二尖瓣成形术后并发机械性溶血的治疗策略

Treatment strategy of mechanical hemolysis after mitral valve repair

目的二尖瓣成形术被广泛应用于先天性及继发性二尖瓣病变的手术治疗中。文中探讨二尖瓣成形术后并发机械性溶血的机制及治疗策略。方法回顾性分析2010年8月至2018年6月解放军南部战区总医院行二尖瓣成形术(含房室管畸形病例)451例患者临床资料。其中16例(3.5%)术后出现机械性溶血(血红蛋白尿、黄疸、贫血),心脏超声检查显示二尖瓣少量返流3例、中量返流9例、大量返流4例,其中12例二尖瓣返流束为高流速(Vmax>4m/s)。根据溶血治疗策略将患者分为2组:再手术组(n=10)确诊溶血后1周内接受再次二尖瓣成形术;保守治疗组(n=6)予以血液透析、输血、利尿、碱化尿液、护肝、口服美托洛尔等对症治疗。所有患者接受随访2～36个月,平均(16.0±7.5)个月,对比患者术后心脏超声结果、溶血症状改善程度、心功能水平等。结果两组术后均无死亡病例。再手术组全部患者症状迅速消退,痊愈出院;保守治疗组4例患者因治疗效果不佳于术后3～11周接受再次手术治疗(行二尖瓣成形1例、二尖瓣机械瓣膜置换3例),术后痊愈出院,另外2例患者长期保守治疗。接受再次手术患者心功能维持在I～II级,复查心脏超声显示二尖瓣微量返流10例,少-中量返流3例,无机械性溶血复发;2例长期保守治疗患者,轻中度贫血,尿胆原1+～2+,二尖瓣返流中量,心功能II级,处于亚临床溶血状态。再手术组患者治疗1周后血红蛋白水平、总胆红素水平、二尖瓣返流量均显著优于保守治疗组,差异有统计学意义(P<0.05);再手术组的再次干预发生情况(0 vs 66.7%)及溶血/亚临床溶血发生情况(0 vs 100%)均显著低于保守治疗组,差异有统计学意义(P<0.05)。结论机械性溶血多发生在二尖瓣成形术后早期,超声可发现具有高剪切力的二尖瓣残余返流,可结合临床血管内溶血症状进行诊断。手术是影响溶血的重要因素。术后出现溶血基本可判定手术失败,应尽早再次行二尖瓣成形手术是最佳选择,保守治疗通常效果不佳。

Objective In recent yaers,mitral valve repair has been widely used in the surgical treatment of congenital and secondary mitral valve lesions. To investigate the mechanism and treatment strategy of mechanical hemolysis after mitral valve repair. Methods A total of 451 consecutive patients registrated in general hospital of southern theatre command who underwent mitral valve repair surgery between August 2010 and June 2018,of whom 16 (3.5%) had complicated mechanical hemolysis(hemoglobinuria, jaundice,anemia),were retrospectively analyzed. Echocardiographic examination showed that there were 3 cases of mild mitral regurgitation( MR),9 cases of moderate MR and 4 cases of severe MR, among which 75% of mitral regurgitation flow were rapid regurgitant jets(Vmax>4m/s). According to the treatment strategy,all cases were divided into two groups:the aggressive reoperation group(n= 10),patients received re-repair procedures within 1 week after hemolysis diagnosis. The conservative treatment group(n=6),patients received symptomatic treatment of hemodialysis,blood transfusion,diuresis,alkalization of urine,liver protection and oral metoprolol et al. All patients were followed up for 2 to 36 months,with an average(16±7.5)months,and the postoperative echocardiographic results, hemolysis symptom improvement and cardiac function were compared. Results No death occurred in the two groups after operation. The symptoms of patients in the aggressive reoperation group receded rapidly and discharged from hospital. 4 patients in the conservative treatment group received reoperation 3~11 weeks after surgery due to poor treatment effect(1 patient underwent re-repair and 3 patients underwent replacement),the other 2 patients received long-term conservative treatment. The cardiac function of the patients undergoing reoperation was maintained at level I^II. Echocardiographic examination showed that mild MR(n=10),mild^moderate MR(n=3),and no recurrence of mechanical hemolysis. Two patients with long-term conservative treatment,mild^moderate anemia, urinogen +^++,moderate MR,cardiac function at level II,were in a subclinical hemolytic state. Conclusion Mechanical hemolysis frequently occurs immediately or soon after mitral valve repair. Hemoglobinuria,jaundice,anemia and postoper echocardiography found the mitral regurgitant flow with high-shear stress,these helpful to the diagnosis. Surgery is an important factor affecting hemolysis. Hemolysis can be a sign of surgical failure,re-repair operation is the best treatment as soon as possible after the hemolysis has been diagnosed.Conservative treatment is not the priority choice.