线圈式人工腱索二尖瓣成形术治疗二尖瓣前叶脱垂的临床分析

Clinical Analysis of Patients Undergoing Mitral Valvuloplasty for Anterior Mitral Leaflet Prolapse with Looped Artificial Chordae

目的总结线圈式人工腱索二尖瓣成形术治疗二尖瓣前叶脱垂的手术技巧、优点及临床效果。方法回顾性分析2009年1月至2011年12月北京安贞医院13例二尖瓣前叶脱垂伴重度反流患者应用线圈式人工腱索行二尖瓣成形术治疗的临床资料,其中男8例,女5例;年龄21～61(39.5±12.9)岁。前叶腱索断裂10例,腱索延长3例。术前左心室舒张期末内径(LVEDD)52～65(58.3±1.7)mm,左心室射血分数(LVEF)53%～65%(58.8%±2.8%)。所有患者均行手术治疗,术中依据脱垂相应位置正常的一级腱索的长度作为参考,用自制测量器精确测量,应用膨体聚四氟乙烯CV4 Gore-Tex缝线穿硬质垫片并环绕测量器制作3～5个线圈,然后将带针的缝线端穿过相应的前叶乳头肌并打结固定,应用另一根Gore-Tex缝线将线圈缝合于脱垂瓣叶的边缘,并使每个线圈相距约5 mm,左心室注水测试二尖瓣反流情况,加用人工瓣环或行双孔成形术,再次左心室注水测试二尖瓣关闭良好,复温、缝合。心脏复跳后再次行食管超声心动图检查二尖瓣成形的效果。出院后常规华法令抗凝3个月。结果全组围术期无死亡。12例行一期线圈式人工腱索加用人工成形环效果满意;1例行人工腱索成形后左心室注水测试不满意,再次加用双孔成形后效果满意,未使用人工成形环。术后即刻超声心动图提示二尖瓣微量至少量反流,LVEDD较术前明显减小[(47.5±2.1)mm vs.(58.3±1.7)mm,P<0.05],LVEF与术前比较差异无统计学意义(58.5%±2.6%vs.58.8%±2.8%,P>0.05)。所有患者术后随访3～36(19.5±3.7)个月,超声心动图检测结果显示二尖瓣有少量反流4例,无或微量反流9例。结论线圈式人工腱索二尖瓣成形术是治疗二尖瓣前叶脱垂一种有效的手术方式,该术式简便,易于操作,效果满意。

Objective To summarize surgical techniques, advantages and clinical outcomes of mitral valvuloplasty for anterior mitral leaflet prolapse with looped artificial chordae. Methods Clinical data of 13 patients with anterior mitral leaflet prolapse and severe mitral regurgitation （MR）who underwent mitral valvuloplasty with looped artificial chordae from January 2009 to December 2011 in Beijing Anzhen Hospital were retrospectively analyzed. There were 8 male and 5 female patients with their age of 21-61 （39.5 ___ 12.9）years. There were 10 patients with anterior mitral leaflet chordal rupture and 3 patients with anterior mitral leaflet elongation. Preoperative left ventricular end-diastolic diameter （LVEDD） was 52-65 （58.3 q-1.7）mm, and left ventricular ejection fraction （LVEF）was 53%-65% （58.8%-t-2.8%）. All the patients underwent mitral valvuloplasty. We measured the neighboring normal chordae with a caliper for reference and constructed the artificial chordal loops on the caliper with expended polytetrafluoroethylene （ePTFE） CV4 Gore-Tex suture lines. Three to five loops were made and fixed to the papillary muscle with a Gore-Tex suture line and the free edge of the prolapsed anterior mitral leaflet with another Gore-Tex suture line, with the intervals between the loops of 5 mm. Left ventricular water testing was performed to evaluate MR status, annuloplasty ring implantation or ＂edge to edge＂ technique was used if nece- ssary, and left ventricular water testing was performed again to confirm satisfactory closure of the mitral valve. Patients received re-warming on cardiopulmonary bypass and the heart incision was closed. The effect of mitral annuloplasty was also assessed by transesophageal echocardiography （ TEE ） after heart rebeating. Warfarin anticoagulation was routinely used for 3 months after discharge. Results There was no perioperative death in this group. Twelve patients received satisfactory out- comes after 1-stage mitral valvuloplasty with looped artificial chordae and annuloplasty ring implantation. One patient didn＇t receive satisfactory outcomes in the left ventricular water testing after mitral valvuloplasty with looped artificial chordae, but satisfactory outcome was achieve after ＂edge to edge＂ technique was used, and annuloplasty ring was not used for this patient. Postoperative echocardiography showed trivial to mild MR in all the patients, their LVEDD was significantly reduced than preoperative LVEDD （47.5 ±2.1 mm vs. 58.3 ± 1.7 ram, P （ 0.05 ）, and there was no statistical difference between postoperative and preoperative LVEF（ 58.5%±2.6% vs. 58.8%±2.8%,P〈 0.05 ）. All the patients were followed up for 3-36 （ 19.5 ±3.7 ） months. Echocardiography showed mild MR in 4 patients and none or trivial MR in 9 patients during follow-up. Conclusion Mitral valvuloplasty with looped artificial chordae is an effective surgical technique for the treatment of ante- rior mitral leaflet prolapse with satisfactory clinical outcomes, and this technique is also easy to perform.