心肌梗死后左心室室壁瘤外科治疗254例临床分析

Clinical analysis of surgical treatment of post-infarction left ventricular aneurysm: a series of 254 patients

目的探讨心肌梗死后左心室室壁瘤外科治疗的手术方式及治疗效果。方法回顾性分析1997年1月至2019年12月在南京医科大学附属南京医院心胸血管外科接受手术治疗的连续254例心肌梗死后左心室室壁瘤患者的临床资料。男性183例,女性71例,年龄31~81岁,中位年龄64.6岁。根据患者室壁瘤的大小和范围选择手术方式,73例接受线性缝合(线性缝合组),181例接受心室内补片成形(补片成形组)。记录术前,术后2周、3个月、1年和5年左心室收缩功能、左心室大小和容积的变化。采用Kaplan-Meier法绘制生存曲线,用Log-rank检验比较两组患者生存率。结果254例患者均顺利完成手术,主动脉阻断时间(67±22)min(范围:33~152 min),体外循环时间(92±32)min(范围:44~196 min)。围手术期病死率为3.5%(9/254),其余患者术后心绞痛均缓解。术后5年心功能(纽约心脏病协会分级)Ⅲ~Ⅳ级患者比例由术前的96.1%(244/254)降至9.9%(16/161)。线性缝合组和补片成形组术后1、3、5年累积总体生存率分别为96%、91%、77%和96%、90%、79%,差异无统计学意义(P=0.562)。线性缝合组射血分数由术前的(39±10)%(范围:22%~50%)升至术后1年的(46±6)%(范围:39%~54%),补片成形组由术前的(38±13)%(范围:26%~51%)升至术后1年的(50±6)%(范围:39%~55%)。结论心肌梗死后左心室室壁瘤外科治疗术后效果满意,根据室壁瘤的大小与范围选择线性缝合或心内补片心室成形,均可取得较满意的近远期手术效果。

Objective To examine the efficacy of two surgical procedures on post-infarction left ventricular aneurysm.Methods The clinic data of 254 patients with post-infarction left ventricular aneurysm,who underwent surgical ventricular reconstruction between January 1997 and December 2019 in Department of Cardiovascular Surgery,Nanjing Hospital Affiliated to Nanjing Medical University was analyzed retrospectively.There were 183 males and 71 females aged from 31 to 81 years,with a median age of 64.6 years.Based on the size of the ventricular aneurysm,there were 73 patient received linear reconstruction(linear group)and 181 patients received endoventricular patch plasty technique(patch plasty group).Ejection fraction,left ventricular systolic and end diastolic volume and left ventricular systolic and end diastolic volume index were recorded preoperatively,2-week,3-month,1-year and 5-year after operation.The survival curves were plotted with Kaplan-Meier method and the survival rates were compared by Log-rank test.Results All patients underwent surgery with a mean cardiopulmonay bypass duration of(92±32)minutes(44 to 196 minutes)and aortic cross clamp duration of(67±22)minutes(33 to 152 minutes).There were 9 perioperative deaths with a mortality rate of 3.5%.Angina pectoris of other cases are relief and heart function improved greatly.Five years after operation,the percentage of cardiac function(New Yord Heart Association)classⅢtoⅣpatients decreased from 96.1%(244/254)to 9.9%(16/161).There was no significant difference in survival rate between linear group and patch plasty group at 1-,3-,5-years postoperatively(96%,91%,77%vs.96%,90%,79%,P=0.562).Ejection fraction increased from(39±10)%(range:22%to 50%)preoperatively to(46±6)%(range:39%to 54%)1-year postoperatively in the linear group,while increased from(38±13)%(range:26%to 51%)preoperatively to(50±6)%(range:39%to 55%)in the patch plasty group.Conclusions Left ventricular reconstruction is quite effective for patients with post-infarction left ventricular aneurysm.The choice of operative approaches is determined by the size and range of ventricular aneurysm.Both linear reconstruction and endoventricular patch plasty technique can got similarly surgical outcomes with near and late curative effect.