1、 二尖瓣修补的方法东方的观点Dr.Tim Wing-Kuk Au FRCS,FHKCS Consultant Surgeon Honorary Clinical Assistant Professor Department of Cardiothoracic SurgeryThe University of Hong Kong,Queen Mary Hospital,Hong Kong SAR心血管治疗领域中的新起点 December 2019 Shanghai,China Cleveland Clinic无症状二尖瓣返流治疗结果的定量分析Maurice Enrique-Saran et al
2、.N Engl J Med 2019;352:875-83二尖瓣返流的概述 无症状的 MR 5-10 年 严重的MR 年死亡率 5%严重MR患者中的猝死 NYHA 分级很差 左心室射血分数很低 房颤 严重 MR(不论何种病因)手术 Grigioni F.JACC 2019 34;7:2078-85Otto C.N Engl J Med 2019,345;10:740-6Enrique-Saran et al.Circulation.1994;90:830-37超声心动图预测器质性二尖瓣返流患者手术治疗后的存活率根据手术前超声心动图检查的EF值预测MR患者手术治疗后的远期存活率Shuhaiber
3、 et al.Eur J Card Thorac Surg.2019;31:267-75ChordsOlivieria 1983Survival1.230.384.04Chords1.230.384.04DegenGillinov 2019Survival1.671.302.15DegenLee 2019Survival1.420.842.40DegenMohty 2019Survival1.751.242.46DegenYacoub 1981Survival2.340.916.05Degen1.681.392.02IschemicCalifiore 2019Survival0.780.193
4、.16IschemicCohn 2019Survival0.530.181.53IschemicGrossi 2019Survival1.340.921.95IschemicMantovani 2019Survival1.480.425.20Ischemic1.180.831.69MixedAdebo 1984Survival1.480.336.70MixedAkins 1994Survival1.600.763.36MixedCraver 1990Survival1.160.393.50MixedEnriguez-Sarano 99?Survival1.641.132.38MixedGall
5、oway 1989Survival1.551.022.35MixedHausmann 2019Survival0.860.581.26MixedKawachi 1991Survival4.330.6429.34MixedPerier 1984Survival2.391.304.37MixedSand 1987Survival1.631.042.57MixedThourani 2019Survival1.531.261.86Mixed1.491.241.78RheumaticAntunes 1987Survival2.131.283.53RheumaticYau 2000Survival2.65
6、1.474.78Rheumatic2.331.593.43Overall1.581.411.78危险比修补 vs 置换 血流动力学更稳定 维持心室的功能 避免使用人工瓣膜 不会出现血栓栓塞和出血 感染机率降低 技术和经验至关重要 分型瓣叶运动描述Ia正常瓣环扩张Ib瓣叶穿孔IIa过度腱索延长IIb腱索破裂 IIc乳头肌梗死/延长IIIa受限瓣叶缩短或粘合或腱索融合IIIb左心室功能异常或动脉瘤导致瓣叶圈合IV不定乳头肌功能失调 退行性二尖瓣返流的Carpentier分级退行性二尖瓣疾病的修补手术后瓣叶-公认的标准修补术前瓣叶 技术难度更高，结果差异较大联合脱垂 Carpentiers 修补术
