重危瓣膜病变合并巨大心脏的外科治疗

目的:报道181例重危瓣膜病变合并巨大心脏的外科治疗体会。方法:回顾性分析181例瓣膜外科病例中合并巨大心脏临床资料,男性76例,女性105例,年龄15～57岁,平均(45.7±15.2)岁。分为2组:巨大左心房(GLA)组84例,左心房内径(LAD)70～150mm,平均(80.3±17.5)mm;巨大左心室(GLV)组97例,左心室舒张末内径(LVEDD)70～112mm,平均(79.4±12.7)mm。患者全部行瓣膜置换术,其中GLA组行主动脉瓣与二尖瓣双瓣膜置换术12例,二尖瓣置换术72例,同期行三尖瓣环缩成形术42例,左心房血栓清出13例;84例均作左心房折叠术。GLV组行主动脉瓣置换术38例,主动脉瓣与二尖瓣双瓣膜置换术27例,二尖瓣置换术32例,二尖瓣置换术均保留全部或部分瓣膜和瓣下结构,同期行三尖瓣环缩成形术18例,左心房血栓清出4例,左心房折叠术21例。结果:手术早期死亡率GLV组和GLA组分别为9.3%和6.0%,GLV组明显高于GLA组(P<0.05);死亡原因GLV组以室性心律紊乱为主(55.6%),明显高于GLA组(P<0.05);GLA组以呼吸衰竭为主。术后1个月超声心动图显示,GLA组LAD平均(60.1±12.1)mm,GLV组LVEDD平均(56.6±16.1)mm,较术前明显缩小(P<0.01)。心功能恢复良好。结论:瓣膜置换同期左心房折叠术有利于改善合并巨大左心房的术后恢复;保留二尖瓣瓣膜及瓣下结构有利于合并巨大左心室病例的恢复。

Surgical treatment of severe heart valvular disease combined with giant heart

Objective:To evaluate the effect of surgical treatment of 181 cases with severe heart valuvlar disease combined with giant heart.Method:Among 785 cases with severe heart valve disease,there were 181 cases (male 76,female 105) with giant heart.The age ranged from 15 to 57 years with an average of (46.7±15.2) years.The patients were divided into giant left atrium(GLA) group(n=84) and giant left ventricular(GLV) group(n=97).Mean left atrial diameter was (80.3±17.5) mm (from 70 mm to 150 mm) in GLA group,in which all patients underwent heart valve replacement(HVR) and left atrial plication(LAP).The HVR procedure including mitral valve replacement(MVR) in 72 and double valves replacement(DVR) in 12 caes.Meanwhile,42 cases under went tricuspid valve plasty and removed thrombi of left atrium in 13.Mean left ventricular endo-diastolic diameter(LVEDD) was (79.3±12.7) mm (from 70 mm to 112 mm) in GLV group,in which the HVR procedure including aortic valve replacement(AVR) 38 cases,MVR 32 and DVR 27.Of the cases with HVR,21 cases were accepted left atrial plication(LAP),and 18 cases with tricuspid valve plasty and removed thrombi of left atrium in 4 cases.Result:The early mortality rates were 6.0%(5/84) in GLA group and lower 9.3%(9/97) in GLA group,P<0.05.The key reason of early deaths was pulmonary failure(60%,3/5) in GLA group.But in GLV group severe ventricular arrhythmia was the main reason(55.6%,5/9) and significantly higher than in GLA group(P<0.05).The others were cured,and followed-up one month.The echcardiogram showed mean LAD(60.1±12.1) mm in GLA group and mean LVEDD(56.6±16.1) mm in GLV group,were reduced significantly than preoperation(P<0.01).The heart function recovered good.Conclusion:The HVR plus LAP could improve early recovery in GLA group.The MVR with preservation mitral valve or/and subvalvular apparatus was a good choice in GLV group.