二尖瓣置换术后左心室后壁早期破裂的外科治疗

Surgical Treatment for Early Left Ventricular Rupture after Mitral Valve Replacement

目的探讨二尖瓣置换术(MVR)后左心室后壁早期破裂的原因、治疗及预防措施。方法回顾性分析1981年5月至2010年11月期间沈阳军区总医院施行二尖瓣置换术2 638例中发生左心室后壁早期破裂7例的临床资料,其中男2例,女5例;年龄28～71岁。术前心功能分级(NYHA)Ⅱ级1例,Ⅲ级6例。心脏彩色超声心动图提示左心室射血分数(LVEF)49%～60%,左心室舒张期末容积(LVEDV)29～42 ml。均在中度低温、全身麻醉、体外循环下行人工心瓣膜置换术。结果 7例左心室后壁早期破裂均经手术修补,其中Ⅰ型2例,Ⅱ型4例,Ⅲ型1例。死亡4例,均死于失血性休克或低心排血量综合征。手术抢救成功3例,术后7～15 d顺利出院。3例生存患者随访4.5～18.0年,一般状况良好,生活质量满意,无晚期假性动脉瘤形成。结论左心室后壁早期破裂修补困难,死亡率较高,应以预防为主;术中一旦发生破裂,应该尽快恢复体外循环,根据实际情况在心腔内、外联合修补较为确实、可靠,有可能挽救患者的生命。

Objective To investigate the cause,treatment,and prevention strategy of early left ventricular rupture after mitral valve replacement（MVR）.Methods We retrospectively analyzed clinical data of 7 patients who had early left ventricular rupture after MVR,among a total of 2 638 MVR patients,between May 1981 and November 2010 in General Hospital of Shenyang Military District.There were 2 male patients and 5 female patients with their age ranging from 28 to 71 years old.One patient was New York Heart Association（NYHA） functional classⅡand 6 patients were NYHA functional classⅢ.Preoperative echocardiography showed that their left ventricular ejection fraction（LVEF） was 49%-60% and their left ventricular end diastolic volume（LVEDV） was 29-42 ml.All the patients underwent prothetic valve replacement under moderate hypothermia,general anesthesia and extracorporeal circulation.Results All the 7 patients underwent surgical repair for their early left ventricular rupture.There were 2 patients with TypeⅠ,4 patients with TypeⅡ,and 1 patient with TypeⅢleft ventricular rupture.Four patients died of hemorrhagic shock or low cardiac output syndrome.Three patients were successfully healed and discharged from hospital 7-15 days after the operation.The 3 surviving patients were followed up for 4.5-18.0 years,and they all had good general condition and satisfactory quality of life.No late pseudo-aneurysm was found during follow-up.Conclusion sEarly left ventricular rupture is difficult to repair with a high mortality.Effective prevention strategy should be applied to avoid it as much as possible.Once left ventricular rupture occurs during the surgery,extracorporeal circulation should be quickly established,and it＇s possible to save patients＇ life by reliable intracardiac and epicardial repair according to patients＇ individual condition.