急性心肌梗死合并二尖瓣反流的外科治疗

目的:初步探讨急性心肌梗死(AMI)合并二尖瓣反流(MR)的外科治疗方法。方法:2008年8月至2011年8月,收治AMI合并MR患者34例。男性25例,女性9例;年龄42～75岁,平均(61.5±10.4)岁。EuroScore评分4～12分,平均5.8分。所有患者均经冠状动脉造影证实,为冠状动脉多支病变无法行介入治疗。心功能平均3.1级(NYHA),心源性休克2例,术前主动脉球囊反搏(IABP)3例。体表超声Doppler检查,根据反流面积及缩流径宽度,将MR分为1+～4+级,其中1+～2+级12例,3+级16例,4+级6例;根据反流部位及室壁运动情况结合冠状动脉造影进行Carpentier二尖瓣反流功能分型:Ⅰ型8例,Ⅱ型4例,Ⅲb型22例;根据左心室舒张末期径线及射血分数(LVEF),判断心肌梗死对心脏结构造成的损伤程度,34例左心室舒张末径37～70 mm,平均(51±7.8)mm,其中>65 mm 6例。综合MR分型、分级及左心室径线决定是否同期行二尖瓣手术。本组采用以下标准:(1)CarpentierⅠ型患者,如MR达到4+级;(2)Carpentier II型,MR为3+～4+级患者;(3)CarpentierⅢb型、MR为4+级同时左心室舒张末径>65 mm患者,同期矫正二尖瓣反流。余均采用单纯冠状动脉搭桥手术。本组单纯冠状动脉搭桥手术28例,冠状动脉搭桥合并二尖瓣成型或替换6例。随访时间1～36个月,平均(20.5±8)个月。结果:全组死亡2例(5.9%),其中围手术期死亡1例,术后1年死亡1例。搭桥根数平均为2.3根/例。完全再血管化27例(79.1%),不完全血管化7例(21.9%)。心功能分级平均1.06级(NYHA)。二尖瓣反流随访结果:28例单纯冠状动脉搭桥组,12例MR完全消失或微量,13例MR为3+级患者手术后减少为微量到少量,MR矫正成功率为89.3%;3例MR无改善或恶化,均为不完全血管化患者。冠状动脉搭桥合并二尖瓣成型或替换组,围手术期死亡1例,1例术后为MR 2+级,4例MR消失。结论:通过综合分析MR分型、分级及左心室舒张末期径线,决定对于急性心肌梗死合并二尖瓣反流的患者是否同期矫正二尖瓣反流,可获得满意的临床疗效。完全再血管化是手术的关键。体外循环辅助下不停跳搭桥,是心肌损伤最小化的前提下,保证完全再血管化的重要手段。

Surgical treatment of acute myocardial infarction combined with mitral valve regurgitation

Objective:To investigate surgical treatment of acute myocardial infarction(AMI) with resultant mitral regurgitation(MR).Methods:Thirty-four consecutive AMI patients Combined with mitral regurgitation from August 2008 to August 2011 in Beijing Anzhen hospital were included in this study.There were 25 males and 9 females,aging from 42-75 years old(mean 61.5±10.4).Euroscore were 4-12,mean average score was 5.8.The coronary angiography of every patient showed that multi-vessel disease which could not tolerate the interventional therapy.NYHA class was 3.1±1.04.Two patients suffered cardiogenic shock,which applied intra-aortic balloon pump counterpulsation(IABP) preoperation.According to reflux area and shrink flow path width in surface ultrasonographic Doppler examination,MR were divided into 1+～ 4+,of which 12 were 1+-2+,16 were 3+,6 were 4+.According to reflux parts and room wall motion combined with coronary angiography for Carpentier MR function classification,8 were Type I,4 were Type II,22 were Type IIIb.According to the left ventricular end-diastolic diameter line and ejection fraction(LVEF) to judge on damage degree of cardiac structure caused by MI,left ventricular end-diastolic diameter 37-70 mm(mean51± 7.8 mm)in the 34 patients,among them 6 patients were more than 65 mm.Analysis by synthesis of MR classification and comprehensive type,left ventricular size line,operators decided whether to do mitral valve operation at one time.Our including criteria is(1) Carpentier typeⅠ,MR 4+;(2) Carpentier type II、MR 3+～4+(3)Carpentier type Ⅲb、MR 4+ combined left ventricular end-diastolic diameter over 65 mm.Other patients just took coronary artery bypass graft surgery(CABG).28 underwent CABG,and 6 underwent CABG combined mitral valvoplasty or replace.Among them,on-pump CABG for 11 patients.,4 were CABG combined mitral valvoplasty,2 were CABG combined mitral valve replacement.Outcomes were monitored for 1 month to 36 months(mean(20.5±8) months).Results:Two patients died(5.9%),1 died perioperative,and 1 died 1year after the surgery.Mean number of patent grafts per case was 2.3,27 were complete revascularization,(79.1%)and 7 were incomplete revascularization(21.9%).NYHA mean class was 1.06.MR follow-up results showed that,in the28 patients who just underwent CABG,12 of which disappeared completely or mild,13 patients with MR level 3+ reduced notable,the success rate of correcting MR is 89.3%;there are 3 patients,all incompletely revascularized,showed no change or even deteriorated.In the CABG combined mitral valvoplasty or replace group,1 died perioperative,MR was 2+ in 1 patient,4 MR disappeared completely.Conclusion:Satisfied clinical efficacy could be acquired by comprehensive analysis of classification and level of MR,and left ventricular end-diastolic diameter line,to determine whether to do mitral valve operation with CABG at one time in patients with AMI Combined MR.Completely revascularization is the key of the surgery.Beating heart CABG under CPB is the important means to ensure completely revascularization under the premise of minimizing myocardial injury.