二尖瓣关闭不全合并巨大左心室外科治疗效果

Study of surgical treatment for mitral regurgitation associated with dilated left ventricle

目的报道原发性二尖瓣关闭不全合并巨大左心室患者外科术后随访结果。方法自2000年1月至2012年12月,本院共对55例慢性二尖瓣关闭不全合并巨大左心室患者进行了二尖瓣手术,其中男性35例,女性20例,年龄8～62（40.5±15.1）岁。病例入选标准：术前诊断为中、重度二尖瓣关闭不全合并左心室舒张末期内径（LVDD）≥65 mm者。该组患者中病因为风湿性19例（占34.5%）,其中2例合并轻度二尖瓣狭窄,退行性变23例（占41.8%）,先天性12例（占21.8%）,感染性1例（占1.9%）。术前心功能分级：NYHAⅡ级17例,NYHAⅢ级34例,NYHAⅣ级4例。胸部X线片C/T示：（0.71±0.16）。病程0.3～38（19.5±11.3）年。心电图显示心房颤动者33例（占60%）。超声心动图（UCG）示患者均为中度或重度二尖瓣关闭不全合并巨大左心室,左室舒张末期内径（LVEDD）为65.0～91.0（71.6±5.5）mm,左室收缩末期内径（LVESD）为45.6～75.2（54.6±5.6）mm,左心室舒张末容积指数（LVEDDI）为28.8～68.3（42.5±7.5）mm/m2,左心室舒张末期容积（LVEDSI）为21.8～50.0（32.4±6.3）mm/m2;左心房内径（LAD）为43.0～110.0（67.9±15.7）mm;射血分数（EF）为30.0%～79.0%（59.5±10.1）%;室间隔厚度为6～13（10.0±1.5）mm。结果全组55例患者中,围术期死亡2例,病死率为3.63%,术后2周UCG示LVDD减小为（58.1±7.6）mm,与术前相比P〈0.01。随访至2012年12月,38例患者得到随访,占总数的71.69%,平均随访时间为19～179（98.41±50.29）个月,至今存活患者33例（86.84%）,其中10例患者心功能I级,20例患者心功能Ⅱ级,2例患者心脏功能Ⅲ级,1例心功能Ⅳ级。随访期间死亡5例,随访总病死率为13.15%,失访15例,失访率为28.3%。因心脏原因死亡者3例,占死亡人数的60.0%。死亡主要原因为慢性心功能不全。非心脏原因死亡的疾病为尿毒症及脑出血。存活患者LVDD进一步减小达（50.0±7.8）mm,与术后围术期LVDD相比有明显缩小（P〈0.001）。结论对于二尖瓣关闭不全合并巨大左心室患者,二尖瓣手术是改善患者左心室功能并使左心室进一步缩小的有效治疗。

Objective To report the surgical outcome of mitral valve surgery for isolated chronic mitral insufficiency with severely dilated left ventricle（ LV）. Methods Between January 2000 and December 2012,55 patients（ 35 male and 20 female） with a mean age of（ 40. 5±15. 1） years,underwent MVR or MVP at PLA general Hospital. Rheumatic MR was found in 19 cases（ 34.5%）,congenital MR in 12 cases（ 21. 8%） and infectious MR in 1 cases（ 1. 9%）. 17 patients were in NYHA functional class II,34 in class Ⅲ and 4 in class Ⅳ. The C / T ratio was 0. 71±0. 16 on chest x-ray. The clinical course was 0. 3-38（ 19. 5±11. 3） years. Electrocardiogram（ ECG） showed 33 patients（ 60%） had atrial fibrillation. Echocardiogram（ UCG） showed severe or moderate MR and LV hypertrophy in all patients. LVDD was： 65. 0-91. 0（ 71. 6±5. 5） mm; Left ventricular end-systolic dimension（ LVESD） was 45.6-75. 2（ 54. 6±5. 6） mm; Left ventricular end-diastolic volume index（ LVEDDI） was 28. 8-68. 3（ 42. 5 ±7. 5） mm / m2; Left ventricular end-diastolic volume index（ LVEDVI） was 21. 8-50. 0（ 32. 4±6. 3） mm / m2; Left atrial diameter was 43. 0-110. 0（ 67. 9±15. 7） mm; Ejective fraction was 30. 0%-79. 0%（ 59. 5±10. 1） %; Interventricular septum was 6-13（ 10. 0 ±1. 5） mm. Results Two of 55 cases died in the peri- operative period（ 3. 63 %）. Two weeks after surgery the UCG showed a reduction of left ventricle diastole diameter（ LVEDD） from（ 71. 6±5. 5） to（ 58. 1±7. 6） mm（ P〈0. 001）. A total of 38 cases（ 71. 69%） were successful followed. In themean follow- up of 19- 179（ 98. 41 ± 50. 29） months,33 patients（ 86. 4 %） survived,with 10 patients in NYHAclass I,20 in class II,2 in class III,and 1 in class IV. 5 deaths（ 13. 15%） were noted during the follow-up,including 3（ 60%）cardiac death. The non-cardiac deathsincludeduremia and cerebral hemorrhage. The LVEDD further decreased from（ 58. 1 ± 7. 6）to（ 50. 0 ± 7. 8） mm after discharge（ P〈0. 001）. Conclusion Mitral valve replacement is indicated in patients with mitral insufficiency and severely dilated left ventricles,and the intervention has the potential to restore the LV volume.