后叶腱索转移治疗二尖瓣前叶脱垂

Application of Posterior Leaflet Chordal Transfer in the Treatment of Anterior Mitral Leaflet Prolapse

目的总结采用后叶腱索转移术治疗二尖瓣前叶脱垂的临床经验和体会，探讨二尖瓣成形术的黄金时机。方法2004年10月至2008年10月治疗二尖瓣前叶脱垂16例，超声心动图检查诊断：二尖瓣前叶脱垂、腱索断裂10例，腱索延长4例，断裂合并延长2例；A1区域脱垂3例，A2区域脱垂6例，A3区域脱垂3例，合并A1、A2区域脱垂2例，A2、A3区域脱垂2例；均采用后叶腱索转移技术，其中1例合并冠心病患者同期施行冠状动脉旁路移植术。结果无手术死亡。出院前超声心动图检查提示：有少量反流2例，微量反流6例，无反流8例。出院后华法林抗凝治疗3个月。随访16例（100％），随访1～46个月（22．0±3．5个月），超声心动图提示：有少量反流3例，微量反流7例，无反流6例，效果优良。心功能Ⅰ级12例，Ⅱ级4例。出院前射血分数（EF）较术前降低（53．0％±3．4％vs．65．0％±4．2％，P=0．013），术后随访时EF与术前比较差异无统计学意义（61．0％±2．1％vs．65．0％±4．2％，P=0．110）；出院前和随访时左心室舒张期末内径较术前明显缩小（50．0±3．2mm，47．0±2．8mmvs．58．0±6．5mm，P=0．031，0．020）；随访时心功能较术前明显改善（P=0．002）。结论后叶腱索转移是治疗二尖瓣前叶脱垂的有效方法，心瓣膜成形术的最佳时期是术前EF值大于60％、左心室轻度增大、心功能在Ⅲ级以上。

Objective To summarize the clinical experiences of the application of posterior leaflet chordal transfer in the treatment of anterior mitral leaflet prolapse, and to investigate the best time for mitral valve repair. Methods From October 2004 to October 2008, 16 patients with anterior mitral leaflet prolapse underwent mitral valve repair. The echocardiography diagnosis revealed that 10 patients had chordal rupture, 4 had chordal elongation, 2 had both rupture and elongation. And there were 3 with A1 segment prolapse, 6 with A2 segment prolapse, 3 with A3 segment prolapse, 2 with both A1 and A2 segment prolapse, 2 with both A2 and A3 segment prolapse. All the patients underwent posterior leaflet chordal transfer, and one of them with coronary artery disease underwent coronary artery bypass grafting. Results There was no operative death. The echocardiography examination revealed that there were 2 patients with mild regurgitation, 6 with trivial regurgitation and 8 with no regurgitation before discharge. The patients received anticoagulation treatment of warfarin for 3 months after discharge. All the patients were followed up for 1-46 months（22.0±3.5 months）. The echoeardiography examination showed that there were 3 patients with mild regurgitation, 7 with trivial regurgitation and 6 with no regurgitation. There were 12 patients with New York Heart Association（NYHA） class Ⅰ , and 4 with class Ⅱ. The left ventricular ejection fraction（LVEF） was lower than that before operation（53.0% ± 3.4% vs. 65.0% ± 4. 2%, P = 0. 013）, and there was no statistical significance compared with that before operation（61.0%±2.1%vs. 65.0%±4.2%, P=0. 110）. The left ventricular end diastolic diameter decreased significantly compared with that before operation（50.0± 3.2 mm, 47.0 % ± 2.8 mm vs. 58.0± 6.5 mm, P= 0. 031,0. 020）. The postoperative cardiac function improved significantly （P= 0. 002）. Conclusion Posterior leaflet chordal transfer is an effective method for anterior mitral leaflet prolapse. The best time for mitral valve repair is when LVEF〉60%, left ventricle enlarges a little, and NYHA class〉 Ⅲ before operation.