二尖瓣关闭不全合并巨大左心室外科治疗及远期随访

目的:报道单纯慢性二尖瓣关闭不全合并巨大左心室患者外科治疗方法和远期随访结果。方法:自1988年4月至2000年9月,我院共对45例单纯慢性二尖瓣关闭不全合并巨大左心室患者进行了二尖瓣置换术(mitral valve replacement,MVR),其中男性28例,女性17例,年龄13~58岁,平均年龄(33.8±10.5)岁。病例入选标准:术前诊断为重度二尖瓣关闭不全合并左心室舒张内径(left ventricle diastole diameter,LVDD)70mm者。该组患者中,病因为风湿性心脏病者36例(占80%),先天性心脏病(先心病)者9例(占20%)。术前心功能分级:NYHAⅡ级13例,Ⅲ~Ⅳ级32例。胸X线片C/T示:0.64±0.12(范围0.47~0.84)。超声心动图(echocardiogram,UCG)示所有患者均患重度二尖瓣关闭不全合并巨大左心室,LVDD为(76.3±4.1)mm(范围:70.2~89.6mm),射血分数(EF)为(45.7±6.3)%(范围:30.0%~66.3%);所有患者均在全麻体外循环下接受MVR。结果:全组45例患者中,围术期死亡2例,病死率为4.4%,术后2w UCG示LVDD减小为(65±5.2)mm(与术前相比P0.01)。随访至2012年9月,37例患者得到随访,占总数的82.2%,平均随访时间为(13.8±0.12)年(144~264个月),至今存活患者23例,占62.2%,其中5例患者心功能Ⅰ级,14例患者心功能Ⅱ级,2例患者心脏功能Ⅲ级2例心功能Ⅳ级。随访期间死亡12例,随访病死率为32.4%,失访2例,失访率为5.4%。因心脏原因死亡9例,占死亡例数的75%,主要原因慢性心功能不全和为抗凝并发症或合并肾功能不全。存活患者LVDD进一步减小达(60.0±6.1)mm,与术后围术期LVDD相比有明显缩小(P0.001)。结论:对于二尖瓣关闭不全合并巨大左心室患者行MVR是一种远期疗效好的外科治疗方法,术后患者左心室能够进一步缩小。远期和慢性心功能不全和抗凝并发症为主要死亡原因。

Long-term results of surgical treatment for mitral regurgitation associated with enlarged left ventricle

Objective：Report long term results of patients operated of mitral valve replacement （MVR） for isolated chronic mitral insufficiency associated with severely enlarged left ventricle （LV）.Methods：Between April 1988 and September 2000,45 patients（28 male and 17 female） with a mean age of （33.8 ± 10.5） years（range：13-58 yrs）,underwent MVR at Anzhen Hospital.Cases collected condition：All patients had aseverly mitral valve regigutation（MR） with LV Diastole Diameter（LVDD） ＞ 70mm.MR was rheumatic in origin in 36 cases（80％） and congenital in 9 cases（20％）.13 cases were in NYHA functional class Ⅱ and 32 cases in class Ⅲ-Ⅳ.At X-ray,the C/T was 0.64 ± 0.12 （range：0.47-0.84）.Echocardiogram （UCG） showed severe MR and L hypertrophy in all patients：LVDD was （76.3 ± 4.1） mm （range：70.2-89.6mm）.Ejective fraction（EF） was （45.7 ± 6.3） ％ （Range：30.0％-66.3 ％）.Mitral valve replacement was performed in all patients under hypothermic cardio-pulmonary by-pass.Result：Two out of 45 cases died in the perioperative period accounting for a mortality rate of 4.4％.Two weeks after surgery the echocardiogram showed a reduction of LVDD [from （76.3 ±6.5） to （65 ±5.2）mm,P ＜0.01].Follow-up results：Follow-up was completed in 37 cases（82.2％）.Mean follow up term was （13.8 ±0.12） years（144-264 months）.21 cases were alive now with a ratio of 56.7％ in 37 cases.5 out of 37 cases was class Ⅰ（NYHA）,and 14 cases was class Ⅱ,2 cases was class Ⅲ.12 cases were dead during follow-up with a ratio of 32.4％,4 cases were out of correspondence with a ratio of 5.4％.9 cases out of all deaths were due to cardiac events with a ratio of 75％,the main cardic events were including anti-congnition complication and chronic cardiac failure or kidny failure.All alives were with LVDD further decreased at late control [from （76.3 ± 6.5） to （60.0 ± 6.1） mm,P ＜ 0.001）.Conclusion：Mitral valve replacement is indicated in patients with mitral insufficiency and very dilated left ventricles,and the intervention has the potential to reduce LV severe dilation and in some cases to revert to normal.Anti-congnition and chronic heart failur were main reasons of late death.