改良腱索转移法治疗二尖瓣前叶脱垂（附16例临床分析）

Chordal transfer and ＂edge-to-edge＂ technique for prolapse of anterior leaflet of mitral valve in 16 cases

目的介绍一种操作简单、效果可靠的矫治二尖瓣前叶脱垂的手术方法。方法2002年1月至2008年5月，应用“缘对缘”技术基础上的腱索转移法治疗二尖瓣前叶脱垂共16例，其中腱索断裂12例，腱索延长4例。超声心动图均显示二尖瓣前叶脱垂致重度关闭不全，平均反流面积（14．76±3．28）cm^2，左心室射血分数33％～69％。按照NYNA分级，术前心功能Ⅲ级5例，Ⅳ级11例。手术首先行脱垂部位前瓣与相应部位后瓣的“缘对缘”缝合，矩形切下缝合处的后瓣，连同相应的腱索、乳头肌，转移至前瓣。再行后瓣成形，完成瓣膜成形手术。所有病人出院前和随访时再次行超声心动图检查。结果手术无死亡，除1例因为术后第3天出现二尖瓣前叶穿孔再次行二尖瓣置换手术外，其余15例手术病人均顺利康复出院。术后远期随访无死亡，心功能全部恢复至Ⅰ级。复查超声心动图二尖瓣瓣口面积3．3—4．8cm^2，平均（3．78±0．52）cm^2，均无明显反流，反流面积（0．45±0．22）cm^2，左房、左室明显缩小[（左房径：术前（48．26±11．12）mm，术后（37．57±9．56）mm，P=0．028；左室舒张末径术前（61．43±8．24）mm，术后（42．35±10．79）mm，P=0．008]。结论“缘对缘”技术基础上的腱索转移法治疗二尖瓣前叶脱垂，操作简单，可以取得良好的成形效果。

Objective To introduce an operative technique for prolapse of the anterior leaflet of mitral valve. Methods From January 2002 through May 2008, chordal transfer and ＂edge-to-edge＂ technique was performed in 16 cases with serious mitral valve regurgitation due to prolapse of the anterior leaflet. The etiology was chordal rupture in 12 cases and chordal elongation in 4. The mean regurgitation area was （14.76 ± 3.28） cm^2. Left ventricular ejection fraction （LVEF） was 33 % -69% before operation. Among those patients, 5 were in NYHA function class Ⅲ 11 in class Ⅳ. Operations were performed under general anesthesia and cardiopulmonary bypass. First, ＂edge to edge＂ technique was performed. The free edge of the prolapsed anterior leaflet was sutured to corresponding posterior leaflet. Then quadrangular resection was performed to transfer segment of posterior leaflet with its attached chordae. At last, the posterior leaflet was appro：dmated after quadrangular resection. Echocardiagraphy was performed in each patient before discharge and at the times of follow-up. Results All patients survived the operation. One patient required mitral valve replacement due to anterior leaflet perforation 3 days after the operation. The rest were free from reoperation. At the time of follow-up, all these patients were in NYHA functional class Ⅰ. Echocardiography showed neither stenosis nor significant regurgitation of the mitral valve. The cross-sectional area of the mitral valve was 3.3 - 4.8 cm^2 [ mean（3.78 ± 0.52） cm^2 3. The mean regurgitation area was （0.45 ± 0.22） cm^2. Both dimension of left atrium and left ventncule reduced significantly. The diameter of left atrium was （48.26 ±11.12） mm pre-operation vs. （37.57 ± 9.56） mm post-operation （ P = 0.028）. The end-diastolic diameter of the left ventricule was （61.43±8.24）mm pre-operation vs （42.35± 10.79） mm post-operation （P=0.008）. Conclusion Chordal transfer and ＂edge- to-edge＂ technique provides good results for repair of anterior leaflet prolapse of mitral valve.