心脏瓣膜病巨大左室的外科治疗经验

^Experinece of Surgical Treatment for Valvular Heart Disease with Giant Left Ventricle

１９８７年１月至１９９２年３月，我们为６５例心脏瓣膜病巨大左室（ＥＤＤ＞７０ｍｍ）病人施行了瓣膜替换术。术前平均ＥＤＤ７８．８ｍｍ，ＥＳＤ５７．３ｍｍ，ＦＳ０．２６。心功能Ⅲ级１６例，Ⅳ级４９例。手术方式：ＭＶＲ１６例，ＭＶＲ＋ＴＶＰ１０例，ＡＶＲ１１例，ＭＶＫ＋ＡＶＲ２１例，ＭＶＲ＋ＡＶＲ＋ＴＶＰ７例。术后早期发生心、肺、肾、肝等重要器官并发症２７例，死亡９例（１３．８％）。ＡＶＲ组（１８．２％）和ＤＶＲ组（１７．９％）死亡率显著高于ＭＶＲ组（７．７％）。术后２～４周超声心动图复查，左室ＥＤＤ、ＥＳＤ均较术前有显著缩小。而ＦＳ、ＥＦ至术后６～１２个月才较术前有显著改善。长期生存５６例中５２例心功能Ⅰ级４２例，Ⅱ级９例，Ⅲ级１例；晚期死亡４例。我们认为，加强围术期处理、强调心肌保护与手术方法的改进，是提高心脏瓣膜病巨大左室病人手术疗效的重要措施。

Sixty-five patients with valvular heart disease associated with giant left ventricle (left ventricular end-diastolic diameter EDD>70mm)were operated on for cardiac valve replacement in our hospital from Jan.1987 through March 1992.Preoperative EDD was 78.8(70.0～98.3)mm,ESD 57.3(50.2～72.8)mm,FS 0.26(0.12～0.33),cardiac/thoracic ratio was from 0.64 to 0.98.NYHA heart function class was Ⅲ in 16 and class Ⅳ in 49.Among them,17 patients had functional tricuspid insufficiency,14 severe impairment of pulmonary function,19 higher than moderate pulmonary hypertension,11 hepatic dysfunction,3 renal insufficiency.Operative procedures consisted MVR in 16 cases,MVR+TVP in 10,AVR in 11,MVR+AVR in 21,MVR+AVR+TVP in 7.Early postoperative complications in 27 patients included low cardiac output syndrome,respiratory failure,renal failure and MOF.Nine deaths occurred within 30 days (13.8%).The mortality in AVR (18.2%) and DVR(17.9%) was significantly higher than that in MVR(7.7%).Postoperative echocardiographic examinations between 2～4 weeks showed that LVEDD and LVESD were decreased significantly and LVFS and EF were not improved significantly as compared with preoperative values respectively,but had sigificantly increased 6 to 12 months postoperatively.The averaged follow-up time of 56 survivals was 2.77 years(6 months to 5.4 years).There were 4 late deaths (2.78% patient-year).of the 52 long-term survivors their heart function was class Ⅰ in 4,cases,Ⅱ in 9,Ⅲ in 1.The authors think that preoperative improvement of patient’s general condition and cardiopulmonary function,enhancing myocardial protection and optimal operative methods during operation,and intensiying postoperative management were important factors affecting operative results of valvular heart disease with giant left ventricle.