventricular dysfunction. Early prophylactic repair is advocated in the presence of severe MR if valve reparability is assured.     

Surgical treatment of ischaemic valve disease

Mitral valve regurgitation secondary to ischaemic heart disease carries a significant mortality even after open-heart surgery. In this study, 21 patients with mitral regurgitation associated with ischaemic heart disease were evaluated with respect to valvular pathology. Pathological examination of the mitral valve revealed chorda elongation or rupture in seven patients (group 1), papillary muscle dysfunction in 10 (group 2), and papillary muscle rupture in four (group 3). Significant preoperative characteristics in each group were subacute haemodynamic deterioration in group 1, chronic severe left ventricular failure in group 2, and a high incidence of acute renal failure associated with haemodynamic shock in group 3. Mitral valve plasty was performed in six patients and mitral valve replacement, using the St Jude Medical valve, in 15. Fourteen patients underwent mitral valve surgery combined with coronary artery bypass grafting. Mitral plasty was applied to the patients with low left ventricular function with mean(s.d.) fraction shortening of 19.2(6.2)% compared with 30.2(8.4)% in patients with mitral valve replacement. There were no operative deaths. Of four late deaths, two in group 1 resulted from infection and myocardial infarction, respectively, and one in group 2 resulted from arrhythmia. One patient in group 3 died from renal failure. It is suggested that incorporation of these therapeutic concepts may lead to satisfactory results in the surgical treatment of ischaemic mitral regurgitation.     

Mitral valve prolapse. Comparison between valvular repair and replacement in severe mitral regurgitation

BACKGROUND: The aim of this study was to analyse long term results of mitral valve repair of degenerative mitral regurgitation compared to valve replacement. METHODS: A hundred-twenty-five consecutive patients with severe mitral valve insufficiency who underwent cardiac surgery from January 1987 to December 1995 were included in the study. Mean age was 55+/-16 years (77 males, 48 females). Mitral repair was performed in 62 patients and mitral valve was replaced in 63 patients. Mean follow-up was 5 years. The repair procedures were based on quadrangular resection of the posterior leaflet, chordal replacement and transposition. Annuloplasty was performed in 100% of cases. The technique of valve replacement was conventional with complete excision of the valve in the majority of cases. RESULTS: Operative mortality following valve repair was 1.6%, no death occurred in the prosthesic group. In the repair group overall survival and re-operation rate were respectively 95.2% and 6.5%, while in the replacement group were 93.7% and 7.9%. No endocarditis and thromboembolic accidents were observed following valvuloplasty, while in the prostheses 6.3% of patients had endocarditis and 1.6% had a thromboembolic event. Mild or moderate left ventricular dysfunction was present in 5 patients after valvuloplasty and in 9 patients with prostheses. CONCLUSIONS: Considering these results we conclude that, in patients with severe degenerative mitral insufficiency, mitral valve repair is warranted whenever it is possible. The advantages given by maintaining the native valve suggest that surgery should be considered in asymptomatic patients before the occurrence of the left ventricular dysfunction.     

重症心脏瓣膜病的外科治疗

目的总结重症心脏瓣膜病的外科治疗结果,探讨提高早期生存率的措施。方法自2000年6月至2005年7月,对78例重症心脏瓣膜病患者施行瓣膜替换术。其中单纯二尖瓣置换12例,二尖瓣置换 三尖瓣成形22例,单纯主动脉瓣置换8例,二尖瓣 主动脉瓣置换 三尖瓣成形35例,二尖瓣置换 冠状动脉旁路移植术1例。结果死亡6例,其中术后并发低心排血量5例,心室颤动治疗无效死亡1例,死亡率7.69%。随访53例,平均随访2.5年,死亡5例。结论对重症心脏瓣膜病患者,注重改善术前心功能,掌握手术时机,尽量保留瓣下组织,选择合适瓣膜,重视围手术期处理,可提高手术成功率。     

Beating heart surgery for the patient of severe mitral regurgitation with a episode of ventricular fibrillation; report of a case

A 77-year-old female was admitted to our hospital with a diagnosis of severe mitral regurgitation. Cardiopulmonary revival was done by an emergent resuscitation for the ventricular fibrillation before admission. She had mild anoxic brain damage and brain magnetic resonance imaging (MRI) revealed severe brain atrophy. Chest X-ray showed severe cardiomegaly and congestion. Beating heart mitral valve replacement was planned for the prevention of reperfusion injury. A cardiopulmonary bypass was established by bicaval drainage and aortic return. The prolapse of anterior leaflet was recognized through transeptal approach after aortic clamp. We selected continuous infusion of antegrade cardioplegia for intraoperative coronary perfusion. Mitral valve replacement was done successfully. During intraoperation and postoperation, ventricular fibrillation did not occur. On-pump beating mitral valve replacement is a good procedure to prevent perioperative ventricular arrhythmia especially such the case with a decompressed myocardial function and with a preoperative episode of lethal ventricular arrhythmia necessary for cardiopulmonary resuscitation.     

