合并巨大左心室心脏瓣膜手术的临床分析

Clinical analyses of cardiovalvular operations in patients with severe dilated left ventricle

目的 研究巨大左心室心脏瓣膜疾病特点、手术指征、手术方法、围术期处理及术后左室形态和功能的变化.方法 2003年1月至2008年12月,我院126例合并巨大左心室的心脏瓣膜病患者接受手术.男79例,女47例,年龄13～81（52±13）岁,病程0.3～42（18±12）年.患者病变均以主动脉瓣和（或）二尖瓣关闭不全为主.行二尖瓣置换术27例,二尖瓣成形术13例,主动脉瓣置换术51例,双瓣置换术25例,主动脉置换＋二尖瓣成形术10例,同期行Bentall手术6例,冠状动脉搭桥术3例,三尖瓣成形术58例,左心房折叠术62例.结果 全组患者围手术期死亡4例,病死率3.17%.2例死于继发于低心排的多脏器功能衰竭,2例死于心室颤动.术后早期发生室性心律失常46例（36.5%）,多器官功能不全26例（20.6%）,低心排血量14例（11.1%）.术前、术后早期（7～14 d）及术后随访（6～12个月）行超声心动图.心脏瓣膜术后左心室呈进行性缩小,左室舒张末直径（LNEDD）术前为（77±6）mm,术后分别为（63±12）mm（7～14 d）和（58±10）mm（6～12个月）（P〈0.01）,但6～12个月左心窒形态大多未能缩小至正常范围.左室射血分数（LVEF）和短轴内径缩短率（LVFS）在术后早期降低,于术后6～12个月恢复至术前水平,但低于正常.LVEF术前为49%±12%,术后分别为42%±9%（7～14 d）,51%±7%（6～12个月）（P〈0.01）.LNFS术前28%±7%,术后25%±4%（7～14 d）,29%±5%（6～12个月）（P〈0.05）.结论 巨大左心室危重心脏瓣膜病可以取得较好的手术效果.加强对室性心律失常的防治具有重要意义.术后早期左心室即开始明显回缩,但左心室收缩功能较术前降低.

Objective To explore the perioperative features of surgical treatment in valvular patients with severe dilated left ventricle and investigate the structural changes of left ventricle and its correlation with cardiac functions. Methods A total of 126 patients with severe dilated left ventricle underwent mitral valve and/or aortic valve operation from January 2003 to December 2008, including mitral valve replacement （MVR） （n = 27）, mitral valvuloplasty （MVP） （n = 13）, aortic valve replacement （AVR） （n = 51）,AVR ＋ MVR （n = 25） and AVR ＋ MVP （n = 10）. There were 79 males and 47 females with a mean age of （52 ± 13）years old. The mean pathological course was （18± 12）years. The pathological changes were mainly of aortic and/or mitral incompetence. The concomitant procedures included Bentall procedure （n =6）, coronary artery bypass grafting （n =3）, tricuspid valvuloplasty （n =58） and left atrial folding （n =62）. Results The perioperative mortality was 3. 17% （4/126）. Two died of multiple organ failure （MOF） secondarily to severe low-output syndrome while another 2 died of sudden ventricular fibrillation.Forty-six （36.5%） patients suffered from ventricular arrhythmia during the earlier postoperative period and they required a venous injection of lidocacin and/or amidaron. Fourteen （1 1. 1%） patients suffered from severe low-output syndrome. Among them, 4 patients were resuscitated with an intro-aortic balloon pump for another 4-6 days. And 26 （20. 6%） cases were complicated with multiple organ failure. The echocardiographic examinations showed that left ventricular dimensions decreased significantly at Days 7-14 postoperatively and progressively at Months 6-12 postoperatively. Left ventricular end-diastolic diameter （LVEDD） was （77 ±6） mm preoperatively and （63 ± 12） mm （Days 7-14）, （58 ± 10） mm （Months 6-12） postoperatively （P 〈0.01）. The contractile function of left ventricle temporarily decreased during the early postoperative stage and improved gradually afterwards. But it was not restored to normal range even until 6-12 m post-operation. Ejection fraction was 49% ± 12% preoperatively and 42% ±9% （Days 7-14）,51% ±7% （Months 6-12） postoperatively （P 〈0. 01）. Left ventricular fraction shortness was 28% ±7% preoperatively and 25% ± 4% （Days 7-14）, 29% ± 5% （Months 6-12） postoperatively （P 〈 0.05）.Conclusion For the patients with severe dilated left ventricle, cardiovalvular operation can achieve an excellent outcome through a rigorous perioperative regiment. The prevention and treatment of postoperative ventricular arrhythmia should be emphasized. The dimension of left ventricle decreases progressively during the early postoperative period. There is a postoperative decline of cardiac functions.