动脉导管未闭合并二尖瓣返流的治疗策略

Treatment strategy of patent ductus arteriosus with mitral regurgitation

目的 总结治疗动脉导管未闭合并二尖瓣关闭不全的临床经验.方法 分析41例动脉导管未闭合并二尖瓣关闭不全患者的临床资料,男性23例,女性18例,年龄1~52（9.5±10.7）岁.术前超声心动图提示动脉导管直径3~11（6.84±2.10）mm,合并二尖瓣返流,10例为轻度返流、16例中度返流、15例重度返流.37例患者的二尖瓣未进行处理,其中16例通过左胸侧后切口结扎动脉导管,21例单纯行介入封堵;2例患者因同时伴有重度三尖瓣返流而在体外循环下同期施行了三尖瓣成形术;2例合并重度二尖瓣关闭不全一般情况较差的患者,首先一期行PDA封堵术,封堵术后2周体外循环下1例行二尖瓣置换,1例行二尖瓣成形术.结果 围术期无死亡,PDA术后均无残余分流.3例术前有反复肺部感染的患者术后呼吸机辅助时间2~5d后顺利脱机,其余患者均恢复顺利.患者出院后门诊随访,术后1周、1个月、3个月复查瓣膜返流情况.单纯处理PDA的患者（共37例）,术后1周心彩超提示与术前比较二尖瓣返流均明显减少;术后3个月与术后1个月比,二尖瓣返流略有减少.术后3个月时二尖瓣无返流19例,轻度返流13例,中度返流5例,无重度返流病例;行体外循环手术者术后均恢复良好,2例一期手术者术后二尖瓣返流为轻度以下,分期行成形者术后二尖瓣返流为轻中度.结论 对动脉导管未闭合并功能性二尖瓣关闭不全患者,采取单纯PDA结扎或者封堵,可有效减轻心脏负担,改善二尖瓣返流状况.对于一般情况较重不能耐受一期手术的患者,可行分期手术,一期先行PDA封堵术,缓解二尖瓣返流和肺动脉高压情况,可有效降低二期二尖瓣手术的风险.

Objective To share the experience of treatment of patent ductus arteriosus with mitral insuf-ficiency. Methods Analysis 41 patients clinical data with patent ductus arteriosus and mitral regurgitation（23 men, 18 women, aged between 1 to 52 years old）. Echocardiography before operation show that the diameter of ductus arteriosus 3-11 （6.84±2.10）mm, and there were 10 cases of mitral regurgitation with mild reflux, moderate reflux in 16 cases, and severe reflux in 15 cases. Among them there were 37 cases with mitral valve without treat-ment. Of which 16 cases patent ligate ductus arteriosus through left thoracic posterior incision, 21 cases underwent transcatheter closure. 2 patients were accompanied by severe tricuspid regurgitation in cardiopulmonary bypass un-dergoing tricuspid valvuloplasty. 2 patients with severe mitral regurgitation （with poor general condition） underwent PDA occlusion firstly, mitral valve replacement was performed at 2 weeks after surgery at one patient, and another one underwent mitral valve replacement. Results There was no death and no residual shunt after PDA occlusion. 3 cases of patients with recurrent pulmonary infection were successfully offline by using ventilator for 2-5 days after the operation, the other patients recovered smoothly. Patients were followed up after discharge,and reviewed the valve regurgitation 1 week, 1 month, 3 months after operation. Postoperative heart color ultrasound of patients who just treat PDA（37cases） show that mitral regurgitation was significantly decreased at 1 weeks after operation. Mitral regurgitation was slightly reduced at 3 months after surgery compared with the postoperative 1 month. 3 months after operation, there were no regurgitation in mitral valve in 19 cases, mild reflux in 13 cases, moderate reflux in 5 cases, and no severe reflux cases. Patients underwent cardiopulmonary bypass surgery were all recovered well . Mi-tral regurgitation was mild in two patients who underwent one-stage surgery . Conclusion PDA ligation or oc-clusion can effectively reduce the burden of the heart and improve the mitral regurgitation in patients with functional mitral regurgitation. For patients in poor conditions who are not able to tolerate radical operation can do staged opera-tion. The first stage of PDA occlusion, which can reduce the mitral regurgitation and pulmonary hypertension, and can effectively reduce the risk of surgical treatment of mitral valve in stage two.