自体心包片加宽瓣膜面积的二尖瓣成形术

Leaflet enlargement with autologous pericardium for repairing mitral valve disease

目的总结自体心包片加宽瓣膜面积的二尖瓣成形术的临床疗效，探讨其手术技巧和适应证。方法2004年7月至2008年6月治疗45例单纯二尖瓣瓣膜病变病人，二尖瓣狭窄10例，关闭不全35例，其中先天性8例，风湿性21例，退行性7例，感染性心内膜炎9例。应用自体心包片行后瓣叶加宽14例，前瓣叶加宽8例，前、后瓣叶都加宽23例；镜式成形12例；人工腱索12例，腱索转移6例，乳头肌开窗4例。全部病例均瓣环成形，应用Duran环16例，Carpentier环29例。并比较手术前、后心功能变化。结果无死亡病例。1例风湿性瓣膜闭合不好，术中改瓣膜置换术。术中食管超声示二尖瓣无反流38例，少量反流6例；二尖瓣有效瓣口面积平均（2．8±0．6）cm^2，跨瓣压差平均（6．21±1．34）mmHg（1mmHg=0．133kPa）。平均随访（18．0±2．1）个月。复查超声示二尖瓣无反流35例，少量反流9例。有效瓣口面积平均（2．5±0．8）cm^2，跨瓣压差平均（7．21±0．45）mmHg，均无需再手术。术前、术后左心室舒张末期内径（56±6）mm对（48±7）mm，P〈0．05；射血分数（0．45±0．23）对（0．51±0．24），P〈0．05；左心房内径（62±23）mm对（50±11）mm，P〈0．05。心功能明显改善，瓣膜功能好。结论自体心包片加宽瓣膜面积补偿瓣叶和（或）腱索的短缩，增加瓣叶活动，增加瓣膜闭合面积，结合瓣环成形，临床疗效肯定。手术操作简单，且自体心包相容性好，术后无需抗凝。

Objective To evaluate the clinic effect of leaflet enlargement with autologous pericardium in repairing mitral valve disease and to describe the technique and discuss its indications. Methods Between July 2004 and June 2008, 45 patients with isolated mitral valve disease, included stenosis in 10 and regurgitation in 35. The causes were congenital heart disease in 8, rheumatic in 21, degenerative in 7 and endocarditis in 9. The procedures were： posterior leaflet enlargement with autologous pericardium in 14, anterior leaflet enlargement in 8, both anterior and posterior leaflet enlargement in 23. In addition, eye to eye technique was in 12, artificial chordal in 12, chordal transfer in 6, papillary muscle repositioning in 4. Mitral annuloplasty was performed in all cases. Before and after surgery, cardiac function parameters were compared. Results No operative deaths occurred. One case wastransfered to mitral valve replacement due to regurgation. Intraoperative transesophageal echocardiography showed no mitral regurgitation in 38 and small regurgitation in 6 cases. The mean mitral valve effective orifice area（MVEOA） was （2.8 ±0.6） cm^2, with a mean gradient pressure of （6.21 ±1.34） mm Hg after operation. The mean followed up was （ 18.0 ±2.1 ） months. Echocardiography study showed that no mitral regurgitation in 35 cases, slight regurgitation in 9, mean mitral effective orifice area was （2.5 ±0.8 ） cm^2 , mean gradient pressure of （7.21 ±0.45 ）mm Hg, no one need reoperation. Postoperative cardiac functions were significantly improved： the average left ventricular end-diastolic diameter （LVEDD） was （48 ±7） mm [preoperative （56 ±6） mm, P〈0.05] , ejection fraction （EF） was0.51 ±0.24（preoperative 0.45 ±0.23, P 〈 0.05 ）, the aver＇age left atrium diameter （LA） was （ 50 ±11 ） mm [ preoperative （62 ±23 ） mm, P 〈 0.05 ]. The function of mitral valves was well performed. Conclusion Leaflet enlargement with autologous pericardium combined with mitral annuloplasty was effective in repairing of diseased mitral valve. The advantages of the procedure including simplicity, good compatibility, avoiding foreign body and no need for anticoagulation.