45例二尖瓣关闭不全成形术的临床分析
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摘要
目的
探讨二尖瓣直视成形术治疗二尖瓣关闭不全的临床效果,分析术前左心室射血分数(LVEF)、左心室收缩末直径(LVESD)与术后出现左心室功能障碍的关联性。
方法
回顾性分析郑州大学第二附属医院2007年6月至2010年3月行二尖瓣直视成形术治疗二尖瓣关闭不全的患者45例,其中男性20例,女性25例,年龄2-66岁,平均(39.4±18.9)岁。病因：1例风湿性二尖瓣关闭不全,8例先天性二尖瓣关闭不全,32例瓣膜退行性二尖瓣关闭不全,2例缺血性心脏病致二尖瓣关闭不全,2例感染性心内膜炎致二尖瓣关闭不全。术前纽约心功能(NYHA)分级：I级4例,II级29例,III级12例。术前超声心动图测量左房直径(LA)47.13±10.86(22-56)mm,左室舒张末直径(LVEDD)54.84±9.31(36-63)mm,左室射血分数为(I.VEF)62.16±6.10(42～77)%,左室收缩末内径(LVESD)40.40±6.43(29-58)mm,二尖瓣返流程度(返流面积与左心房面积的比值)38.44±8.23%,其中重度返流16例,中度返流29例。手术均在体外循环浅低温下施行,术中根据二尖瓣病理改变及病变部位的不同采用的成形方式有：人工瓣环成形术、缘对缘成形术、瓣叶穿孔及裂隙修补术、腱索转移技术、后瓣叶楔形或矩形切除术及sliding术。术中应用打水试验评价成形效果。术后1周复查心脏超声心动图,比较术前、术后各指标的变化。通过电话或门诊随访心功能状况。
结果
术后1周复查超声心动图示：左房直径(LA)37.04±7.46(20-53)mm,左室舒张期末内径(LVEDD)47.20±7.57(32-59) mm,左室收缩末内径(LVESD)37.07±4.13(30-46)mm,二尖瓣返流程度6.86±3.17%,以上各指标与术前相比明显缩小,差异均有统计学意义(P<0.05)。左室射血分数(]VEF)由术前62.16±6.10(42～77)%下降至55.22±6.90(43～71)%,也有一定程度的降低。术后二尖瓣返流程度明显改善,其中12例二尖瓣无返流,33例仅轻度返流。以术前EF≥64%、LVESD <37mm作为预测术后患者出现EF<50%的分割线。则本组病例中EF<50%的患者共有13例,其中术前EF≥64%且LVESD<37mm者1例,术前EF<64%或LVESD>37mm者2例,术前EF<64%且LVESD≥37mm者10例。门诊及电话随访3月-4年(平均2.8年),术后3个月44例患者纽约心功能(NYHA)分级：Ⅰ级34例(77.3%),Ⅱ级8例(18.2%),Ⅲ级2例(4.5%),1例感染性心内膜炎患者因再次出现心力衰竭而死亡。
结论
1.根据二尖瓣关闭不全病变的不同病因、病理特征,采取相应的成形方式可有效的纠正关闭不全、改善心功能状态。
2.术前EF<64%且LVESD≥37mm的患者术后出现左心室功能障碍的可能最大,故综合判断术前EF值及LVESD,可对术后是否出现左室功能障碍的预测提供依据。
Objective:
To investigate the clinical effect of mitral valvuloplasty for mitral valve regurgitation and studied the relationship between Preoperative EF and LV end-systolic diameter and occurrence of LV dysfunction after mitral valvuloplasty.
