Ⅲb型缺血性二尖瓣反流外科治疗方式的早期临床效果及中远期疗效比较

Early and Mid-long Term Effects of Surgical Treatment Methods for Type Ⅲb Ischemic Mitral Regurgitation

目的分析二尖瓣成形术或二尖瓣置换术治疗CarpentierⅢb型缺血性二尖瓣反流的临床经验,评估该技术的治疗方法选择和中远期疗效。方法回顾性分析从2000年1月至2014年3月南京市第一医院心血管外科308例冠心病合并Ⅲb型缺血性二尖瓣反流的患者行冠状动脉旁路移植术同期行二尖瓣成形术或二尖瓣置换术患者的临床资料,其中男215例、女93例,年龄30~78(62.7±11.5)岁。按二尖瓣手术方式分为两组:172例行二尖瓣成形术,为二尖瓣成形术组,其中限制性瓣环成形术170例(全环128例,C形环42例),交界环缩术2例;136例行二尖瓣置换术,为二尖瓣置换术组,其中置换机械瓣11例,生物瓣125例。结果所有患者主动脉阻断时间(81.9±21.5)min。体外循环时间(122.0±31.3)min。全组围术期死亡6例(1.9%)。两组术中主动脉阻断时间、体外循环时间、移植血管支数及左乳内动脉使用率差异无统计学意义(P>0.05)。术后早期结果显示,二尖瓣置换术组的术后低心排血量综合征、室性心律失常发生率高于二尖瓣成形术组(P<0.05)。术后随访1~85个月。两组中远期疗效中的生存率差异无统计学意义(P>0.05),二尖瓣置换术组二尖瓣反流程度和再次换瓣手术率均低于二尖瓣成形术组(P<0.05)。结论 CarpentierⅢb型缺血性二尖瓣反流患者行二尖瓣成形术的近期疗效较瓣膜置换术好,中远期随访发现保留瓣下装置的二尖瓣置换术有较低的瓣膜相关并发症发生率。

Objective To summarize the clinical experience in the treatment of Carpentier's type Ⅲb ischemic mitral regurgitation through the mitral valve repair versus mitral valve replacement,and to evaluate the early and midlong term effects.Methods We retrospectively analyzed the clinical data of 308 consecutive patients with type Ⅲb ischemic mitral regurgitation undergoing coronary artery bypass grafting(CABG) with mitral valve repair(a repair group,n=172) or with mitral valve replacement(a replacement group,n=136) in our hospital between January 2000 and March 2014.Among the 308 patients,215 were males and 93 were females with mean age of 62.7±11.5 years(ranged30-78 years).In the repair group,170 patients underwent restrictive mitral annuloplasty(128 patients with total ring,42 patients with C ring),and 2 patients underwent commissural constriction.In the replacement group,11 patients underwent mechanical valve prosthesis and 125 patients underwent biological valve prosthesis.Results The time of total aortic cross-clamp was 81.9±21.5 min.The time of total extracorporeal circulation was 122.0±31.3 min.Six patients died during the perioperative period.No significant differences were observed between the two groups in general information(P>0.05).There were no significant differences between the two groups in aortic cross-clamp time,total extracorporeal circulation time,numbers of bypass grafts and the usage rate of left internal mammary artery.The early result after the surgery showed that the incidence rates of low cardiac output and ventricular arrhythmia were significantly higher in the replacement group compared with those in the repair group.The patients were followed up for 1-85 months.No significant difference was revealed in the mid-long term survival rate between the two groups.The severity of mitral regurgitation and the rate of redo mitral valve replacement were significantly lower in the replacement group compared with those in the repair group(P<0.05).Conclusion The early-term curative effect of valve repair is better than valve replacement for the treatment of Carpentier's type Ⅲb ischemic mitral regurgitation.In mid-long term,Chordal-sparing mitral valve replacement remains a low incidence of valve-related complications compared with mitral valve repair.