7、后瓣叶 Q 形切除术 前瓣叶 瓣叶转位 人工腱索 Gore-Tex 5/0退行性MV修补术的结果西方 vs 东方 人数死亡率STS 数据库1.5%Gillinov 201935440.3%De Bonis 20197380.3%Suri*2019641.6%*David 20197010.7%Kasegawa 20191811.3%Nakajima 2019160.0%Cinghatanadgige 2019432.3%Song 20191841.0%退行性二尖瓣返流 东方 =西方 TEE的重要性 返流束的方向判断容易出错 盐水注射试验:有或无 Barlows 罕见但是很困难分型瓣叶活动描述I
8、a正常瓣环扩张Ib瓣叶穿孔IIa过度腱索延长IIb腱索断裂IIc乳头肌 梗死/延长IIIa受限瓣叶缩短或粘合或融合IIIb左心室功能异常或动脉瘤导致的瓣叶圈合IV不定乳头肌功能失调 改良Carpentier 分级:缺血性 MR缺血性二尖瓣返流的机制 慢性 Lveine et al.Circulation 112(5)August 745-58 Bursi,F.et al.Circulation 2019;111:295-301773773例例MIMI后患者，根据超声心动图检查后患者，根据超声心动图检查MRMR严重程度的不同分组，严重程度的不同分组，3030天内各天内各组的总存活率组的总存活率
9、(实线代表无实线代表无MRMR，点线代表轻度，点线代表轻度MRMR，虚线代表中度或重度，虚线代表中度或重度)NIL MR 50%Mild MR 38%Mod or severe MR 12%亚洲的问题有多严重?中国国家心血管疾病中心2019 报道:全国缺血性心脏病的发病率为4.2%每年新增的MI患者为500,000例 城市预测 预计每年新增的缺血性MR患者例数：60,000 院内死亡率 1.4%修补 vs 21%置换 P=0.06 5 年再次手术率修补 14%vs 置换 3%P=0.003缺血性二尖瓣返流中二尖瓣修补和二尖瓣置换缺血性二尖瓣返流中二尖瓣修补和二尖瓣置换的比较的比较Osman O
10、.Al-Radi,MBBS,Peter C.Austin,PhD,Jack V.Tu,MD,Tirone E.David,MD,and Terrence M.Yau,MD,MS慢性缺血性慢性缺血性MR的各种修补技术的各种修补技术 瓣环成形术 瓣口过小 Bolling(n=140)Carpentier 法Acar(n=44)第二腱索松解 David(n=30)LV成形术，比如:DorsMericanti(n=46)后乳头肌复位术 Kron(n=18)缘对缘修补术 Bhudia(n=146)*北京上海年份 1976-971978-03患者45053416女性(%)52.439.6年龄40.540.
11、0风湿性(%)8092二尖瓣(%)54.3100机械瓣 100100死亡率(%)3.83.310 年存活率(%)9394出血&血栓%患者，年份1.590.85 中国二尖瓣手术的回顾Shuhaiber et al.Eur J Card Thorac Surg.2019;31:267-75ChordsOlivieria 1983Survival1.230.384.04Chords1.230.384.04DegenGillinov 2019Survival1.671.302.15DegenLee 2019Survival1.420.842.40DegenMohty 2019Survival1.751
12、.242.46DegenYacoub 1981Survival2.340.916.05Degen1.681.392.02IschemicCalifiore 2019Survival0.780.193.16IschemicCohn 2019Survival0.530.181.53IschemicGrossi 2019Survival1.340.921.95IschemicMantovani 2019Survival1.480.425.20Ischemic1.180.831.69MixedAdebo 1984Survival1.480.336.70MixedAkins 1994Survival1.
