二尖瓣关闭不全保留全瓣下结构二尖瓣置换术后近中期疗效分析

Analysis of short-term and medium-term efficacy of mitral valve replacement with preservation of total subvalvular structure for mitral insufficiency

目的研究二尖瓣置换术中保留全瓣下结构的可行性以及是否更有利于患者术后心功能的恢复。方法回顾性分析恩施土家族苗族自治州中心医院2017年1月至2020年12月因二尖瓣关闭不全行二尖瓣置换手术患者的临床资料,根据术中是否保留二尖瓣瓣下结构分为三组:A组(38例)为全部保留二尖瓣前瓣及后瓣瓣下结构;B组(134例)为保留全部或部分后瓣瓣下结构;C组(33例)为全部切除前瓣及后瓣瓣下结构。统计各组患者手术时间、体外循环时间、主动脉阻断时间、术后呼吸机使用时间、ICU停留时间及并发症发生率;术后1周、3个月和6个月复查心脏超声心动图的二尖瓣瓣口流速(MVE)、左室舒张末内径(LVED)、左室射血分数(LVEF)及左室短轴缩短率(LVFS)。结果术前三组手术时间、体外循环时间、主动脉阻断时间、术后呼吸机使用时间、ICU停留时间比较差异无统计学意义(P>0.05);围手术期无死亡病例,所有患者均痊愈出院,心脏彩超结果显示MVE、LVED、LVEF及LVFS均较术前有所改善。术后超声结果显示1周、3个月和6个月MVE比较差异无统计学意义(P>0.05),术后1周,A组LVED低于B组和C组[(44.90±5.59)mm比(46.13±6.15)mm、(48.33±5.59)mm],差异有统计学意义(P<0.05)。术后3个月,A组LVED、LVFS分别高于B组和C组[(43.37±5.61)mm比(44.69±5.45)mm和(53.42±5.35)mm、(33.92±3.34)%比(31.67±3.20)%和(30.37±6.96)%],差异有统计学意义(P<0.05)。术后6个月,A组LVED低于B组和C组[(41.86±3.27)mm比(47.85±6.93)mm和(53.42±8.17)mm],LVFS高于B组和C组[(33.42±2.64)%比(32.18±5.98)%和(32.28±2.58)%],差异有统计学意义(P<0.05)。结论保留二尖瓣全瓣下结构不会导致人工瓣膜功能障碍,不增加手术并发症。术后显示出更好的LVED缩小和更好的LVFS,更有利于患者心功能的恢复。

Objective To study the feasibility of preserving the subvalvular structure during mitral valve replacement and whether it is more conducive to the recovery of cardiac function.Methods The clinical data of 205 patients who underwent mitral valve replacement due to mitral insufficiency in Enshi Central Hospital from January 2017 to December 2020 were analyzed retrospectively.According to whether the subvalvular structure of mitral valve was preserved during operation,they were divided into three groups:group A was to preserve all the subvalvular structures of anterior and posterior mitral valve,group B retained all or part of the subvalvular structure of the posterior valve,in group C,all anterior and posterior subvalvular structures were removed.The operation time,cardiopulmonary bypass time and aortic occlusion time of patients in each group were counted.Postoperative ventilator use time,ICU stay time and incidence of complications;mitral flow velocities(MVE),left ventricular end diastolic dimension(LVED),left ventricular ejection fraction(LVEF)and left ventricular fractional shortening(LVFS)were rechecked by echocardiography at 1 week,3 months and 6 months after operation.Results There were no significant differences in operation time,cardiopulmonary bypass time,aortic occlusion time,ventilator use time and ICU stay time among the three groups before surgery(P>0.05).There were no death cases in perioperative period,and all patients were cured and discharged from hospital.The results of cardiac color ultrasound showed that MVE,LVED,LVEF and LVFS were improved compared with those before operation.Postoperative ultrasound results showed no significant difference in MVE at 1 week,3 months and 6 months(P>0.05).At 1 week after surgery,LVED in group A was lower than that in group B and C:(44.90±5.59)mm vs.(46.13±6.15)mm,(48.33±5.59)mm.The difference was statistically significant(P<0.05).Three months after operation,LVED and LVFS in group A were higher than those in group B and group C:(43.37±5.61)mm vs.(44.69±5.45)mm and(53.42±5.35)mm,(33.92±3.34)%vs.(31.67±3.20)%and(30.37±6.96)%,respectively.The differences were statistically significant(P<0.05).At 6 months after operation,LVED in group A was lower than that in group B and group C:(41.86±3.27)mm vs.(47.85±6.93)mm and(53.42±8.17)mm.LVFS was higher than that in group B and group C:(33.42±2.64)%vs.(32.18±5.98)%and(32.28±2.58)%,and the differences were statistically significant(P<0.05).Conclusions Preserving the whole subvalvular structure of mitral valve will not lead to prosthetic valve dysfunction and increase surgical complications.After operation,it showed better reduction of left ventricular end diastolic diameter and better left ventricular shortening rate,which was more conducive to the recovery of cardiac function.