二尖瓣成形术治疗二尖瓣关闭不全的疗效分析

Clinical efficacy of mitral valvuloplasty in treatment of mitral regurgitation

目的分析二尖瓣瓣膜成形术(MVP)治疗中重度二尖瓣关闭不全(MR)患者的临床疗效.方法以2013年6月至2017年6月徐州医科大学附属沭阳医院心胸外科收治的28例行MVP的MR患者为研究对象行回顾性分析,其中男性17例,女性11例;年龄50~72岁,平均(61.5±10.6)岁.所有患者术前均存在中重度MR.术前根据患者的合并症、病变部位的定位和合并腱索断裂与否,评估选择可行的MVP术式及合并手术:所有患者均采用正中切口、体外循环下手术治疗,术中行二尖瓣楔形切除、矩形切除及缘对缘缝合方法修补二尖瓣,合并腱索断裂或腱索冗长的行e-PTFE线人工腱索植入,常规行二尖瓣成型环植入,术中注水观察评估瓣膜成行效果.术中采取的二尖瓣成形方法统计:7例(25.0%)植入1~3根腱索,行二尖瓣矩切除术9例(32.1%),二尖瓣楔形切除术8例(28.6%),二尖瓣缘对缘缝合4例(14.3%),所有患者均置入鞍形二尖瓣成形环.对于合并心房颤动的患者同期行单纯左心耳切除术(LAA),或心房颤动射频消融术(AB)+LAA;合并冠心病,则同期行冠状动脉搭桥术(CABG);合并中度及以上的三尖瓣关闭不全,则同期行三尖瓣成形环植入手术(TVP).1例(3.6%)患者行MVP+CABG,1例(3.6%)行MVP+TVP+LAA;3例(10.7%)行MVP+TVP+AB+LAA;5例(17.9%)行MVP+TVP;18例(64.3%)行单纯MVP.术后予华法林抗凝治疗3~6个月,合并心房颤动者终身抗凝治疗.统计所有患者采取的手术方式,包括合并手术、二尖瓣成形方法;对比患者术前及术后2年的返流、心功能改善情况以及LAD、左心室舒张末内径(LVEDD)、左心室射血分数(LVEF)水平的差异.结果所有患者术前均为中重度返流,术后2年复查心脏彩超:21例(75.0%)无明显二尖瓣返流,6例(21.4%)二尖瓣轻度返流,1例(3.6%)二尖瓣中度返流.且所有患者的心功能较术前均提升1~2级.术前LAD[(49.42±12.58)mm],术后2年LAD[(38.17±9.84)mm],术前LVEDD[(50.91±7.93)mm],术后LVEDD[(44.37±7.42)mm],术后均较术前明显缩小;术前LVEF(51.69±9.71)%,术后LVEF(62.79±8.53)%,术后LVEF较术前明显增加.结论MVP治疗MR安全有效、疗效显著,但远期效果还待进一步研究随访.

Objective To summarize and retrospectively analyze the clinical efficacy of mitral valvuloplasty(MVP)in patients with moderate to severe mitral regurgitation(MR).Methods From June 2013 to June 2017,28 patients with MR who underwent MVP were admitted to the Department of Cardiothoracic Surgery,Shuyang Hospital of Xuzhou Medical University and they were used as study objects to conduct a retrospective case analysis.Among them,there were 17 males and 11 females,aged from 50 to 72(61.5±10.6)years.All patients had obvious clinical symptoms before the operation,and the presence of moderate to severe MR was confirmed by echocardiography.Before surgery,we evaluated and selected feasible MVP surgery and combined surgery according to the patient’s comorbidities,location of the lesion and whether complicated with chordae rupture.All patients were treated with median incision and surgery under cardiopulmonary bypass.During the operation,mitral valve wedge resection,rectangular resection and edge-to-edge suture were used to repair the mitral valve,and the e-PTFE thread artificial tendon was used to repair rupture or lengthy of the chordae.The mitral valve forming ring was implanted routinely,and water was injected during the operation to observe and evaluate the effect of valve formation.By intraoperative mitral valvuloplasty,7 cases(25.0%)were implanted with 1 to 3 chordae,9 cases(32.1%)underwent mitral valve rectangular resection,and 8 cases(28.6%)underwent mitral valve wedge resection,4 cases(14.3%)of mitral valve edge-to-edge suture,and all patients were implanted with saddle-shaped mitral annuloplasty ring.Patients combined with atrial fibrillation underwent simple left atrial appendage resection(LAA)or atrial fibrillation radiofrequency ablation(AB)plus LAA at the same time;for coronary heart disease,coronary artery bypass surgery(CABG)combined with moderate or above for tricuspid regurgitation,tricuspid annuloplasty(TVP)was performed at the same time.1 patient(3.6%)underwent MVP+CABG,1 patient(3.6%)underwent MVP+TVP+LAA,3 patients(10.7%)underwent MVP+TVP+AB+LAA,5 patients(17.9%)underwent MVP+TVP,and 18 cases(64.3%)underwent simple MVP.Warfarin was treated with anticoagulation for 3 to 6 months after operation,and patients with atrial fibrillation were treated with lifelong anticoagulation.Statistics of all patients’surgical methods were conducted,including combined surgical types,mitral valvuloplasty methods,comparison of patients’regurgitation,cardiac function improvement and differences in LAD,LVEDD,and LVEF before and 2 years after surgery.Results All patients had moderate and severe regurgitation before operation.Two years after operation,echocardiography showed that 21 cases(75.0%)had no obvious mitral regurgitation,6 cases(21.4%)had mild mitral regurgitation,and 1 case(3.6%)had moderate mitral regurgitation.The cardiac function of all patients was improved by 1-2 grades.The preoperative LAD[(49.42±12.58)mm],2-year LAD[(38.17±9.84)mm],preoperative LVEDD[(50.91±7.93)mm],postoperative LVEDD[(44.37±7.42)mm],postoperative;preoperative LVEF(51.69±9.71)%,postoperative LVEF(62.79±8.53)%,LVEF increased significantly after operation.Conclusion MVP treatment of MR is safe and effective,but the long-term effect needs further study and follow-up.