13、600.763.36MixedCraver 1990Survival1.160.393.50MixedEnriguez-Sarano 99?Survival1.641.132.38MixedGalloway 1989Survival1.551.022.35MixedHausmann 2019Survival0.860.581.26MixedKawachi 1991Survival4.330.6429.34MixedPerier 1984Survival2.391.304.37MixedSand 1987Survival1.631.042.57MixedThourani 2019Survival
14、1.531.261.86Mixed1.491.241.78RheumaticAntunes 1987Survival2.131.283.53RheumaticYau 2000Survival2.651.474.78Rheumatic2.331.593.43Overall1.581.411.78分型瓣叶活动描述修补技术Ia正常瓣环扩张 瓣环成形术Ib瓣叶穿孔 IIa过度腱索延长 Gore-Tex or 缩短术IIb腱索断裂IIc乳头肌梗死/延长Gore-Tex or 缩短术IIIa受限瓣叶缩短或粘合或腱索融合心包补片口角成形术腱索,乳头肌开窗术IIIb左心室功能异常或动脉瘤导致瓣叶圈合IV不定乳
15、头肌功能失调 风湿性二尖瓣返流的病理生理学风湿性二尖瓣返流重建手术的远期预后（风湿性二尖瓣返流重建手术的远期预后（29年）年）Sylvain Chauvaud,MD;Jean-Franois Fuzellier,MD;Alain Berrebi,MD;Alain Deloche,MD;Jean-Nol Fabiani,MD;Alain Carpentier,MD,PhDMethods and ResultsFrom 1970 to 1994,951 patients with rheumatic MV insufficiency were operated on with the recons
16、tructive techniques elaborated by Alain Carpentier.Mean age was 25.8 years(4 to 75),and sinus rhythm was present in 63%.The functional classification used was type I,normal leaflet motion,71 patients(7%);type II,prolapsed leaflet,311 patients(33%);and type III,restricted leaflet motion,345 patients(
17、36%).The combined lesion of prolapse of the anterior leaflet and restriction of the posterior was present in 224 patients(24%).Surgical techniques used were implantation of a prosthetic ring in 95%,shortening of the chords and leaflet enlargement with autologous pericardium,and commissurotomy.Hospit
18、al mortality rate was 2%.The mean follow-up was 12 years(maximum,29 years):8618 patients per year.Actuarial survival was 89 19%at 10 years and 82 18%at 20 years.The rate of thromboembolic events was 0.4%patients per year(33 events),with 3 deaths.Freedom from reoperation was 82 19%at 10 years and 55
19、25%at 20 years.The main cause(83%)of reoperation was progressive fibrosis of the MV.The actuarial rate of reoperation was 2%patients per year and was correlated to the degree of preoperative fibrosis.功能分级型，瓣叶活动正常的患者有71例（7%）；型，瓣叶脱垂者311例（33%）；型，瓣叶活动受限者345例（36%）。二尖瓣前叶脱垂同时伴后叶受限的患者共224例（24%）。随访12年（最长29年）
20、：每年8618例患者。10年的实际存活率为8919%，20年为8218%。每年血栓栓塞事件的发生率为0.4%（33例），其中3例患者死亡。10年内无需再次手术的患者占8219%，20年为5525%。再次手术的主要原因为二尖瓣进行性纤维化 Carpentier-Edwards环13265.7口角成形术10652.7腱索转移2311.4腱索缩短189前叶延长术147后叶延长术63%总修补人数=201 例患者二尖瓣修补联合主动脉瓣置换治疗风湿性心脏病二尖瓣修补联合主动脉瓣置换治疗风湿性心脏病Huynh-Quang Tri Ho,MD,Van-Phan Nguyen,MD,Kim-Phuong Pha
21、n,MD,Nguyen-Vinh Pham,Huynh-Quang Tri Ho,MD,Van-Phan Nguyen,MD,Kim-Phuong Phan,MD,Nguyen-Vinh Pham,PhD PhD Heart Institute,Ho Chi Minh City,Vietnam MS 30%MR 37%Mixed 33%死亡率修补 1.4%置换 0.7%1组中9年内无需再次二尖瓣手术者占84.2 13%，2组为 92 7.4%(log-rank test:p=0.42)戊二醛戊二醛处理的自体心包补片瓣膜修补术治疗复杂性二尖瓣病变处理的自体心包补片瓣膜修补术治疗复杂性二尖瓣病变C
22、hoi-Keung Ng,MD,Joachim Nesser,MD,Christian Punzengruber,MD,Otmar Pachinger,MD,Johannes Auer,MD,Herbert Franke,MD,and Peter Hartl,MDAnn Thorac Surg 2019;71:7885 63例患者超过10年 院内死亡率为 5 年内无再次手术 95%技术 扩大50%戊二醛0.625%-30 分钟 6/0 或 7/0 Gore-Tex 缝线 风湿性二尖瓣修补术后无再次手术风湿性二尖瓣修补术后无再次手术患者的存活率患者的存活率 风湿性 MR 10 年无再次手术的存活
