缺血性二尖瓣关闭不全的外科治疗

Surgery treatment of ischemic mitral regurgitation

目的 探讨缺血性二尖瓣关闭不全的外科治疗方法 ,分析影响手术疗效的因素。方法 1998年 4月至 2 0 0 3年 11月 ,外科治疗 4 4例冠心病缺血性二尖瓣关闭不全 ,其中轻～中度 7例 ,中度 2 4例 ,重度 13例。行二尖瓣成形术 30例 ,其中交界区瓣环成形术 12例 ,用人工瓣环行瓣环成形术 17例 ,1例行双孔二尖瓣成形 ;4例同时行后瓣叶楔形切除 ,1例作腱索转移。瓣膜置换术 14例 ,置入双叶机械瓣 12例 ,生物瓣 2例。结果 全组手术死亡 7例 ,其中低心排出量综合征或心衰死亡 4例 ,心律失常 2例 ,脑栓塞 1例。 33例术后平均随访 2 0个月 ,远期死亡 2例 ,生存者远期心功能I～II级 2 9例 ,III级 2例。术后超声复查左心室内径较术前明显缩小 [(6 2 3± 6 3)mm对 (5 4 3± 7 1)mm]。行瓣膜成形术者远期复查超声显示无反流或轻微反流 12例 ,轻度反流 5例 ,中度反流 2例。瓣膜置换术者 12例出现瓣周漏 ,其余病例瓣膜功能良好。统计分析显示 ,左心室功能、临床心功能级别与手术风险相关。结论 冠心病合并二尖瓣关闭不全应积极处理 ,手术矫治方式应根据瓣膜病理改变及心功能决定 ,尽量施行瓣膜成形术。

Ovbective To report our experience of surgical treatment for ischemic mitral regurgitation. Methods From April 1998 to November 2003,44 patients with ischemic mitral valve regurgitation underwent mitral valve plasty (MVP,30) or replacement (MVR,14) and CABG. There were 7 cases with mild-moderate MI,24 with moderate MI,13 with severe MI before operation. The procedures of MVP included: commissural annuloplasty in 12,posterior ring annuloplasty in 15,Carpetier's ring annuloplasty in 2,qurdrangular valvulectomy in 4,cordal transplantation in 1,and 'double-orifice' technique in 1. Mechanical valves were implanted in 12 MVR patients and biological in 2. Results There were 7 operative deaths (15.9%). The causes of death were heart failure in 4 cases,arrhythmia in 2 and strode in 1. 33 patients were followed up to a mean period of 20 months. There was 2 late death. 29 patients were in NYHA functional class I and II,3 in class III. UCG examination for MVP patients showed no pr trivial MI in 12 patients,mild in 5,moderate in 2 cases. LV size decreased significantly [(62.3±6.3) mm vs. (54.3±7.1)mm]. There was 1 case of perivalvular leak in MVR group. Statistical analysis showed severe preoperative symptom,significantly enlarged LV size and severely depressed LV function were risk factors of operative death. Conclusion Coronary artery desease with ischemic mitral regurgiatation should be treated aggressively. Operative technique should be based on valve pathology. Valve repair should be considered if possible.