二尖瓣替换术后人工瓣膜不匹配对肺动脉高压及心房纤颤射频消融治疗效果的影响

Impact of patient-prosthesis mismatch on pulmonary arterial pressure and the efficacy of radiofrequence ablation therapy for atrial fibrillation after mitral valve replacement in rheumatic heart diseases

目的:研究二尖瓣替换术后人工瓣膜不匹配(Patient-prosthesis mismatch,PPM)的发生情况,及PPM对患者术后肺动脉收缩压及心房纤颤(房颤)射频消融术效果的影响。方法:从2004年10月至2006年10月手术治疗风湿性二尖瓣狭窄或狭窄合并关闭不全的患者29例,其中男性13例,女性16例;年龄30～70岁,平均年龄(53±11.7)岁,均为持续性房颤心律。手术方法为二尖瓣人工瓣膜替换术加Cox-mazeⅢ°房颤射频消融术,使用的人工瓣膜包括机械瓣22例,生物瓣7例。术后计算瓣膜有效开口面积(EOA)和瓣膜有效开口面积指数(IndexedEOA,EOAI),并测定肺动脉收缩压。将EOAI≤1.2cm2/mm2定义为瓣膜不匹配,肺动脉收缩压≥40mmHg(1mmHg=0.133kPa)定义为肺动脉高压。结果:无手术及随访期死亡。随访12～36个月,平均(21.3±7.6)个月。29例患者中17例手术后有效瓣口面积(EOAI)≤1.2cm2/mm2,PPM发生率为58.6%,无PPM(Non-PPM)12例。PPM组与Non-PPM组相比,术后肺动脉收缩压分别下降为(51.4±9.8)mmHg及(35±6.7)mmHg(P<0.01);术后持续肺动脉高压的比例分别64.7%(11/17)及33.3%(4/12),P<0.01;术后1年房颤复发率分别为35.3%(6/17)及25%(3/12),P<0.05;左心房经线分别减少到(50.7±11.2)mm及(42±10.4)mm,P<0.05。结论:风湿性二尖瓣替换术后PPM的现象较为常见。二尖瓣位PPM对患者术后持续的肺动脉高压及射频消融术后房颤的复发率有重要影响。

Objective：To study the incidence of patient-prosthesis mismatch （PPM）,and its impact on pulmonary arterial pressure and the efficacy of radiofrequence ablation for atrial fibrillation after mitral valve replacment in rheumatic heart diseases. Methods：From October 2004 to October 2006,data from 29 patients 〔male 13,female 16,mean age of （53 ±11.7） years〕with rheumatic heart diseases,underwent mitral valve replacement（MVR）,concomitant operations including radiofrequence ablation therapy for atrial fibrillation in 29 cases. 22 mechanical valves and 7 bioprostheses were selected. Mitral valve effective orifice area （EOA）, indexed effective orifice area（ EOAI） and pulmonary arterial pressure were caculated. patient-prosthesis mismatch was defined as an indexed EOAI≤1. 2 cm2 /m2,whereas pulmonary arterial hypertension as systolic pulmonary arterial pressure≥40 mm Hg（1 mm Hg = 0. 133 kPa）. Results： No death in operation and during follow-up. The follow-up time was from 12 to 36 months 〔mean of （21. 3 ± 7. 6） months〕. 58. 6% （17 /29） patients occurred PPM defined as EOAI≤1. 2 cm2 /m2,and Non-PPM in 12. Significant differences were found （Postoperative systolic PA pressure was （51. 4 ±9. 8）mm Hg vs （35 ±6. 7） mm Hg,respectively,P 0. 01） at the end of one year follow-up in PPM group and Non-PPM group. The persistence of PA hypertension were compared significantly in two groups （64. 7% vs 33. 3% ,respectively,P 0. 01）. The Recurrence of atrial fibrillation in PPM group was 35. 3% ,which was significant higher than Non-PPM group as 25% （P 0. 05）,and the left atrium also were significant differences in two groups 〔（50. 7 ± 11. 2） mm vs （42 ± 10. 4） mm,respectively,P 0. 05〕. Conclusion：Patient-prosthesis mismatch after mitral valve replacement is not uncommon,it has important effect on persistent PA hypertension and the recurrence of atrial fibrillation after operation.