经左心房或左心室室壁瘤切口行二尖瓣成形术的疗效评价

Clinical experience of mitral valve plasty through left atrium or left ventricle for the treatment of left ventricular aneurysm and mitral valve regurgitation

目的评价经左心房(LA)或左心室(LV)室壁瘤切口行二尖瓣成形术的手术疗效。方法1997年1月至2005年4月,23例病人因冠状动脉粥样硬化性心脏病伴室壁瘤形成行冠状动脉旁路移植及室壁瘤手术,同时因缺血性二尖瓣关闭不全行二尖瓣成形术。其中经房间隔左心房切口行二尖瓣成形术10例(A组),经左心室室壁瘤切口行二尖瓣成形术13例(B组)。手术在全麻低温体外循环下,首先完成冠状动脉旁路移植术,然后行二尖瓣成形术和室壁瘤手术。结果B组体外循环和主动脉阻断时间较A组缩短,但差异无统计学意义(P>0.05),气管插管、住ICU及术后住院时间、术后LA大小、LV大小、EF值两组间差异均无统计学意义(P>0.05)。但与术前相比,两组术后左心房、室大小均显著减小(P<0.05),EF显著改善(P<0.05)。全组死亡2例,A组、B组各1例,病死率8.7%(2/23例)。远期随访A组1例术后7个月因应激性溃疡出血、肝功能衰竭死亡,另1例术后4个月因严重的二尖瓣关闭不全行二尖瓣置换术;B组无死亡及二次手术病例。生存者心功能I～II级,症状明显改善,二尖瓣结构、功能正常或仅轻-中度关闭不全。结论经左心室室壁瘤切口入路行二尖瓣成形术疗效满意,该术式可将二尖瓣和左心室形态、功能的恢复同时设计,整体构思,相同的术野和同时兼顾手术操作,实现二尖瓣与左心室结构和功能快速有效的重建;且避免了常规右心房、房间隔或房间沟切口,简化手术操作,减轻心肌损伤,缩短手术时间。

Objective To evaluate the clinical results of the coronary artery bypass grafting with the concomitant left ventricular aneurysmectomy and mitral valve plastic using a transventricular approach via aneurysmectomy or a left atrium approach. Methods From January 1997 to April 2005, 23 patients underwent coronary artery bypass grafting with concomitant left ventrieular anemysmectomy and mitral valve plasty, There were 17 males and 6 females, with mean of （59.83± 12.21）years （age 32 to 74 years）. ＇Ihe body weights were 54 to 85 （71.93 ±11.82） kg. 10 patients underwent concomitant mitral valve plasty through a left atrium approach （group A）, and 13 through a transventrieular approach via aneurysmeetomy （group B）. Between the two groups, there were no differenees in the age, body weight, the size of the left atrium and left ventrieular, the value of EF and the ratio of C/T. Coronary revascu- larization was accomplished first, then concomitant mitral valve plasty and left ventrieular aneurysrnectorny. Results Compared with the group A, the time of the CPB and the aortic occlusion was decreased in group B, but there was no significant difference （ P 〈 0.05）. The endotracheal intubation time, ICU and hospital slay had no difference between the group A and group B （ P 〉 0.05）. The postoperative echocardiography shown lhat the size of the left atrium and left ventricular, the value of EF had no difference between the two groups （ P 〉 0.05）. However, compared with the parameter before operation, the size of the left atrium and left ventrieular were obvious decreased, the value of EF was obvious increased for both groups （ P 〈 0.05） The 2 patients （8.7%） died postoperatively, one patient （ 1/10, 10 % ） in group A, and one （ 11/13, 7.7 % ） in group B. The main reason of death was the severe low cardiac out- put and heart failure. During follow-up period, one patient in group A had mitral valve replacement 4 months after the fast operation for the severe mitral valve regurgitation. One patient in group A died 7 months after the first operation of the alimentary tract bleeding and hypohepatia. All surviving patients were in New York Heart Association functional class 1 or 11, and had either no mitral valve regurgilation or only mild mitral valve regurgitation. Conclusion Surgical outcome for patients of the coronary artery bypass grafting with the concomitant left ventrieular aneurysmectomy and mitral valve plasty through a transventrieular approach via anemysmectomy is satisfactory. This approach can avoid incision of the right atrium, provide a safe and reliable surgical intervention and reduce the operation time, thus decrease the complications and minimize the myocardial injury.