23、率 85 90%风湿性联合瓣膜病变 10年无再次手术的存活率 70 80%机械瓣膜 10年无再次手术的存活率 90 95%第一次第一次MV修补手术到再次手术的时间修补手术到再次手术的时间间隔间隔 技术相关技术相关=6.04 7.18 瓣膜相关瓣膜相关=45.44 33.65手术相关的并发症手术相关的并发症:-手术指征错误 严重的瓣膜疾病 瓣膜修补几率低 -技术错误 修补技术不恰当 操作错误 -第一次修补手术不完善 -修补技术不稳定 瓣膜相关的并发症瓣膜相关的并发症:-疾病的自然进展Vietnam 心脏中心Prof.NV Phan风湿性瓣膜病手术修补的技术要领 风湿性返流 80%成功率 腱索增粗
24、开窗术或切除术+Gore-Tex 瓣叶缩短心包补片 第二腱索松解术 瓣膜成形术风湿性瓣膜病中瓣环扩张非常常见 口角成形术 风湿性联合瓣膜病变 成功率存在差异 腱索增粗切除腱索/PM+Gore-Tex 置换 腱索缩短心包补片 第二腱索松解术 瓣膜成形术心包补片技术能够使用更长的环 口角成形术+去除钙化（1）瓣叶显著增厚或（2）双侧连合部钙化或（3）瓣环受限时应避免使用修补术 香港大学二尖瓣置换 vs 修补修补 Gore-Tex心包补片环.何种环?一览表房颤是一种严重的疾病十年死亡率十年死亡率Framingham 研究研究62%58%30%21%Men Women 不伴房颤不伴房颤 伴有房颤伴有房
25、颤24%10%2%3%50-59 60-69 70-7980-89房颤患者心梗的发生率房颤患者心梗的发生率 按年龄分组按年龄分组手术-Maze 手术二尖瓣修补 谢谢 symptomsESC 2019:严重慢性器质性二尖瓣返流的手术指征 EurHeartJ201928:230-268有症状的患者伴有症状的患者伴 LVEF 30%and ESD 45 mm and/or LVEF 60%)无症状的患者伴左心室功能正常，房颤或肺动脉高压无症状的患者伴左心室功能正常，房颤或肺动脉高压IaC患者合并严重的左心室功能异常患者合并严重的左心室功能异常(LVEF 55 mm)对药物治疗反映不佳，且能够修补的可
26、能性高，死亡率较低对药物治疗反映不佳，且能够修补的可能性高，死亡率较低无症状的患者伴左心室功能正常，无症状的患者伴左心室功能正常，IIbB且能够修补的可能性且能够修补的可能性高，手术风险低高，手术风险低 Mitral Valve Repair StrategiesPerspective EASTDr.Tim Wing-Kuk Au FRCS,FHKCS Consultant Surgeon Honorary Clinical Assistant Professor Department of Cardiothoracic SurgeryThe University of Hong Kong,Q
27、ueen Mary Hospital,Hong Kong SARNew Horizon in Cardiovascular Treatments December 2019 Shanghai,China Cleveland ClinicQuantitative Determinants of the Outcomeof Asymptomatic Mitral RegurgitationMaurice Enrique-Saran et al.N Engl J Med 2019;352:875-83Facts about MR Asymptomatic MR 5-10 years Severe M
28、R annual mortality 5%Sudden death in severe MR Poor NYHA class Low LV ejection Atrial fibrillation Severe MR(irrespective of etiology)Surgery Grigioni F.JACC 2019 34;7:2078-85Otto C.N Engl J Med 2019,345;10:740-6Enrique-Saran et al.Circulation.1994;90:830-37Echocardiographic Prediction of Survival A
29、fter Surgical Correction of Organic Mitral RegurgitationShuhaiber et al.Eur J Card Thorac Surg.2019;31:267-75ChordsOlivieria 1983Survival1.230.384.04Chords1.230.384.04DegenGillinov 2019Survival1.671.302.15DegenLee 2019Survival1.420.842.40DegenMohty 2019Survival1.751.242.46DegenYacoub 1981Survival2.3
30、40.916.05Degen1.681.392.02IschemicCalifiore 2019Survival0.780.193.16IschemicCohn 2019Survival0.530.181.53IschemicGrossi 2019Survival1.340.921.95IschemicMantovani 2019Survival1.480.425.20Ischemic1.180.831.69MixedAdebo 1984Survival1.480.336.70MixedAkins 1994Survival1.600.763.36MixedCraver 1990Survival
31、1.160.393.50MixedEnriguez-Sarano 99?Survival1.641.132.38MixedGalloway 1989Survival1.551.022.35MixedHausmann 2019Survival0.860.581.26MixedKawachi 1991Survival4.330.6429.34MixedPerier 1984Survival2.391.304.37MixedSand 1987Survival1.631.042.57MixedThourani 2019Survival1.531.261.86Mixed1.491.241.78Rheum
