146例严重肺动脉高压者二尖瓣替换术疗效分析

Effects of Mitral Valve Replacement in 146 Patients with Severe Pulmonary Hypertension

评价风湿性二尖瓣病变伴重度肺高压病人的手术效果。采用方差分析、卡方检验对肺动脉收缩压（ＳＰＡＰ）≥９．３３ｋＰａ（１ｋＰａ＝７．５ｍｍＨｇ）并接受二尖瓣替换术（ＭＶＲ）的１４６病人的临床资料进行分析，将其分为４组。Ａ组：极重度肺高压（ＳＰＡＰ≥１３．３ｋＰａ）；Ｂ组：心功能严重低下组（心脏指数ＣＩ≤３３．３４）；Ｃ组：心功能减低或正常组（３３．３４≤ＣＩ≤６６．６８）；Ｄ组：高心排血量组（ＣＩ≥６６．６８）。其中每组按一次和二次手术再分为２个亚组。结果示一次手术组总死亡率为５．３％；Ａ１、Ｂ１、Ｃ１、Ｄ１４组术前临床情况、所用术式和心脏阻断时间等无差异，但Ｂ１组低心排（２４．２％）早期死亡率（１５．２％）明显高于其它３组（Ｐ＜０．０５），而Ｄ组无死亡。二次手术组总死亡率为２８．２％；各亚组低心排及死亡率均明显高于一次手术各组。由此认为，二尖瓣病变伴重度肺动脉高压病人，ＭＶＲ后低心排和早期死亡率与术前心脏指数有关。当心脏指数＞３３．３４时，即使肺动脉压和全肺阻力同时极度增高者，术后低心排和死亡率亦不因此增加。当ＣＩ＜３３．３４时，术后低心排及早期死亡率较高。

Aim:To evaluate the clinical results of mitral valve replacement on valve disease and severe pulmonary hypertension.Clinical material and method:146 patients with severe pulmonary hypertension(SPAP≥70mmHg)underwent mitral valve replacement(MVR).Patients were divided into four groups depending on cardiac catheterization records before operation.Group A:SPAP≥100mmHg;Group B:SPAP≥70mmHg,CI≤3.34;Group C:SPAP≥70mmHg,CI≤66.68 and Group D:SPAP≥70mmHg,CI≥66.68.Each group was further divided into two subgroups:First time operative and reoperative subgroups.Results:The hosptal mortality was 5.3%.The occurrance of lower cardiac output syndrom was 24.2% and mortality was 15.2% in group B,significantly higher than that of group A,C and D(P<0.05).There were no differences on preoperative clinical materials,operative methods,and aortic crossclamping time among group A1,B1,C1 and D1.There was no operative death in group D.The overall mortality for reoperative cases was 28.2%.Conclusion:When preoperative CI is more than 33.34,there would not be increasing mortality and postoperative occurrence of lower cardiac output syndrom even if PAP and total pulmonary resistance reached an extreme high level.There were higher morbidity and mortality if preoperative CI was less than 33.34,or for reoperative patients.