老年风湿性二尖瓣病变行二尖瓣修复术与生物瓣膜置换术中期效果比较

目的比较60岁以上老年患者风湿性二尖瓣修复(MVP)与生物瓣膜置换(MVR)的中期效果。方法选取2014年1月至2016年1月北京安贞医院瓣膜外科诊疗中心行风湿性二尖瓣修复或生物瓣置换手术的60岁以上老年风湿性二尖瓣病变患者,包括同期行三尖瓣修复术及房颤射频消融术患者;排除合并主动脉瓣手术、冠状动脉旁路移植手术、二次手术患者,最终纳入患者82例。根据二尖瓣手术方式分为二尖瓣修复组(MVP组,25例)和生物瓣置换组(MVR组,57例)。采用Kaplan-Meier法进行生存分析并绘制曲线,通过Log Rank方法比较两组患者5年生存率的差异。结果围手术期全组患者平均年龄(66.37±4.41)岁。54.9%的患者心功能(NYHA分级)Ⅲ级。两组患者在体外循环时间(P=0.99),主动脉阻断时间(P=0.88),术后住院时间(P=0.76)差异均无统计学意义。MVR组3例患者住院期间死亡,病死率5.3%;MVP组无住院期死亡(P=0.24)。随访5年,最长随访63个月,平均随访47.03个月。MVR组6例死亡,其中4例死于心脑血管不良事件,2例死于非心脑血管不良事件。MVP组无死亡。两组均无再手术病例。结论风湿性二尖瓣病变的老年患者采用二尖瓣修复手术治疗能够获得较好的中期效果。     

Mitral valve repair with aortic valve replacement is superior to double valve replacement

OBJECTIVES: Double valve replacement has been advocated for patients with combined aortic and mitral valve disease. This study investigated the alternative that, when feasible, mitral valve repair with aortic valve replacement is superior. Patients and Methods: From 1975 to 1998, 813 patients underwent aortic valve replacement with either mitral valve replacement (n = 518) or mitral valve repair (n = 295). Mitral valve disease was rheumatic in 71% and degenerative in 20%. Mitral valve replacement was more common in patients with severe mitral stenosis (P =.0009), atrial fibrillation (P =.0006), and in patients receiving a mechanical aortic prosthesis (P =.0002). These differences were used for propensity-matched multivariable comparisons. Follow-up extended reliably to 16 years, mean 6.9 +/- 5.9 years. RESULTS: Hospital mortality rate was 5.4% for mitral valve repair and 7.0% for replacement (P =.4). Survivals at 5, 10, and 15 years were 79%, 63%, and 46%, respectively, after mitral valve repair versus 72%, 52%, and 34%, respectively, after replacement (P =.01). Late survival was increased by mitral valve repair rather than replacement (P =.03) in all subsets of patients, including those with severe mitral valve stenosis. After repair of nonrheumatic mitral valves, 5-, 10-, and 15-year freedom from valve replacement was 91%, 88%, and 86%, respectively; in contrast, after repair of rheumatic valves, it was 97%, 89%, and 75% at these intervals. CONCLUSIONS: In patients with double valve disease, aortic valve replacement and mitral valve repair (1) are feasible in many, (2) improve late survival rates, and (3) are the preferred strategy when mitral valve repair is possible.     

Mitral valve replacement for a severely calcified mitral annulus

We herein describe a surgical technique in a mitral valve replacement for a hemodialysis patient presenting with mitral valve stenosis and severe mitral annular calcification. Mitral annular calcification extending to the left ventricular myocardium was resected using a cavitron ultrasonic surgical aspirator (CUSA) to make a flat plane from the left atrium to the left ventricle. An autologous pericardium was secured to the posterior left ventricular wall and to the left atrial wall covering the mitral annulus for annular reconstruction. In the posterior mitral annulus, the prosthetic valve was fixed onto this pericardial patch. After the operation, the patient recovered well without any embolic complications. The prosthetic valve functions normally without any perivalvular leakage. Decalcification using the CUSA and the annular reconstruction with a pericardial patch is therefore indicated in valve replacement for patients with severe mitral annular calcification.     