Methods:
From June2007to March2010in the second affiliated hospital of Zhengzhou university,a total of45consecutive patients with mitral valve insufficiency whom undertaken mitral valvuloplasty were summarized retrospectively, including20males and25female patients, ages2-66years, mean(39.418.9) years old. Etiology:there were32cases of mitral degenerative prolapse,2of ischemic mitral valve insufficiency,8of congenital mitral valve disease,1of rheumatic mitral valve disease, and2of infective endocarditis. Preoperative New York Heart Association (NYHA) classification indicated that there were4patients in class1,29in class Ⅱ and12in class Ⅲ. Preoperative echocardiographic measurements of the diameter of the left atrium (LA) was47.13±10.86(22to56) mm, left ventricular end-diastolic diameter (LVEDD) was54.84±9.31(36to63) mm, left ventricular ejection fraction (LVEF) was62.16±6.10(42to77)%, left ventricular end-systolic diameter (LVESD) was40.40±6.43(29to58) mm, degree of mitral regurgitation (reflux area and left atrial area ratio) was38.44±8.23%. All patients had been operated underwent cardiopulmonary bypass with mild hypothermia. The Valvuloplasty technique included sliding technique, quadrangular resection, annuloplasty, chordal transfer technique, edge to edge technique. During the operation, the method to evaluate the surgical efficacy was by saline injection test. After one week, echocardiogram indicated the change between preoperative and postoperative. The follow-up examination was by telephone or outpatient.
Results:
Echocardiography evaluation showed that after the operation that the left atrial dimension, left ventricular end-diastolic diameter, left ventricular endsystolic diameter, the ejection fraction, the degree of mitral regurgitation (reflux area and left atrial area ratio) were significantly decreased. Postoperative follow-up ranged from3months to4years, and there was only one patient death early postoperative because of heart failure. The cardiac function ranged from NYHA Class Ⅰ to Ⅲ. There were13people suffer the post-operative LV dysfunction (EF<50%).On the basis of a analysis, the number of post-operative LV dysfunction was1when EF was≥64%and LVESD<37mm,2with EF<64%or LVESD≥37mm, and10with EF<64%and LVESD≥37mm.
Conclusions:
1. According to the different causes of mitral regurgitation lesions and pathological features, we can corrective regurgitation effectively and improve cardiac function With proper valvoplasty technique.
2. Preoperative EF and LV end-systolic diameter allow the prediction of LV dysfunction after MVP in patients.
探讨二尖瓣直视成形术治疗二尖瓣关闭不全的临床效果,分析术前左心室射血分数(LVEF)、左心室收缩末直径(LVESD)与术后出现左心室功能障碍的关联性。
方法
回顾性分析郑州大学第二附属医院2007年6月至2010年3月行二尖瓣直视成形术治疗二尖瓣关闭不全的患者45例,其中男性20例,女性25例,年龄2-66岁,平均(39.4±18.9)岁。病因：1例风湿性二尖瓣关闭不全,8例先天性二尖瓣关闭不全,32例瓣膜退行性二尖瓣关闭不全,2例缺血性心脏病致二尖瓣关闭不全,2例感染性心内膜炎致二尖瓣关闭不全。术前纽约心功能(NYHA)分级：I级4例,II级29例,III级12例。术前超声心动图测量左房直径(LA)47.13±10.86(22-56)mm,左室舒张末直径(LVEDD)54.84±9.31(36-63)mm,左室射血分数为(I.VEF)62.16±6.10(42～77)%,左室收缩末内径(LVESD)40.40±6.43(29-58)mm,二尖瓣返流程度(返流面积与左心房面积的比值)38.44±8.23%,其中重度返流16例,中度返流29例。手术均在体外循环浅低温下施行,术中根据二尖瓣病理改变及病变部位的不同采用的成形方式有：人工瓣环成形术、缘对缘成形术、瓣叶穿孔及裂隙修补术、腱索转移技术、后瓣叶楔形或矩形切除术及sliding术。术中应用打水试验评价成形效果。术后1周复查心脏超声心动图,比较术前、术后各指标的变化。通过电话或门诊随访心功能状况。
结果
术后1周复查超声心动图示：左房直径(LA)37.04±7.46(20-53)mm,左室舒张期末内径(LVEDD)47.20±7.57(32-59) mm,左室收缩末内径(LVESD)37.07±4.13(30-46)mm,二尖瓣返流程度6.86±3.17%,以上各指标与术前相比明显缩小,差异均有统计学意义(P<0.05)。左室射血分数(]VEF)由术前62.16±6.10(42～77)%下降至55.22±6.90(43～71)%,也有一定程度的降低。术后二尖瓣返流程度明显改善,其中12例二尖瓣无返流,33例仅轻度返流。以术前EF≥64%、LVESD <37mm作为预测术后患者出现EF<50%的分割线。则本组病例中EF<50%的患者共有13例,其中术前EF≥64%且LVESD<37mm者1例,术前EF<64%或LVESD>37mm者2例,术前EF<64%且LVESD≥37mm者10例。门诊及电话随访3月-4年(平均2.8年),术后3个月44例患者纽约心功能(NYHA)分级：Ⅰ级34例(77.3%),Ⅱ级8例(18.2%),Ⅲ级2例(4.5%),1例感染性心内膜炎患者因再次出现心力衰竭而死亡。
结论
1.根据二尖瓣关闭不全病变的不同病因、病理特征,采取相应的成形方式可有效的纠正关闭不全、改善心功能状态。
2.术前EF<64%且LVESD≥37mm的患者术后出现左心室功能障碍的可能最大,故综合判断术前EF值及LVESD,可对术后是否出现左室功能障碍的预测提供依据。
Objective:
To investigate the clinical effect of mitral valvuloplasty for mitral valve regurgitation and studied the relationship between Preoperative EF and LV end-systolic diameter and occurrence of LV dysfunction after mitral valvuloplasty.
