二尖瓣环成形术在左室成形术合并CABG手术中的应用

为寻求一种有效治疗继发于缺血性心肌病的缺血性二尖瓣关闭不全 (IMR)的外科治疗方法 ,对 46例术前诊断为陈旧性心肌梗死合并缺血性二尖瓣关闭不全的患者〔43例 (93 % )患者因出现心衰而手术治疗 ;心功能(NYHA)Ⅳ级者 2 5例 ,占 5 4% ,二尖瓣中重度关闭不全者 3 2例 ,占 70 %〕在进行二尖瓣成形术的同时行左室成形术及冠状动脉旁路移植术 (CABG)。手术方法 :完成冠状动脉移植远端吻合后切开室壁瘤 ,经左心室途径在心室面行二尖瓣环成形术 ,之后以Dor手术方式行左心室成形术 ,最后完成冠状动脉移植物的近端吻合。结果 :围手术期总病死率为 1 5 .2 % ;EF(射血分数 ) <3 0 %的患者病死率为 2 0 .0 % ,而EF≥ 3 0 %者病死率为 1 1 .5 %。术后左室收缩末期及舒张末期容积均显著降低 (P <0 .0 0 1 ) ,肺动脉压亦显著下降 (P <0 .0 5 )。 85 %的患者术后二尖瓣关闭不全 (MR)消失或极轻 ;晚期病死率为 1 5 % ;中期存活率为 71 %。结果提示 :虽然这种复杂手术的病死率较高 ,但疗效尚令人满意。

Mitral Annuloplasty During Left Ventricular Restoration Associated With CABG

The aim was to study a more effective surgical approach to treat Chronic ischemic mitral regurgitation(IMR) secondary to ischemic cardiomyopathy. Forty-six patients 〔(64±10) years〕 with previous anterior transmural myocardial infarction and mitral regurgitation compose the study group. Indication for surgery was heart failure in 93% of pts; 25 patients were in NYHA class Ⅳ. Mitral regurgitation was moderate to severe in 32 patients (70%). This surgical approach consisted in endoventricular mitral annuloplasty without prosthetic ring combined with ventricular reconstruction, and coronary artery bypass grafting(CABG). Global perioperative mortality rate was 15.2%; it was 20.0% in patients with EF<30% and 11.5% in patients with EF≥30%. End diastolic and end systolic volumes significantly decreased after surgery(P< 0.001); Pulmonary pressure decreased significantly(P< 0.05). Postoperative MR was absent or minimal in 85% of patients; Late mortality was 15%; Mid-term overall survival rate of 71% seemed promising in this series of patients at extremely high risk for mortality and subsequent cardiac events. This complex surgical procedure has a relatively high operative mortality, but the results are promising. The results of mitral repair should persist over time because the valve leaflets and the subvalvular apparatus are normal, and the two trigones are particularly strong to bear the tension of the stitch.