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心臟瓣膜手術的百年堅持與探索—2023亞洲心臟瓣膜中國論壇紀要

系統性紅斑狼瘡患者行二尖瓣成形術一例

The Effect of Edgetoedge Mitral Valve Plasty on Left Ventricular Diastolic Function

Objective To investigate the effect of edgetoedge mitral valve plasty on left ventricular diastolic function and in order to find the validity and safety of this procedure. Methods From Feb. 2006 to Dec. 2007, thirty cases with mitral regurgitation were divided into two groups. Quadrangular resection was performed on fifteen cases with posterior proplapse in control group, and edgetoedge mitral valve plasty was performed on fifteen cases with anterior or bileaflet proplapse in experimental group, and ring annuloplasty(Medtronic ring) was used in both groups. The hemodynamics were monitored and recorded with SwanGanz catheter at the time of postoperation，2 h, 4 h, 6 h and 12 h after operation. Left ventricular diastolic function was also evaluated with echocardiography using color Doppler and tissue Doppler imaging in the patients with sinus rhythm. The ratio of the peak E velocity and A velocity(E/A), the ratio of the early diastolic peak flow velocity to the early diastolic mitral valve annular movement velocity(E/Em), and the ratio of early diastolic mitral valve annular movement velocity to late diastolic mitral valve annular movement velocity（Em/Am）were measured before operation and 1 week after operation respectively. Results Mitralvalve area were significantly reduced at 1 week after operation compared with that before operation in both groups (control group 3.63±1.06 cm2 vs. 7.18±2.41 cm2, experimental group 3.44±1.02 cm2 vs. 6.51±3.06 cm2, Plt;0.05）; and mitral regurgitant grade were significantly reduced at 1 week after operation in both groups as well(control group 0.53±0.64 cm2 vs.3.60±0.51 cm2, experimental group 0.67±0.82 cm2 vs.3.40±0.63 cm2, Plt;0.05). However, there was no significant difference for mitral valve area and mitral regurgitant grade between two groups before and after operation（Pgt;0.05）. In experimental group, there were no significant change of evaluations of E/A,E/Em and Em/Am before and after operation（E/A 1.28±0.36 vs. 1.95±1.06,E/Em 8.79±2.16 vs. 8.13±3.02, Em/Am 1.39±0.38 vs. 1.31±041，Pgt;0.05). There was no significant change of pulmonary artery wedge pressure (PAWP) before and after operation between two groups（13.60±4.37 mm Hg vs.12.20±3.53 mm Hg, Pgt;0.05）. Conclusion Edgetoedge mitral valve plasty technique is available and has no significant influence on left ventricular diastolic function, and a doubleorifice mitral valve has similar hemodynamic change compared with a physiological mitral valve.

Mitral Valvuloplasty for the Treatment of Infective Endocarditis and Mitral Regurgitation

ObjectiveTo investigate clinical outcomes of mitral valvuloplasty (MVP)for the treatment of infective endocarditis (IE)and mitral regurgitation (MR). MethodsFrom March 2002 to January 2012, 33 patients with IE and MR underwent MVP in Fu Wai Hospital. There were 23 male and 10 female patients with their age of 10-67 (35.7±17.8)years. Thirteen patients had previous cardiac anomalies. Preoperatively, there were 5 patients with mild MR, 15 patients with moderate MR and 13 patients with severe MR. There were 5 patients in New York Heart Association (NYHA)functional classