复杂二尖瓣前叶脱垂不同术式选择探讨

目的:总结腱索转移、人工腱索、瓣叶折叠及双孔技术在二尖瓣成形术中的临床应用和体会,提高临床治疗效果。方法:回顾性分析2007年1月至2013年8月,采用四种成形技术治疗的以二尖瓣前叶脱垂为主病例122例,其中男性68例,女性54例,年龄18~69岁,平均(43±7.9)岁,A1区脱垂21例,A2区脱垂12例,A3区脱垂28例,A1合并A2区脱垂26例,A2合并A3区脱垂35例,合并后叶脱垂16例。术前心功能分级(NYHA分级)Ⅱ级67例,Ⅲ级55例。45例采用腱索转移技术,54例采用人工腱索技术,12例采用瓣叶折叠技术,11例采用双孔技术,5例合并冠心病同期行冠状动脉旁路移植术(前降支单支桥3例,回旋支单支桥2例,)。结果:腱索转移组和人工腱索组均无围手术期死亡,瓣叶折叠组1例患者术后第8天死于多脏器功能衰竭,双孔技术组1例患者术后13 d死于肺部感染。出院前心脏超声显示:腱索转移组少量反流6例,微量反流14例,未见明显反流25例。人工腱索组少量反流16例,微量反流15例,未见明显反流23例。瓣叶折叠组少量反流8例,微量反流4例。双孔技术组少量反流9例,微量反流2例。四组术前、出院前、术后6个月左心室射血分数、左心室舒张末内径、收缩末内径差异无统计学意义(P0.05)。四组术前舒张末内径、收缩末内径较出院前、术后6个月舒张末内径、收缩末内径差异有统计学意义(P0.05)。四组出院前射血分数较术前、术后6个月低,差异有统计学意义(P0.05)。腱索转移组术后14个月1例患者因转移的腱索缝合缘撕脱造成二尖瓣大量反流再次手术置换二尖瓣。人工腱索组1例患者术后6个月频繁出现血红蛋白尿再次手术置换二尖瓣。结论:四种成形技术可以满足各种类型复杂二尖瓣前叶脱垂的处理。腱索转移适合单纯的前叶脱垂病变;人工腱索适用范围更广泛,容易学习;瓣叶折叠适用范围稍窄,适合初学者;双孔技术适用范围较广,不应作为首选方法,可和其他方法联合应用。四种方法均有良好的近期效果,值得去掌握和应用。

Surgical treatment of complicated anterior leaflet prolapse of mitral valve

Objective：To summarize the clinical outcomes and experiment of chordae transfer,artificial chordae,leaflet folding,double-orifice repair in mitral valve repair and to improve the clinical therapeutic effects.Methods：Clinical data of 122 patients with anterior leaflet prolapse who underwent mitral valve repair by the four technique from January 2007 to August 2013 were retrospectively analyzed.There were 68 male and 54 female with age from 18 to 69 years old（43 ± 7.9）.Of the 122 patients,61 had prolapse of a single segment （A1,21 ;A2,12 ;A3,28）,and 61 had prolapse of multiple segments（A1 and A2,26 ;A2 and A3,35）,combined with 16 posterior leaflet prolapse.67 patients were in New York Heart Association（NYHA） functional class Ⅱ,and 55 in class Ⅲ preoperation.45 patients underwent chordae trasfer technique,54 patients underwent artificial chordae,12 by leaflet folding and 11 by double-orifice with 5 patients combined with coronary artery bypass grafting（2 for the circumflex,3 for anterior descendens）.Results：There was no perioperative death in chordae transfer group and artificial chordae group,combined with 1 death for multiple organs failure after the eighth day postoperation in leaflet folding group,and 1 death for pulmonary infection 13 days later in double-orifice group.Echocardiography before discharge showed mild regurgitation in 6 patients,trivial regurgitation in 14 patients,normal in 25 patients in chordae transfer group,in artificial chordae group mild regurgitation in 16 patients,trivial regurgitation in 15 patients,normal in 23 patients,in leaflet folding group mild regurgitation in 8 patients,trivial regurgitation in 4 patients,and in double-orifice group mild regurgitation in 9 patients,trivial regurgitation in 2 patients.Left ventricular ejection fraction （LVEF）,end-diastolic dimension （LVEDD）and end-systolic dimension （LVESD） of the four group had no statistical difference pre-operation,before discharge and 6 months after operation（P ＞ 0.05）.There was statistical difference in LVEDD and LVESD pre-operation than before discharge and 6 months after operation in the four groups （P ＜ 0.05）.LVEF before discharge was lower than that of pre-operation and 6 months after operation in all groups （P ＜ 0.05）.1 patient underwent redo mitral valve replacement for avulsion of suture margin 14 months after repair in chordae transfer group and 1 patient received redo mitral valve replacement for persistent hemoglobinuria after half a year in artificial choadae group.Conclusion：The four reapir technique are all suitable for complicated anterior leaflet prolapse.Chordae transfer is suited to pure anterior leaflet prolapse,artificial chordae has a extensive range of application and easy to learn relatively.Leaflet folding has a narrow scope of implication,suiting the greenhand.Double-orifice can be combined with other techniques for the extremely wide scope of application.The four technique have a good short-time clinical outcomes,worthy of study and application.