保留后瓣及瓣下结构的二尖瓣置换术临床分析

目的总结保留二尖瓣后瓣及瓣下结构二尖瓣置换术(MVR)的经验,评价其临床效果。方法回顾性分析首都医科大学北京安贞医院2006年1月至2011年3月行MVR患者1 035例的临床资料,其中男562例,女473例;年龄37～78(53.84±13.13)岁。风湿性心脏瓣膜病712例,退行性瓣膜病323例;二尖瓣狭窄为主389例,二尖瓣关闭不全为主646例;均排除冠状动脉疾病。不保留后瓣及瓣下结构的MVR(不保留组)457例,保留后瓣及瓣下结构的MVR(保留组)578例,两组患者术前情况差异无统计学意义。分析比较两组患者手术后并发症、死亡率,以及左心室大小与功能。结果不保留组与保留组患者的死亡率(2.63%vs.1.21%,P=0.091)及并发症发生率(8.53%vs.7.44%,P=0.519)差异无统计学意义,但不保留组左心室破裂发生率高于保留组(1.09%vs.0.00%,P=0.012);术后6个月心脏超声心动图提示左心室舒张期末内径(LVEDD)较术前缩小,但两组差异无统计学意义;两组患者左心室射血分数(LVEF)均较术前提高,保留组中二尖瓣关闭不全为主患者的LVEF优于不保留组(56.00%±3.47%vs.53.00%±3.13%,P=0.000),两组二尖瓣狭窄为主的患者中LVEF差异无统计学意义(57.00%±5.58%vs.56.00%±4.79%,P=0.066)。结论保留二尖瓣后瓣及瓣下结构的MVR安全有效,可以减少术后左心室破裂的发生并改善术后心功能。

Clinical Outcomes of Preservation of Posterior Leaflet and Subvalvular Structures in Mitral Valve Replacement

Objective To summarize our experience and clinical outcomes of preservation of posterior leaflet and subvalvular structures in mitral valve replacement(MVR).Methods We retrospectively analyzed the clinical data of 1 035 patients who underwent MVR in Beijing An Zhen Hospital from January 2006 to March 2011.There were 562 male patients and 473 female patients with their age of 37-78(53.84±13.13)years old.There were 712 patients with rheumatic valvular heart disease and 323 patients with degenerative valve disease,389 patients with mitral stenosis and 646 patients with mitral regurgitation.No patient had coronary artery disease in this group.For 457 patients in non-preservation group,both leaflets and corresponding chordal excision was performed,while for 578 patients in preservation group,posterior leaflet and subvalvular structures were preserved.There was no statistical difference in demographic and preoperative clinical characteristics between the two groups.Postoperative mortality and morbidity,and left ventricular size and function were compared between the two groups.Results There was no statistical difference in postoperative mortality(2.63% vs.1.21%,P = 0.091)and morbidity(8.53% vs.7.44%,P=0.519)between the non-preservation group and preservation group,except that the rate of left ventricular rupture of non-preservation group was significantly higher than that of preservation group(1.09% vs.0.00%,P=0.012).The average left ventricular end-diastolic dimension(LVEDD) measured by echocardiography 6 months after surgery decreased in both groups,but there was no statistical difference between the two groups.The average left ventricular ejection fraction(LVEF) 6 months after surgery was significantly improved compared with preoperative average LVEF in both groups.The average LVEF 6 months after surgery in patients with mitral regurgitation in the preservation group was significantly higher than that in non-preservation group(56.00%±3.47% vs.53.00%±3.13%,P = 0.000),and there was no statistical difference in the average LVEF 6 months after surgery in patients with mitral stenosis between the two groups(57.00%±5.58% vs.56.00%±4.79%,P = 0.066).Conclusion Preservation of posterior leaflet and subvalvular structures in MVR is a safe and effective surgical technique to reduce the risk of left ventricle rupture and improve postoperative left ventricular function.