1、542例二尖瓣成形临床疗效及随访结果分析中国医学科学院 阜外心血管病医院成人中心许建屏背景二尖瓣成形手术优点o 避免长期抗凝o 保护左心功能o 减少心内膜炎风险o 降低术后栓塞、溶血等换瓣风险临床资料o 阜外医院1996.102008.7o 542例MVP 男性 359 例；女性 183 例o 年龄 783（42.6）岁o 病种分类临床资料o 术前超声二尖瓣返流量临床资料术前超声左心房内径 左心室舒张期末径 EF49.5213.50mm 59.218.05mm 62.3110.06 临床资料o 术前心功能(NYHA)手术方法o CPB 正中开胸 房间隔径路o 瓣膜病变 单纯前叶病变 144例
2、单纯后叶病变 290例 前叶后叶病变 108例 手术方法手术方式 例数单纯楔形切除 42楔形切除瓣环环缩 265265楔形切除人工环 单纯人工环 单纯缘对缘 37缘对缘人工环 腱索转移 13腱索缩短 10人工腱索 6手术方法o 平均体外循环时间 97.8237.92 mino 平均主动脉阻断时间 66.9332.14 minp 术中检测 二尖瓣瓣口注水试验 食道超声手术方法TVPCABGAVP结果 并发症 心律失常 4例 术后出血二次开胸 12例 循环衰竭ECMO辅助 1例 肾功能不全 血液透析 4例 IABP 辅助 1例 术后谵妄，延迟脱呼吸机 6例 总计 28例结果o 术后早期死亡2例 术
3、后低心排 1例 顽固室颤 1例p 随访 504 例 3月11年（平均37月）p 晚期死亡 4 例 心律失常 2 例 脑血管意外 1 例 原因不明 1 例 结果o 术后行MVR 5例 3例术后3年 1例术后4年 1例4个月o 发生溶血 1例 2个月后再次手术成形 结果o 术后NYHA 分级结果o 二尖瓣反流结果o UCG 结果比较左心房内径 左心室舒张期末径 EF49.5213.50mm59.218.05mm62.3110.06 38.215.22mm 49.837.21mm 57.087.09术前术后值0.050.050.05讨论o退行性瓣膜病95可实行MVP 本组病例 退行性变比例80%病变
4、区域 多为局部腱索断裂或过长 合并瓣环扩大比例较高（12%）讨论o 经典成形技术楔/矩形切除瓣环折叠术讨论o 经典技术人工环2006.7-2008.7人工环（175例）73%讨论o 经典成形技术 楔形切除 瓣环环缩 人工成形环p 技术易掌握p 成形效果好p 大多数患者采用88（477例）手术方式 例数单纯楔形切除 42楔形切除瓣环环缩 265265楔形切除人工环 单纯人工环 单纯缘对缘 37缘对缘人工环 腱索转移 13腱索缩短 10人工腱索 6讨论o Edge to edge 辅助成形A2-P2讨论o Edge-to-edge交界缝合交界缝合讨论o 本组中应用“缘对缘”技术共计108例o 7例
5、术中食道超声 少量反流o 术后二尖瓣瓣口 流速 1.140.28m/s 压差 4.763.07mmHg p 二尖瓣均无明显狭窄 p 合并前叶病变的主要辅助成形技术讨论o 腱索转移 腱索缩短讨论o 本组 单纯前叶病变 前、后叶病变 腱索缩短技术10例 腱索转移13例 o 超声结果：中量反流 2例 少中量反流 2例p 国外文献：腱索缩短 失败率最高11.5%腱索转移技术效果良好 5年免除再手术率96%讨论o 人工腱索国外文献报道应用GORE-TEX 腱索 15年随访免于再手术率 92，反流无再发 85讨论o 先天性二尖瓣发育异常瓣叶裂讨论o 先天性二尖瓣发育异常后瓣异常瓣环过度增生讨论o 先天性二
6、尖瓣发育不良双孔二尖瓣降落伞状二尖瓣讨论o 先天性二尖瓣发育异常 畸形复杂 手术无定式 多种手术成形方法的组合 根据病变部位、程度灵活 选用前乳头肌缺如讨论o 风湿性二尖瓣病变 手术难度大 严格把握手术适应症 75的RHD 病例可成形 本组24例 瓣叶改变轻 2例少中量反流 无再次手术换瓣讨论o 国内文献报道 闭式扩张术后再手术年限12.56.7年，再狭窄率1035 球囊扩张术结果与闭扩结果相近似 直视下对瓣叶质地较软，无显著卷曲，融合 二尖瓣成形应有良好的效果 结论o 经典成形方法适用于大多数病例，效果好o 复杂先天性二尖瓣发育不良病例 多种组合 灵活运用p 风心病成形 严格把握适应症 不拘
7、泥于成法，不执着于成形Outcome of 542 cases Mitral Valve RepairChinese academy of medical sciences FuWai hospitalXu JianPingPrefaceo Advantage of MVP Avoid long time anticoagulation Protect the function of left ventricular Decrease the risk of SBE Lower the risk of embolism and hemolysis postoperatiomMaterial a
8、nd methodo FuWai hospital 1996.102008.7o 542cases MVP male 359；female 183o Age 7Ms-83(42.6)Yso AetiologyMeterial o Degree of MI in UCG PreoperationMaterialo UCG preoperation LA LVED EF49.5213.50mm 59.218.05mm 62.3110.06 Material o NYHA preoperationSurgical Techniqueo CPB atrial spect incisiono Damag
9、e part of Mitral valve Anterior leaflet 144 cases Posterior leaflet 290 cases both 108 casesSurgical techniquesSurgical techniques casecuniform incision 42cuniform incision annuloplasty 265265cuniform incision ring ring edge to edge 37edge to edgering chordae transposition 13chordae shorten 10additi
10、onal chordae 6Surgical techniqueso CPB time 97.8237.92 mino Aorta clamp time 66.9332.14 minp Intraoperative test infusion water to lv through MV transesophageal echocardiographySurgical techniquesTVPCABGAVPAVPCABGTVP(united operation）vntricular aneurysm ectomyComplications arhythmia 4 casesbleeding
