冠心病合并左室室壁瘤的外科治疗

Surgical treatment of coronary heart disease combined with left ventricular wall tumor

目的总结冠心病合并左心室室壁瘤(LVA)的外科治疗经验。方法 2005年10月至2015年6月,61例冠心病合并左心室室壁瘤的患者,在全麻低温体外循环下行冠状动脉旁路移植加左室室壁瘤切除术。平均搭桥3.4±0.9支,其中全动脉化搭桥21例。室壁瘤切除方法:行闭式折叠缝合术4例,标准线性修补术53例,心室内补片成形术4例。同期行左房血栓清除术8例、二尖瓣成形术4例、二尖瓣置换术46例、室间隔穿孔修补术1例、三尖瓣成形1例、房间隔缺损修补术1例、房间隔折叠术1例。结果术后1个月内死亡3例,2例死于多脏器功能衰竭,1例死于低心排、肺感染。术后并发症:消化道出血1例,低心排4例,室性心律失常1例,呈短阵室速,行ICD植入,肺部感染3例,切口延期愈合3例。41例随访1~5年,随访率67%,其中心功能Ⅲ级者3例,Ⅱ级18例,Ⅰ级20例。左心室舒张末期内径从术前58.7±9.6mm缩小到术后52.1±8.6mm,差异有统计学意义(P<0.05);心脏射血分数平均0.45±0.06,较术前(0.36±0.08)显著提高,差异有统计学意义(P<0.05)。结论冠心病合并左室室壁瘤的病人在体外循环下行冠状动脉旁路移植加左室室壁瘤切除可以取得满意的疗效。完善的心肌保护措施、充分的心肌再血管化及适宜的左室成型方法是手术成功的关键。术前心功能差、巨大室壁瘤是手术的高危因素。

Objective To summarize the surgical treatment experience of coronary heart disease with left ventricular aneurysm( LVA). Methods From October 2005 to June 2015,61 patients with coronary heart disease combined with left ventricular aneurysm were treated with coronary artery bypass graft and left ventricular aneurysm resection. The average bypass was 3. 4 plus or minus 0. 9,of which 21 were all arterialized. 4 cases of closed folding suture,53 cases of standard linear repair,and 4 cases of cardiac repair. Line during the same period left atrial thrombus removal of 8 cases,4 cases of PM,46 cases of mitral valve replacement and repair of ventricular septal perforation in 1 case,1 case of tricuspid valve forming,repair of atrial septal defects( 1 case,fold the interatrial septum surgery in 1 case. Results 3 patients died within 1 month after surgery,2 died from multiple organ failure,and 1 died from low heart rate and lung infection. Postoperative complications: 1 case of digestive tract bleeding,4 cases with low heart rate,1 case of ventricular arrhythmia,and 3 cases of pulmonary infection,3 cases of pulmonary infection and 3 cases of delayed wound healing. 41 cases were followed up for 1 ~ 5 years,the follow-up rate was 67%,including cardiac function Ⅲ level 3 cases,Ⅱ 18 cases,20 cases I level. The left ventricular diastolic inner diameter was 58. 7-9. 6 mm narrowed to 52. 1 + 8. 6 mm,the difference is significant( P<0. 05);Cardiac ejection fraction average 0. 45 + 0. 06, preoperative( 0. 36 + 0. 08) significantly improved, P < 0. 05. Conclusion The patients with coronary heart disease combined with left ventricular aneurysm can obtain satisfactory curative effect on coronary artery bypass grafting with left ventricular aneurysm. Complete myocardial protective measures, adequate cardiac revascularization and appropriate left ventricular forming method are the key to successful operation. Preoperative cardiac dysfunction and large ventricular aneurysm are the risk factors for surgery.