32、aticAntunes 1987Survival2.131.283.53RheumaticYau 2000Survival2.651.474.78Rheumatic2.331.593.43Overall1.581.411.78Repair vs Replacement Superior hemodynamics Preservation of ventricular function,Avoidance of prosthetic valve Freedom from thromboembolism&bleeding Lower infection rate Skill and experie
33、nce counts TypeLeaflet motionDescriptionIaNormalAnnular dilatationIbLeaflet perforationIIaExcessiveChordal elongationIIbChordal ruptureIIcPapillary muscle Infarction/elongationIIIaRestrictedLeaflet retraction or Commissural or chordal fusionIIIbLeaflet tethering by LV dysf(x)or aneurysmIVVariablePap
34、illary muscle dysf(x)Carpentier Classification of Mitral Degenerative RegurgitationMitral repair for degenerative diseasesPosterior leaflet-universal standard repair Anterior leaflet more technical difficult and variable resultsCommissural prolapse Carpentiers repair Posterior leaflet Q resection An
35、terior leaflet leaflet transferArtificial Chordae Gore-Tex 5/0Results of degenerative MV repair West vs East numbermortalitySTS datebase1.5%Gillinov 201935440.3%De Bonis 20197380.3%Suri*2019641.6%*David 20197010.7%Kasegawa 20191811.3%Nakajima 2019160.0%Cinghatanadgige 2019432.3%Song 20191841.0%Degen
36、erative Mitral Regurgitation East =West Importance of TEE Pitfalls of regurgitant jet direction Saline jet test:yes or no Barlows rare but difficultTypeLeaflet motionDescriptionIaNormalAnnular dilatationIbLeaflet perforationIIaExcessiveChordal elongationIIbChordal ruptureIIcPapillary muscle Infarcti
37、on/elongationIIIaRestrictedLeaflet retraction or Commissural or chordal fusionIIIbLeaflet tethering by LV dysf(x)or aneurysmIVVariablePapillary muscle dysf(x)Modified Carpentier Classification:Ischemic MR Mechanism of Ischemic Mitral Regurgitation-Chronic Lveine et al.Circulation 112(5)August 745-58
38、 Bursi,F.et al.Circulation 2019;111:295-301Overall survival according to degree of MR in 773 patients who underwent Overall survival according to degree of MR in 773 patients who underwent echocardiography within 30 days after MI(solid line indicates no MR,dotted line mild echocardiography within 30
39、 days after MI(solid line indicates no MR,dotted line mild MR,and dashed line moderate or severe MR)MR,and dashed line moderate or severe MR)NIL MR 50%Mild MR 38%Mod or severe MR 12%How big is the problem in Asia?China National Center for Cardiovascular Disease 2019 Report:Prevalence of IHD was 4.2%
40、in the country 500,000 new cases of MI each year urban estimate Estimated new cases severe Ischemic MR annually:60,000 In-hospital mortality 1.4%repair vs 21%replacement P=0.06 5 yr re-operation raterepair 14%vs replacement 3%P=0.003Mitral Repair Versus Replacement for Ischemic Mitral RegurgitationO
