非体外循环下采用自制二尖瓣成形装置手术治疗轻至中度缺血性二尖瓣关闭不全

Off-pump Surgical Therapy for Mild-to Moderate-Ischemic Mitral Regurgitation Using a Self-designed Device

目的尝试在非体外循环冠状动脉旁路移植术(OPCAB)期间对轻至中度缺血性二尖瓣反流(IMR)患者采用自制二尖瓣成形装置进行外科处理,并评估其疗效。方法回顾性分析自2009年9月至2011年8月北京安贞医院6例轻至中度IMR患者(男4例、女2例,年龄52～73岁)在OPCAB期间采用自制二尖瓣成形装置进行二尖瓣成形的临床资料。在处理IMR前及处理后通过经食管超声心动图测定IMR程度、二尖瓣瓣环前后径、左心室短轴径、左心室长轴径、左心室球形指数(左心室短轴径/左心室长轴径)等;通过Swan-Ganz导管测量并记录主动脉平均压、肺动脉平均压和中心静脉压等。比较围术期相关心功能指标。结果无住院死亡。二尖瓣成形后IMR均消失、二尖瓣瓣环前后径[(3.43±0.08)cm vs.(3.68±0.08)cm;t=5.430,P=0.001]、左心室短轴径[(4.80±0.21)cm vs.(5.53±0.11)cm;t=7.530,P=0.001]和左心室球形指数(0.64±0.02 vs.0.74±0.01;t=11.110,P=0.002)均较处理前明显减小;左心室长轴径无明显变化(P>0.05);术中血流动力学指标无明显变化。术后3个月6例患者(随访率100%)均在门诊复查,均无自主临床症状,心功能均改善至Ⅰ级(NYHA)。超声心动图提示:二尖瓣无反流4例,有微量反流2例。结论在OPCAB期间采用自制二尖瓣成形装置成形治疗IMR,直接完成了左心室塑型,规避了体外循环风险,即刻疗效确切,对循环指标影响甚小,有一定的临床应用价值。

Objective To evaluate the effect of a surgical method for treating mild- to moderate-ischemic mitral regurgitation （IMR） using a self-designed device during off-pump coronary artery bypass grafting （OPCAB）. Methods From September 2009 to August 2011, six patients （4 males, 2 females; age was 52-73 years ） with mild- to moderate-IMR underwent OPCAB and concomitant mitral valvuloplasty using a self-designed device in Beijing An Zhen Hospital. Their degree of IMR, anteroposterior diameter of mitral annulus, left ventricular long-axis diameter, left ventricular short-axis diameter and left ventricular spherical index （left ventricular short-axis diameter/left ventricular long -axis diameter） were measured using transesophageal Doppler echocardiography before and after mitral valvuloplasty. Their mean aorta pres- sure, mean pulmonary artery pressure and central venous pressure were also measured via Swan-Ganz catheter before and after mitral valvuloplasty. Periopemtive cardiac function indexes were compared. Results There was no in-hospital death. IMR of all patients disappeared postoperatively. After mitral valvuloplasty their anteroposterior diameter of mitral annulus （3.43±0.08 cm vs. 3.68±0.08 cm; t=5. 430, P=0.001 ）, left ventricular short-axis diameter （4.80±0.21 cm vs. 5.53±0. 11 cm; t=7. 530, P=0. 001） and left ventricular spherical index （0. 64±0. 02 vs. 0. 74±0. 01 ; t=11. 110, P=0. 002） significantly decreased than those before mitral valvuloplasty. But their left ventricular long-axis diameter and hemodynamic indexes did not change significantly after mitral valvuloplasty. All the six patients were followed up at the out-patient department 3 months postoperatively without autonomous symptoms. Their heart function improved to I class （New York Heart Association）. Echocardiography showed 4 patients without IMR and 2 patients with trace of minimal IMR. Conclusion Off-pump surgical therapy for mild- to moderate- IMR during OPCAB can help the patients reverse remodeling of the left ventricle, avoid the risks of cardiopulmonary bypass and improve cardiac function with good shortterm effects. This method may be a good choice for treating patients with IMR.