经心尖途径介入治疗复杂二尖瓣瓣周漏的疗效评价：附7例报道

Evaluation of the therapeutic effect of interventional therapy of paravalvular leakage （PVL） after mitral and aortic valve replacement-7cases

目的评价经心尖途径介入治疗复杂二尖瓣瓣周漏的临床疗效。方法2014年1月至2016年12月，对7例双瓣机械瓣置换术后二尖瓣瓣周漏的患者行经心尖途径介入封堵治疗。其中男5例，女2例，年龄42～64（51．3±7．1）岁，既往有感染性心内膜炎病史5例。术前心功能Ⅲ级3例，Ⅳ级4例，距离初次手术时间6．5—8（3．6±3．1）年，二尖瓣反流量9．5～23．1（13．3±4．7）ml。手术采用全麻经左侧第6肋间小切口方法，在杂交手术室内完成。评价患者的围手术期死亡率、并发症、心功能改善、有无溶血以及术后残余二尖瓣反流等指标。结果全组手术成功率100％。总体手术时间90—300（145．7±71．8）min，其中DSA照射时间6～25（12．1±6．5）min，住院时间5—12（10．2±3．5）d。术后主要并发症包括咯血1例，血尿和急性肾功能衰竭1例，输血2例，输血量分别为1200ml和3290ml。术后出院前患者心功能均有不同程度改善，二尖瓣反流量减少至0—1．0（0．43±0．45）ml（P〈0．05），患者生存良好，未出现严重并发症。结论经心尖途径介入治疗复杂二尖瓣瓣周漏具有无需体外循环及心脏停跳，创伤小、住院时间短、DSA时间短、术后恢复快，治疗费用低等优点，对于复杂二尖瓣瓣周漏治疗具有明显优势。但这种方式操作难度大，适应证把握要严格，需要术者熟练掌握外科及经导管介入技术，通过个性化选择封堵器、早期治疗溶血等并发症等方法能够提高此类疾病的治疗成功率及长期效果。

Objective To evaluate the efficacy of interventional therapy via apical approach in complex mitral valve paravalvular leakage （PVL）. Methods From January 2014 to December 2016, interventional therapy by apical approach was used in 7 patients with mitral valve PVL after mechanical valve re- placement. There were 5 male and 2 female with mean age of 42 - 64 （51.3±7.1 ） years. Six patients had a history of previous infective endoearditis. There were 3 cases of NYHA heart function = Ⅲ, and 4 cases =Ⅳ. The period of time between interventional therapy and previous operation was 6. 5 - 8 （ 3.6±5.1 ） years, with mitral regurgitation volume ： 9. 5 - 23.1 （ 13.3±4. 7 ） ml. Interventional therapy of small incision meth- od via the left sixth intercostal was carried out in the catheterization laboratory or the hybrid operation room with the patient under general anesthesia. Follow-up evaluation included peri-operational mortality, complications, improvement of cardiac function, hemolysis and postoperative residual mitral regurgitation. Results The success rate of total operati（m was 100%. The average operation time was 90 - 300 （ 145.7±71.8 ） rain, anti the DSA radiation time was 6 -25（ 12. 1±6. 5 ）rain, with average hospitalization time nf5 - 12 （ 10. 2±3.5 ）d. The main post-operative complications included 1 ease of hemoptysis, I ease of hematuria anti acute renal failure, and 2 eases of blood transfusion, with blood transfusion volume of 1 200 ml and 3 290 ml, respectively. During the follow-up, there was no death. Mitral regurgitation volume decreased to 0 - 1.0（0. 43±0.45 ） ml （ P 〈 0. 05 All patients had improved heart function in different degree and no serious complications. Conclusions lnlerventional therapy via apical approach in complex milral valve PVL has the advantages of being a simpler and safer approach, less trauma, shorter time of hospitalization, faster post-operative reeovery and lower treatment cost. Its disadvantages are high difficult operation, strict indications and high technical requirements for the surgeon. By improving operation skills, choosing individualized occluders and treatment of early hemolytic complications, the success rate and long-term effect of interventional therapy can get further improved.