全保留二尖瓣及瓣下结构在重症二尖瓣关闭不全患者二尖瓣置换术中的应用

Bileaflet Preservation in Mitral Valve Replacement for Patients with Severe Mitral Regurgitation

目的探讨全保留二尖瓣及瓣下结构在重症二尖瓣关闭不全患者二尖瓣置换术中的应用经验,评价其临床效果。方法回顾性分析2011年6月至2013年1月在广东省人民医院心血管外科因重症二尖瓣关闭不全行全保留二尖瓣及瓣下结构二尖瓣置换术17例患者的临床资料,其中男14例,女3例;年龄38~82（63.41±11.82）岁;合并心房颤动13例;术前纽约心脏学会（NYHA）心功能分级Ⅲ级5例,Ⅳ级12例;缺血性二尖瓣关闭不全7例,退行性二尖瓣关闭不全9例,风湿性二尖瓣关闭不全1例。结果所有患者均行全保留二尖瓣及瓣下结构的二尖瓣置换术,同期行冠状动脉旁路移植术4例;其中生物瓣11例,机械瓣6例。全组患者住院期间无死亡,均顺利出院,住院期间未并发低心排血量综合征,无左心室破裂。17例患者均随访,随访时间2~25（16.44±5.02）个月。随访期间1例患者因术后2个月发生二尖瓣重度瓣周漏死亡。其余患者人工二尖瓣功能良好,无抗凝和瓣膜引起的并发症,心功能较术前明显改善,心功能NYHA分级恢复至Ⅰ级11例,Ⅱ级4例,Ⅲ级1例。术后早期及随访期间心胸比率、左心房内径、左心室舒张期末内径及收缩期末内径与术前相比均明显减小。而术后早期左心室射血分数（LVEF）与术前相比有所降低[（50.94%±8.78%）vs.（55.31%±10.44%）,P=0.04],术前LVEF与随访期间的差异无统计学意义[（55.31%±10.44%）vs.（56.13%±9.67%）,P=0.73],随访期间LVEF与术后早期相比显著增加[（56.13%±9.67%）vs.（50.94%±8.78%）,P=0.02]。术后早期与随访期间人工二尖瓣压力减半时间（PHT）差异无统计学意义[（95.06±19.00）ms vs.（94.56±19.19）ms,P=0.91]。结论全保留二尖瓣及瓣下结构在重症二尖瓣关闭不全患者二尖瓣置换术中应用安全有效,可以改善左心室重构及术后心功能。

Objective To analyze clinical experience and outcomes of bileaflet preservation in mitral valve replace- ment （MVR） for patients with severe mitral regurgitation （MR）. Metbods We retrospectively analyzed clinical data of 17 patients with severe MR who underwent MVR with bileaflet preservation in the Department of Cardiovascular Surgery of Guangdong General Hospital from June 2011 to January 2013. There were 14 males and 3 females with mean age of 63.41 _ 11.82 years （range, 38 to 82 years ）. There were 13 patients with atrial fibrillation. Preoperatively, 5 patients were in New York Heart Association （NYHA） functional class Ill, and 12 patients were in NYHA class IV. There were 7 patients with ischemic MR, 9 patients with degenerative MR, and 1 patient with rheumatic MR. Results MVR with bileaflet preservation was performed for all the patients. Concomitant coronary artery bypass grafting was performed for 4 patients. Eleven patients received bioprosthetic MVR, and 6 patients received mechanical MVR. There was no in-hospital death,postoperative low cardiac output syndrome or left ventricular rupture. All the 17 patients were followed up for a mean duration of 16.44±5.02 months （range, 2 to 25 months）. During follow-up, 1 patient died of severe paravalvular leak 2 months after surgery. All the other patients had good mitral valve function. None of the patients had anticoagulation or prosthetic valve related complication. Patient＇s heart function was significantly improved. Eleven patients were in NYHA functional class I , 4 patients were in NYHA class H, and 1 patient was in NYHA class III . Cardiothoracic ratio, left atrial dimension, left ventricular end-diastolic dimension and left ventricular end-systole dimension postoperatively and during follow-up were significantly smaller than preoperative values. Postoperative left ventricular ejection fraction （LVEF） was significantly lower than preoperative LVEF （50.94%± 8.78% vs. 55.31% ± 10.44%, P=0.04 ）, but LVEF during follow-up was not statistically different from preoperative LVEF （55.31%±10.44% vs. 56.13%±9.67%, P=0.73）, and LVEF during follow-up was significantly higher than postoperative LVEF （56.13%± 9.67% vs. 50.94%±8.78%,P=0.02）. There was no statistical difference between postoperative mitral pressure half-time （PHT）and PHT during follow-up （95.06±19.00 ms vs. 94.56± 19.19 ms, P=0.91 ）. Conclusion MVR with bileaflet preservation is a safe and effective surgical technique for patients with severe MR, and can significantly improve postoperative left ventricular remodeling and function.