41、sman O.Al-Radi,MBBS,Peter C.Austin,PhD,Jack V.Tu,MD,Tirone E.David,MD,and Terrence M.Yau,MD,MSVarious Repair Techniques for Chronic Ischemic MR Annuloplasty Undersized Bolling(n=140)Carpentier methodsAcar(n=44)2nd Chordae ReleasesDavid(n=30)LV Restoration eg:DorsMericanti(n=46)Relocation of Post.PMK
42、ron(n=18)Edge-to-Edge Repair Bhudia(n=146)*Beijing ShanghaiYear 1976-971978-03Patients45053416Female(%)52.439.6Age40.540.0Rheumatic(%)8092Mitral(%)54.3100Mechanical valve100100Mortality(%)3.83.310 yr survival(%)9394Bleeding&thrombosis%patient.year1.590.85 Mitral Valve Surgery review in China Shuhaib
43、er et al.Eur J Card Thorac Surg.2019;31:267-75ChordsOlivieria 1983Survival1.230.384.04Chords1.230.384.04DegenGillinov 2019Survival1.671.302.15DegenLee 2019Survival1.420.842.40DegenMohty 2019Survival1.751.242.46DegenYacoub 1981Survival2.340.916.05Degen1.681.392.02IschemicCalifiore 2019Survival0.780.1
44、93.16IschemicCohn 2019Survival0.530.181.53IschemicGrossi 2019Survival1.340.921.95IschemicMantovani 2019Survival1.480.425.20Ischemic1.180.831.69MixedAdebo 1984Survival1.480.336.70MixedAkins 1994Survival1.600.763.36MixedCraver 1990Survival1.160.393.50MixedEnriguez-Sarano 99?Survival1.641.132.38MixedGa
45、lloway 1989Survival1.551.022.35MixedHausmann 2019Survival0.860.581.26MixedKawachi 1991Survival4.330.6429.34MixedPerier 1984Survival2.391.304.37MixedSand 1987Survival1.631.042.57MixedThourani 2019Survival1.531.261.86Mixed1.491.241.78RheumaticAntunes 1987Survival2.131.283.53RheumaticYau 2000Survival2.
46、651.474.78Rheumatic2.331.593.43Overall1.581.411.78TypeLeaflet motionDescriptionRepair techniqueIaNormalAnnular dilatationAnnuloplastyIbLeaflet perforationIIaExcessiveChordal elongationGore-Tex or shorteningIIbChordal ruptureIIcPapillary muscle Infarction/elongationGore-Tex or shorteningIIIaRestricte
47、dLeaflet retraction or Commissural or chordal fusionPericardial patchCommissuroplastyChordal,PM fenestrationIIIbLeaflet tethering by LV dysf(x)or aneurysmIVVariablePapillary muscle dysf(x)Pathophysiology of Rheumatic Mitral RegurgitationLong-Term(29 Years)Results of Reconstructive Surgery in Rheumat
48、ic Mitral Valve InsufficiencySylvain Chauvaud,MD;Jean-Franois Fuzellier,MD;Alain Berrebi,MD;Alain Deloche,MD;Jean-Nol Fabiani,MD;Alain Carpentier,MD,PhDMethods and ResultsFrom 1970 to 1994,951 patients with rheumatic MV insufficiency were operated on with the reconstructive techniques elaborated by
49、Alain Carpentier.Mean age was 25.8 years(4 to 75),and sinus rhythm was present in 63%.The functional classification used was type I,normal leaflet motion,71 patients(7%);type II,prolapsed leaflet,311 patients(33%);and type III,restricted leaflet motion,345 patients(36%).The combined lesion of prolap
50、se of the anterior leaflet and restriction of the posterior was present in 224 patients(24%).Surgical techniques used were implantation of a prosthetic ring in 95%,shortening of the chords and leaflet enlargement with autologous pericardium,and commissurotomy.Hospital mortality rate was 2%.The mean
