冠心病合并慢性中度缺血性二尖瓣关闭不全的外科治疗

Surgery Treatment of Chronic Moderate Ischemic Mitral Regurgitation in Coronary Artery Disease

目的 探讨冠心病合并中度缺血性二尖瓣关闭不全（IMR）的外科治疗及其预后。方法 从1998年1月至2006年5月共收治冠心病合并中度IMR患者28例，均为冠状动脉病变合并单纯二尖瓣关闭不全，手术均在中度低温体外循环下行冠状动脉旁路移植术（CABG）和同期二尖瓣手术。二尖瓣成形术（MVP）24例，其中Reed法成形9例，Reed法成形同时加成形环8例，脱垂二尖瓣叶切除同时加成形环7例；二尖瓣置换术（MVR）4例，其中置换机械瓣1例，生物瓣3例。结果 术后早期无死亡患者，应用主动脉内球囊反搏（IABP）1例。术后随访26例，随访3～80个月，平均41个月，远期死亡2例（MVP1例、MVR1例）。随访MVP患者生存22例，心功能Ⅰ级13例，Ⅱ级6例，Ⅲ级3例，较术前明显改善；多普勒超声心动图检查二尖瓣无反流5例，微量反流7例，轻度反流6例，中度反流3例，重度反流1例，左房容积（LAV）54．1±12．7ml，左心室舒张期末容积（LVEDV）60．9±14．8ml，左心室射血分数（LVEF）0．59±0．15，与术前比较差异均有统计学意义（P〈0．05）。随访MVR患者生存2例，心功能Ⅰ级1例，Ⅱ级1例；多普勒超声心动图检查瓣膜功能良好。结论 对冠心病合并中度IMR患者应在行CABG时同期进行处理，IMR处理的方法以MVP同时加用成形环的早期临床效果较好，但是对左室功能差和左室壁运动异常的患者远期效果需要进一步观察。

Objective To investigate the treatment and prognosis of moderate ischemic mitral regurgitation （IMR） in coronary artery disease（CAD）. Methods From .January 1998 to May 2006, 28 patients of CAD with moderate IMR underwent coronary artery bypass grafting （CABG） and mitral valve plasty（MVP, 24） or mitral valve replacement （MVR, 4）. The Reed method were used in 9 cases, the annuloplasty ring were used in 15 cases. Mechanical valve were implanted in i case and biological valve in 3 cases. Results There was no operative or hospital death. Twenty-six patients were followed up to a mean period of 41 months. There were two late death（one was MVP, the other was MVR）. In MVP cases, nineteen patients were in New York Heart Association （NYHA） functional class Ⅰ and Ⅱ , 3 in class Ⅲ , which was better than that of preoperative one. Ultrasonic cardiography （UCG） examination showed no mitral regurgitation in 5 cases, mild in 7, light in 6, moderate in 3, severe in 1. Left atrial volume （LAV） and left ventricular end-diastolic volume （LVEDV） were 54. 1 ±12.7ml and 60. 9±14.8 ml, decreased more significantly than that preoperatively （P〈0.05）. In MVR cases, 2 cases were survival and followed. One patient was in NYHA functional class Ⅰ , 1 in class Ⅱ , which was better than that of preoperative one. Conclusion Moderate IMR with CAD should be treated carefully. MVP with annuloplasty ring have better early results. For patients with bad heart function and abnormal left ventricular wall motion, the late results need more studies.