Methods:
From June2007to March2010in the second affiliated hospital of Zhengzhou university,a total of45consecutive patients with mitral valve insufficiency whom undertaken mitral valvuloplasty were summarized retrospectively, including20males and25female patients, ages2-66years, mean(39.418.9) years old. Etiology:there were32cases of mitral degenerative prolapse,2of ischemic mitral valve insufficiency,8of congenital mitral valve disease,1of rheumatic mitral valve disease, and2of infective endocarditis. Preoperative New York Heart Association (NYHA) classification indicated that there were4patients in class1,29in class Ⅱ and12in class Ⅲ. Preoperative echocardiographic measurements of the diameter of the left atrium (LA) was47.13±10.86(22to56) mm, left ventricular end-diastolic diameter (LVEDD) was54.84±9.31(36to63) mm, left ventricular ejection fraction (LVEF) was62.16±6.10(42to77)%, left ventricular end-systolic diameter (LVESD) was40.40±6.43(29to58) mm, degree of mitral regurgitation (reflux area and left atrial area ratio) was38.44±8.23%. All patients had been operated underwent cardiopulmonary bypass with mild hypothermia. The Valvuloplasty technique included sliding technique, quadrangular resection, annuloplasty, chordal transfer technique, edge to edge technique. During the operation, the method to evaluate the surgical efficacy was by saline injection test. After one week, echocardiogram indicated the change between preoperative and postoperative. The follow-up examination was by telephone or outpatient.
Results:
Echocardiography evaluation showed that after the operation that the left atrial dimension, left ventricular end-diastolic diameter, left ventricular endsystolic diameter, the ejection fraction, the degree of mitral regurgitation (reflux area and left atrial area ratio) were significantly decreased. Postoperative follow-up ranged from3months to4years, and there was only one patient death early postoperative because of heart failure. The cardiac function ranged from NYHA Class Ⅰ to Ⅲ. There were13people suffer the post-operative LV dysfunction (EF<50%).On the basis of a analysis, the number of post-operative LV dysfunction was1when EF was≥64%and LVESD<37mm,2with EF<64%or LVESD≥37mm, and10with EF<64%and LVESD≥37mm.
Conclusions:
1. According to the different causes of mitral regurgitation lesions and pathological features, we can corrective regurgitation effectively and improve cardiac function With proper valvoplasty technique.
2. Preoperative EF and LV end-systolic diameter allow the prediction of LV dysfunction after MVP in patients.
引文
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[2]Ira R.A.Goldsrmith, Gregory Y.H.Lip, Ramesh L.Patel. A prospective study of changes in the quality of life of patients following mitral valve repair and replacemen[J].European Journal of Cardio-thoracic Surgery,2001,20:949-955.
[3]Enriquez-SaranoM, Tajik AJ, Schaff HV, et al.Echocardiographic prediction of left ventricular function after correction of mitral regurgitation:results and clinical implication[J]. J Am Coll Cardiol,1994,24:1544-1546.
[4]Christophe Tribouilloy, Dan Rusinaru, Catherine Szymanski, et al. Predicting left ventricular dysfunction after valve repair for mitral regurgitation due to leaflet prolapse:additive value of left ventricular end-systolic dimension to ejection fraction[J].European Journal of Echocardiography,2011(12):702-710.
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