11、12 casesCirculation failure ECMO 1 caseRenal failure 4 casesIABP assist 1 caseTo delay take out tracheal intubation 6casesTotal 28 casesResults o Early postoperation death 2 cases low output 1case ventricular fibrillation 1casep Follow-up 504 cases 3Ms-11Ys(37Ms)p Advanced stage death 4 cases arhyth
12、mia 2 cases cerebral accident 1 case unknown aetiology 1 case Results o After MVP operation Re-do MVR 5cases 3cases postoperation 3years 1case postoperation 4years 1case postoperation 4monthso Hemolysis 1case re-MVP after 2 monthsResults o NYHA postoperation(follow-up)Results o Mitral regurgitation(
13、follow-up)Results o UCGLA LVED EF49.5213.50mm59.218.05mm62.3110.06 38.215.22mm 49.837.21mm 57.087.09preoperativep valve0.050.050.05postoperativeComment oRetrogression valve disease95 patients can be done MVP Our cases,80%cases were retrogressionReason rupture of chordae or excess of chordar together
14、 with annulus dilatation (12%)Comment o Classic MVP techniques-cuniform incision+annuloplastyComment o Classic MVP techniques-cuniform ring(soft)2006.7-2008.7 ring 73%Comment o Classic techniques cuniform incision annuloplasty ringp Easy to graspp Good effectp Most patinents 88（477cases）Comment o Ed
15、ge to edge assist methodA2-P2Comment o Edge-to-edgeCommissure sutureComment o In our cases“edge to edge”108 caseso 7cases ITEE mild MI；follow-up mild MIo MV flow velocity 1.140.28m/s pressure 4.763.07mmHg p MV no significant stenosis p Together with anterior leaflet damage:mainly assist repair techn
16、iqueComment o chordae transposition shortenComment o In our cases anterior leaflet damage chordae shorten 10 cases transposition 13 cases o UCG：Moderate MI 2 cases Mild to moderate 2 casesp literatures：chordae shorten 11.5%failure chordae transposition have good effect 5 years free from re-do 96%Com
17、ment o Artificial chordaeLiterature:GORE-TEX artificial chordae 15years follow-up,free from re-do 92，free from MI 85Comment o Congenital MV malformationMV leaflet cleftComment o Congenital mitral valve malformationsAnnula dilataionSupravalvular ringComment o Congenital mitral valve malformationsDoub
18、le orificeParachute mitral valveComment o Congenital mitral valve malformations malformation complex surgical techniques should be choosed due to valve malformationAPM absenceComment o RHD Difficult Indication strict 75 RHD cases MVP Our 24 cases leaflet damage light follow-up 2cases mile to moderat
19、e MI NO re-do operationComment o Report time of restenosis after closed mitral commissurotomy 12.56.7 years，Restenosis ratio 1035 on pump,we should get better MVP result.Conclusion o Classic techniques(cuniform incision,annuloplasty,ring)have good effect.o Congenital mitral valve malformations need experience of multiple MVP techniques.p Severe damage in RHD MV,valve replacement should be chosed.
