综合应用二尖瓣成形术治疗复杂二尖瓣关闭不全的中远期效果

目的:回顾性分析综合应用二尖瓣成形术矫治复杂二尖瓣关闭不全的中远期临床效果。方法:2003年1月2014年3月,综合应用多项成形技术修复23例复杂二尖瓣关闭不全患者瓣膜,患者年龄14~71(45±23)岁。术前超声心动图提示二尖瓣关闭不全:中度6例,重度17例,均存在2个以上的反流点;联合应用后瓣矩形切除、前叶三角形切除、腱索缩短、腱索转移、缘对缘二孔化、置入人工腱索、置入人工瓣环等技术修复二尖瓣。术中采用注水试验和经食管超声心动图检查评估成形效果。手术后每年进行1次超声心动图检查,采用Kaplan-Meier方法评估术后随访期死亡率和无二尖瓣反流发生率。结果:全组患者无手术死亡和住院死亡,随访时间为(71±37)个月,2例患者失访(9%),1例患者于术后3年死于心力衰竭,预计11年总体生存率为95%。根据最近一次超声心动图随访结果,22例存活患者中,3例患者分别于术后9个月、72个月和96个月发生中度二尖瓣反流,免于中度以上二尖瓣反流的预计发生率为76.4%。无患者因为二尖瓣反流复发或者其它原因进行二次心脏手术。结论:正确判断二尖瓣闭锁不全的病理改变,综合应用多种成形技术可以取得良好的二尖瓣成形中远期效果。

Integrated application of multiple valvular plasty techniques for repairing complex mitral insufficiency: clinical experience of a single center

AIM: To retrospectively summarize mid-term clinical results of repairing complex mitral valve insufficiency with multiple valvular plasty techniques. METHODS: From January 2003 to March 2014,23 patients with mitral valve insufficiency [age 14-71( 45 ± 23) years]were included in the study. The causes of mitral insufficiency consisted of mitral valve mucous degeneration( n = 14),mitral chordae tendinae rupture( n = 5),secondary atrial septal defect( n = 1),infectious lesions( n = 1) and coronary heart disease with mitral papillary muscle dysfunction( n = 2). Preoperative echocardiography showed moderate mitral valve insufficiency in six cases and severe insufficiency in 17 cases. Multiple techniques including edge to edge mitral repair,rectangular resection of posterior leaflet flap,tendon transfer,chordate shortening,artificial chordate implantation,and prosthetic annuloplasty ring implantation were used to restore the functional anatomy of mitral valves. Hydrostatic test and transesophageal echocardiography were used to evaluate the effects of mitral valve repair during the operation. Follow-up was conducted with yearly transthoracic echocardiography annually for all postoperative patients. Mid-to long-term mortality and freedom from moderate to severe mitral regurgitation were estimated with Kaplan-Meier method.RESULTS: There were no intra-hospital deaths. The average follow-up time was( 71 ± 37) months and two patients( 8. 7%) were absent from follow-up. During the follow-up,one patient died of heart failure and the overall estimated survival rate in the 11 years for this cohort of patients was 95%. According to the last results of echocardiography,moderate mitral valve regurgitation recurred,respectively 9,72 and96 months after operation in 3 /22 surviving patients and the recurrence rate of the estimated freedom from moderate to severe mitral valve insufficiency was 76. 4%. No patient underwent re-operation due to recurrence of mitral valve insufficiency or other reasons. CONCLUSION: Integrated application of multiple techniques of mitral valve plasty based on careful evaluation of pathological changes of the mitral valve produces good mid-to long-term results in patients with complex mitral valve insufficiency.