非移植性外科重构手术治疗终末期心瓣膜病

Non-transplantation Surgical Cardiac Remodeling Operation for End-stage Cardiac Valve Disease

目的通过对终末期心瓣膜病患者围手术期进行严格管理后施行非移植性外科重构手术（解剖和功能重构手术）,评价其术后的临床效果和应用前景。方法回顾性分析2005年12月至2009年7月安徽医科大学第二附属医院收治的31例终末期心瓣膜病患者的临床资料,其中男14例,女17例;年龄27~74岁,平均年龄40.4岁。术前3 d所有患者接受连续性肾脏替代治疗,9例患者术前1~3 d行主动脉内球囊反搏治疗。行二尖瓣置换术13例、主动脉瓣置换术7例、三尖瓣置换术4例、双瓣膜置换术7例;所有患者同期行心房、心室减容术：包括左心房部分切除或折叠术19例次、左心室部分切除术7例次、左心房＋左心室减容术5例次、右心房部分切除术21例次、右心室部分切除术3例次。同期行De Vega成形术5例、三尖瓣成形环成形术14例、冠状动脉旁路移植术3例。术后和随访期采用超声心动图观察患者的心功能、心房和心室的改变。结果术后发生低心排血量死亡1例,1例术后胸腔引流量增多,经二次开胸止血后并发纵隔和切口感染,自动出院。失访1例;随访29例,随访时间3~12个月。随访期间死亡3例,其中2例心功能不全加重,1例突发脑卒中。随访12个月时,患者心功能改善明显,心功能分级（NYHA）Ⅰ级12例、Ⅱ级7例、Ⅲ级3例、Ⅳ级3例。术后12个月射血分数（54.00%±8.00%vs.25.00%±3.00%）和心脏指数[3.30±0.50 L/（min.m2）vs.1.10±0.30 L/（min.m2）]均较术前明显增高,而左心室舒张期末内径（52.00±10.00 mm vs.95.00±12.00 mm）和左心房内径（39.00±8.00 mm vs.70.00±12.00 mm）均较术前明显减小（P〈0.05）。结论终末期心瓣膜病患者通过术前积极的调整和准备后施行非移植性外科重构手术,是治疗终末期心脏病患者的一种新选择。

Objective To evaluate the effectiveness and prospect of non-transplantation surgical cardiac remodeling for end-stage cardiac valve disease by performing the remodeling operation（including anatomical and functional remodeling） after strict peri-operative adjustment for end-stage cardiac valve disease.Methods We retrospectively analyzed the clinical data of 31 patients,including 14 males and 17 females,with end-stage cardiac valve disease who were treated with surgical cardiac remodeling operation from December 2005 to July 2009 in the 2nd Hospital of Anhui Medical University. Their age ranged from 27 to 74 years with an average age of 40.4 years.Continuous renal replacement therapy（CRRT） was carried out 3 days before surgery in all patients and intra-aortic balloon pumping（IABP） was performed 1-3 days before operation in 9 patients.Among the patients,there were 13 patients of mitral valve replacement（MVR）,7 patients of aortic valve replacement（AVR）,4 patients of tricuspid valve replacement（TVR）,and 7 patients of double valve replacement（DVR）.At the same time,all patients underwent ventricular or atrial volume reduction operation,including 19 patients of left atrial partial excision or plication,7 patients of partial left ventricular excision,5 patients of left atrial and left ventricular volume reduction operation,21 patients of partial right atrial excision,and 3 patients of partial right ventricular excision.Besides,there were 5 patients of De Vega plasty,14 patients of annuloplasty and 3 patients of coronary artery bypass grafting（CABG）.The echocardiogram was used to observe the change of heart function,atrium and ventricular in patients on postoperative and follow-up period.Results After surgery,one patient died of low cardiac output syndrome,and one other patient gave up because of incision and mediastinum infection after re-operation for hemorrhage. Twenty-nine patients were followed up for 3 to 12 months with 1 case lost.During the follow-up,3 patients died,of whom 2 died of deterioration of heart function and 1 died of sudden stroke.In the 12th month during the follow-up,heart function of all other 25 patients showed obvious improvements with 12 classⅠ,7 class-Ⅱ,3 class-Ⅲ and 3 class-Ⅳ heart function according to NYHA classification.At the end of the follow-up,ejection fraction（54.00%±8.00% vs.25.00%±3.00%） and cardiac index [3.30±0.50 L/（min·m2） vs.1.10±0.30 L/（min·m2）] were significantly higher than those before operation（P0.05）,whereas left ventricular end diastolic diameter（52.00±10.00 mm vs.95.00±12.00 mm） and left atrial diameter（39.00±8.00 mm vs.70.00±12.00 mm） both decreased significantly than those before operation（P0.05）.Conclusion Cardiac remodeling operation for end-stage cardiac valve disease after active adjustment and preparation can achieve similar results to operation for severe valve diseases,providing a new choice for end-stage heart disease.