Anterolateral right thoracotomy for mitral valve procedure after previous coronary artery bypass grafting with functioning internal mammary artery grafts

AIM: Mitral valve procedure after previous coronary artery bypass grafting (CABG) with functioning internal mammary artery (IMA) grafts has high risk. Especially, internal mammary artery grafts injury may be fatal. The anterolateral right thoracotomy affords easy access to the right atrium with minimal dissection, and minimizes the risk of injury to the IMA grafts. We reviewed our operative technique and outcome after mitral valve procedure after previous CABG with functioning IMA grafts. METHODS: Thirteen patients (11 male and 2 female, mean age of 67.7+/-8.5 years, range 54 to 80 years) underwent mitral valve replacement after previous CABG with functioning IMA grafts from march 1993 to september 2002. The mean interval between the previous CABG and the mitral valve procedure was 3.8 years (range 9 months to 8 years). Four patients had simultaneous mitral valve procedures at initial CABG (2 repairs and 2 replacements). The operation has performed through the anterolateral right thoracotomy, under ventricular fibrillation with moderate hypothermia and without cardioplesia. RESULTS: Mitral valve repair was performed in 3 patients, mitral valve replacement in 10 patients. The mean coronary bypass time was 69.1+/-16.2 min (range 45 to 98 min). The operation time was 159.3+/-29.4 min (range 120 to 219 min). Intensive care unit stay days was 1.9+/-1.6 days (range 1 to 5 days). Peak CK/CK-MB values were 555.1+/-290.4 IU/16.6+/-10.7 IU (range 176 to 924 IU/7 to 44 IU). Peak troponin I value was 9.5+/-5.2 pg/mL (range 4 to 17.8 pg/mL). There was no IMA injury and no early death. Other complications were newly arrhythmia in 3 patients, renal insufficiency in 1 patient, reoperation for bleeding in 1 patient. CONCLUSIONS: Anterolateral right thoracotomy approach, ventricular fibrillation with moderate hypothermia without cardioplesia were a safe and good method for mitral valve operation after previous CABG with functioning IMA graft.     

肥厚梗阻性心肌病合并二尖瓣病变的外科治疗

目的 分析肥厚梗阻性心肌病合并二尖瓣病变的病理特点,探讨外科治疗策略.方法 1996年10月至2009年6月,外科手术治疗62例肥厚梗阻性心肌病病人,其中男41例,女21例;年龄6～68岁,平均(34.05±15.26)岁;体重27～83 kg,平均(60.42±12.71)kg.术前超声心动图(UCG)均提示二尖瓣SAM征,50例合并不同程度的二尖瓣关闭不全(MR).手术在全麻低温体外循环下完成,按常规经主动脉切口行室间隔心肌切除术,同期完成二尖瓣置换术(MVR)12例,二尖瓣成形术(MVP)9例.围术期常规UCG、心电图及X线胸片检查,评价左心房(LA)、左心室(LV)、左窒流出道流速及压差(LVOT)、左室射血分数(EF)、二尖瓣的结构和功能.结果 全组体外循环40～290 min,平均(104.23±47.14)min,主动脉阻断20～195 min,平均(66.76±36.32)min;气管插管5～21 h,平均(13.23±11.76)h.LA术前(43.46±7.21)mm,术后(34.56±5.23)mm;左室流出道压差术前(103.84±44.04)mm Hg(1 mm Hg=0.133 kPa),术后(23.54±17.78)mm Hg;室间隔厚度术前(26.93 ±5.23)mm,术后(17.12±5.67)mm,均显著下降(P＜0.05).术后MR和SAM症基本消失或显著减轻.手术死亡4例(6.4%,4/62例),主要死因为严重低心排综合征、严重心律失常及急性肾功能衰竭.主要并发症有完全左束支传导阻滞(33例)、室内传导阻滞(7例)、完全性房室传导阻滞(6例)、左前分支阻滞(5例)、Ⅰ度房室传导阻滞(5例)、心房颤动(4例).远期随访生存者症状消失,生活质量明显改善,心功能Ⅰ～Ⅱ级,二尖瓣结构功能良好;无远期死亡、并发症或再次手术.结论 肥厚梗阻性心肌病常常合并二尖瓣病变,室间隔肥厚心肌切除术,充分的疏通左心室流出道可基本消失MR和SAM征;如二尖瓣本身有严重先天性发育异常或继发性病变,首选MVP,疗效满意,因人工心脏瓣膜及术后抗凝治疗并发症,MVR不作为常规手术方式.