线圈法人工腱索植入治疗二尖瓣关闭不全的近中期疗效分析

Short-to Mid-term Results of Artifi cial Chordal Loops for the Treatment of Mitral Insuffi ciency Due to Mitral Valve Prolapse

目的 总结线圈法人工腱索植入治疗二尖瓣脱垂导致的瓣膜关闭不全的临床经验。 方法 北京安贞医院心外科2008年1月至2011年8月应用线圈法人工腱索植入治疗二尖瓣关闭不全的患者共22例，男15例、女7例，年龄26～69 （53.1±8.5） 岁。心功能分级（NYHA） Ⅱ级6例，Ⅲ级16例。前叶腱索断裂14例，前叶腱索延长2例，前后叶腱索均有断裂4例，后叶腱索断裂2例。均合并重度以上二尖瓣反流，1例合并三房心，1例合并冠心病。左心室舒张期末内径49～67 （58.1±3.9） mm，射血分数（EF） 58%～69% （61.8%±6.1%），心胸比率0.53±0.16。应用自制的腱索测量器，测量病变腱索邻近正常腱索的长度作为人工腱索的长度，根据瓣叶脱垂的范围，在测量器上制作人工腱索线圈数根，然后将其固定在相应乳头肌和脱垂瓣叶游离缘，常规进行瓣环成形。同期行三房心矫治术1例，冠状动脉旁路移植术1例。所有患者出院后华法林抗凝治疗3个月。 结果 无手术死亡，术后出现血红蛋白尿1例，伤口感染1例，经治疗后均痊愈。出院前超声心动图提示无反流或微量反流1例，微量反流21例。术后左心室舒张期末内径43～53 （48.3±2.1） mm，较术前明显改善。术后门诊随访4～39 （18.3±5.2） 个月，少量反流5例，无或微量反流17例。心功能分级（NYHA） Ⅰ级17例，Ⅱ级5例，较术前明显改善。 结论 线圈法人工腱索植入治疗二尖瓣脱垂所致的二尖瓣关闭不全，手术操作简单易行，近中期疗效满意。

Objective To summarize our clinical experience of artificial chordal replacement with loop technique for the treatment of mitral insufficiency （MI） due to mitral valve prolapse. Methods From January 2008 to August 2011,pre-measured expanded polytetrafluoroethylene （ePTFE） loops were used for the treatment of MI in 22 patients in the Department of Cardiac Surgery,Beijing Anzhen Hospital. There were 15 males and 7 females with their age of 26-69（53.1±8.5） years. Six patients were in NYHA class Ⅱ and 16 patients were in NYHA class Ⅲ. There were 14 patients with anterior mitral leaflet chordal rupture,2 patients with anterior mitral leaflet chordal elongation,4 patients with bothanterior and posterior mitral leaflet chordal rupture,and 2 patients with posterior mitral leaflet chordal rupture. All the patientshad severe MI. One patient had concomitant cor triatriatum,and another patient had coronary heart disease. Left ventricularend-diastolic diameter （LVEDD） was 49-67 （58.1±3.9） mm,ejection fraction （EF） was 58%-69% （61.8±2.1%）,andcardiothoracic ratio was 0.53±0.16. We measured the length of normal chordae adjacent to the ruptured or elongated chordaewith a caliper for reference,and constructed the artificial chordal loops on the caliper with ePTFE suture according to thescope of mitral valve prolapse,then fixed the loops to the corresponding papillary muscles and free edge of the prolapsed mitral leaflets. Ring annuloplasty was routinely performed for all the patients. One patient received concomitant repair for cor triatriatum, and another patients underwent concomitant coronary artery bypass grafting. All the patients received oral anticoagulation with warfarin for 3 months after discharge. Results There was no in-hospital death. Postoperatively,1 patient had hemoglobinuria and another patient had wound infection,both of whom were cured after treatment. Pre-dischargeechocardiography showed mild or no MI in 1 patients and trivial MI in 21 patients. Postoperative LVEDD was 43-53 （48.1±2.1） mm and significantly smaller than preoperative LVEDD. All the patients were follow up for 4-39 （18.3±5.2）months after discharge. During follow-up,there were 5 patients with mild MI and 17 patients with none or trivial MI. Seventeen patients were in NYHA classⅠ,5 patients were in NYHA class Ⅱ,and their heart function was significantly improved than preoperative heart function. Conclusion Artificial chordal replacement with loop technique is easy to perform with satisfactory short-to mid-term results for the treatment of MI due to mitral valve prolapse.