二尖瓣成形术在感染性心内膜炎二尖瓣关闭不全治疗中的应用

Mitral Valvuloplasty for the Treatment of Infective Endocarditis and Mitral Regurgitation

目的评价二尖瓣成形术治疗感染性心内膜炎二尖瓣关闭不全的疗效。方法自2002年3月至2012年1月共有33例感染性心内膜炎二尖瓣关闭不全患者在北京阜外心血管病医院接受二尖瓣成形术,其中男23例、女10例,年龄10～67（35.7±17.8）岁。13例有心脏基础解剖病变。术前二尖瓣轻度反流5例,中度反流15例,重度反流13例。心功能分级（NYHA）Ⅰ级5例,Ⅱ级23,Ⅲ级4例,Ⅳ级1例。所有患者均行二尖瓣成形术,活动期手术14例。同期行主动脉瓣置换术6例,三尖瓣成形术5例,冠状动脉旁路移植术1例,左心房粘液瘤切除术1例,主动脉窦瘤修补术1例。成形方法包括心包修补穿孔5例,瓣叶切除缝合17例,双孔法成形3例,腱索转移及人工腱索5例,15例使用人工成形环。结果围术期死亡1例,于术后7 d并发急性心肌梗死死亡。32例存活患者均康复出院。出院前超声心动图提示：左心室舒张期末内径、左心房内径分别为（48.9±7.6）mm及（31.7±7.4）mm,较术前有明显改善（P=0.000）。32例患者完成随访,随访时间6～125（73.0±38.6）个月。随访期间无死亡,无心内膜炎复发及出血栓塞等并发症。1例术后3年因二尖瓣狭窄而行二尖瓣机械瓣置换术。心功能分级（NYHA）Ⅰ级25例,Ⅱ级5例,Ⅲ级2例。二尖瓣有少量反流4例,中量反流1例,无反流26例;舒张期二尖瓣流速偏快（1.7 m/s）1例,主动脉瓣中量反流1例。左心室舒张期末内径及左心房内径与术后早期比较差异无统计学意义,射血分数较术后早期改善（60.9%±6.6%vs.57.5%±6.7%;P=0.043）。结论二尖瓣成形术治疗感染性心内膜炎二尖瓣关闭不全疗效可靠,左心房、左心室内径显著减小,心功能改善明显。

Objective To investigate clinical outcomes of mitral valvuloplasty （MVP） for the treatment of infective endocarditis （IE） and mitral regurgitation （MR）. Methods From March 2002 to January 2012, 33 patients with IE and MR underwent MVP in Fu Wai Hospital. There were 23 male and 10 female patients with their age of 10-67 （35.7±17.8） years. Thirteen patients had previous cardiac anomalies. Preoperatively, there were 5 patients with mild MR, 15 patients with moderate MR and 13 patients with severe MR. There were 5 patients in New York Heart Association （NYHA） functional class I , 23 patients in class II, 4 patients in class HI and 1 patient in class IV. All the patients received MVP including 14 patients received MVP in active phase of IE. Concomitantly, 6 patients received aortic valve replacement, 5 patients received tricuspid valvuloplasty, 1 patient received coronary artery bypass grafting, 1 patient received resection of left atrial myxoma and 1 patient received repair of aortic sinus aneurysm. Surgical procedures included pericardial patch closure of leaflet perforation in 5 patients, leaflet excision and suturing in 17 patients, double-orifice method in 3 patients, chordae transfer and artificial chordae implantation in 5 patients, and annuloplastic ring implantation in 15 patients. Results One patient died of acute myocardial infarction 7 days after the operation. All other 32 patients were successfully discharged. Echocar- diography before discharge showed left ventricular end-diastolic diameter （LVEDD, 48.9±7.6 mm） and left atrial diameter （LAD, 31.7 ± 7.4 mm） were significantly smaller than preoperative values （P=-0.000）. Thirty-two patients were followed up for 6-125 （73.0±38.6） months. There was no death, IE recurrence, bleeding or thromboembolism during follow-up. One patient received mitral valve replacement for mitral stenosis 3 years after discharge. There were 25 patients in NYHA func- tional class I , 5 patients in class I1 and 2 patients in class HI. There were 4 patients with mild MR, 1 patient with moderate MR, and 26 patients had no MR. One patient had faster mitral inflow at diastolic phase （ 1.7 m/s ）. One patient had moderate aortic regurgitation. LVEDD and LAD during follow-up were not statistically different from those before discharge. Left ventricular ejection fraction during follow-up was significantly higher than that before discharge （60.9%± 6.6% vs. 57.5%±6.7%, P=0.043）. Conclusion MVP is a reliable surgical procedure for patients with IE and MR, and can significantly reduce left atrial and left ventricular diameter and improve cardiac function postoperatively.