不同保留瓣下结构方法行二尖瓣置换术的对比研究

目的:总结不同保留瓣下结构方法在二尖瓣置换术中的临床应用和体会,提高临床治疗效果,降低术后病死率和并发症发生率。方法:回顾性分析2005年5月至2013年7月,102例以二尖瓣病变为主的患者,实施了保留二尖瓣瓣叶及瓣下结构的瓣膜置换术(均置换的机械瓣膜),其中男性48例,女性54例,年龄22~67岁,平均(46±10.1)岁,术前诊断二尖瓣狭窄为主22例,二尖瓣狭窄合并关闭不全56例,二尖瓣关闭不全为主24例,合并三尖瓣中度以上关闭不全38例,合并心房颤动35例,合并左心房血栓3例。术前射血分数(EF)33%~65%,平均(52±8.2)%。心功能分级(NYHA分级)Ⅱ级7例、Ⅲ级76例、Ⅳ级19例。同期选择行保留后叶及瓣下结构以及不保留瓣膜和瓣下结构的二尖瓣置换术的患者各102例作为对照组。三组患者术前情况比较,差异无统计学意义(P0.05)。结果:保留全瓣组无围手术期死亡;保留后叶组术后早期死亡2例(1.96%),1例死于严重低心排出量综合征(低心排),1例死于肺部感染;不保留组术后早期死亡5例(4.90%),3例死于左心室后壁破裂,2例死于严重低心排。术后6个月心脏超声随访结果显示保留全瓣组术后左心室射血分数(LVEF)、左心室舒张末期内径(LVEDD)、左心室收缩末期内径(LVESD)均较保留后叶组和不保留组有改善,其中LVEF和LVESD的差异有统计学意义(P0.05)。结论:保留全瓣及瓣下结构的二尖瓣置换术近期效果优良,适合各种类型的二尖瓣病变,主要是以二尖瓣关闭不全为主的病变。该方法操作上较为复杂,适合经验丰富的外科医生。保留后叶适合二尖瓣狭窄为主,瓣环偏小的患者。

The comparative research of mitral valve replacement with different preservation of subvalvular apparatus

Objective：To summarize the clinical outcomes and experiment of mitral valve replacement with different chordal-sparing technique and to improve the clinical therapeutic effects,reduce mortality and complication.Methods：Clinical data of 102 patients with mitral valve diseases who underwent total chordalsparing mitral valve replacement（all with mechanical valve prosthesis）from May 2005 to July 2013 were retrospectively analyzed.There were 48 male and 54 female with age from 22 to 67 years old（46 ± 10.1）.Pre-operation diagnosis was mitral valve stenosis in 22 patients,mitral valve stenosis and insufficiency in 56 patients,regurgitation in 24 patients,combined with more than moderate tricuspid regurgitation in 38 patients,atrial fibrillation in 35 patients,left atrial thrombus in 3 patients.The preoperation left ventricular ejection fraction were 33％ ～65％,mean （52 ± 8.2）％.7 patients were in New York Heart Association（NYHA） functional class Ⅱ,76 patients in class Ⅲ and 19 patients in class Ⅳ preoperation.At the same time,each 102 patients were chosen as control group which underwent mitral valve replacement with posterior chordal preservation and nonchordal preservation.There was no statistical difference in preoperative clinical characteristics between the three groups （P ＞ 0.05）.Results：There was no perioperative death in total chordal-sparing group.In posterior chordal group,1 died for low cardiac output syndrome and 1 died for severe pulmonary infection.Five patients were died for left ventricular rupture（3 patients） and severe low cardiac output（2 patients） in nonchordal group after operation.Left ven tricular ejection fraction （LVEF） 、end-diastolic dimension （LVEDD） and end-systolic dimension（LVESD） of total chordal-sparing group were improved than that of posterior chordal group and nonchordal group 6 months follow-up after surgery by echocardiography,and there was statistical difference in LVEF and LVESD between the three groups（P ＜ 0.05）.