冠心病合并室壁瘤的外科治疗

Surgical Treatment for Patients with Coronary Heart Disease and Ventricular Aneurysm

目的总结成人冠心病合并室壁瘤患者的外科临床特点及治疗结果,分析其治疗效果。方法回顾性分析2011年1月至2012年11月阜外心血管病医院86例冠心病合并室壁瘤患者行外科手术治疗的临床资料,其中男70例,女16例;年龄(57.7±10.6)岁;体重(71.7±10.5)kg。术前心脏超声心动图或左心室造影示左心室血栓形成22例。冠状动脉造影检查示:3支血管病变47例,2支病变29例,单支病变10例。行非体外循环室壁瘤直接线性缝合术16例,体外循环下单纯线性缝合术39例,心内膜环缩术15例,心内膜环缩加补片成形术16例。同期行冠状动脉旁路移植术64例。结果围术期死亡2例(2.3%),分别死于心室颤动和多器官功能衰竭。移植旁路血管(2.3±1.2)支。随访78例(92.9%),随访时间2～24个月。随访期间患者心绞痛症状明显缓解,心功能有不同程度地改善。心电图未见新发的心肌缺血表现。与术前相比较,左心室射血分数增高(51%±7%vs.41%±9%,t=6.20,P=0.00),左心室舒张期末内径缩小[(54.2±6.2)mm vs.(56.0±6.8)mm,t=4.60,P=0.00]。结论室壁瘤手术同期行冠状动脉旁路移植术(或室间隔穿孔修补术、二尖瓣成形术等)是心肌梗死后室壁瘤积极有效的治疗措施。只要制订良好的手术方案,根据室壁瘤的大小,无论是采用何种治疗方式,个体化治疗都可以取得满意的近期临床治疗效果。

Objective To summarize clinical characteristics and treatment results of adult patients with coronary heart disease and ventricular aneurysm, and evaluate surgical outcomes. Methods Clinical data of 86 adult patients with coronary heart disease and ventricular aneurysm who underwent surgical treatment in Fu Wai Hospital from January 2011 to November 2012 were retrospectively analyzed. There were 70 male and 16 female patients with their average age of 57.7± 10.6 years and average body weight of 71.7± 10.5 kg. Preoperative echocardiography or left ventriculography showed left ventrieular thrombus in 22 patients. Coronary angiography showed 47 patients with 3 vessel disease, 29 patients with 2 vessel disease, and 10 patients with single vessel disease. Sixteen patients underwent direct linear suturing of the aneurysm off pump, 39 patients underwent simple linear suturing under cardiopulmonary bypass, 15 patients received endov- entricular purse-string reconstruction, and 16 patients received endoventricular purse-string reconstruction and patch plasty. Three patients underwent reexploration for bleeding. Sixty-four patients received concomitant coronary artery bypass grafting （CABG）. Results Postoperatively 2 patients （2.3%） died of refractory ventricular fibrillation and multiple organ dysfun- ction syndrome respectively. Patients undergoing concomitant CABG received 2.3 ± 1.2 grafts on the average. Seventy-eight patients （92.9%） were followed up for 2-24 months after discharge. During follow-up, patients＇ angina symptoms significantly resolved, heart function improved in varying degrees, and no new sign of myocardial ischemia was found on electrocardiogram. Left ventricular ejection fraction （LVEF） was significantly higher than preoperative LVEF （ 51% ± 7% vs. 41% ± 9% , t= 6.20, P=0.00）, and left ventricular end-diastolic diameter （LVEDD）was significantly smaller than preoperative LVEDD （54.2±6.2 mm vs. 56.0±6.8 mm,t=4.60,P=0.00）. Conclusion Ventricular aneurysm repair and concomitant CABG（or ventricular septal perforation repair, mitral valvuloplasty et al） are positive and effective treatment strategies for postinfarc- tion ventricular aneurysm. Satisfactory clinical outcomes can be achieved by individualized treatment based on appropriate surgical strategies according to the size ofventricular aneurysm.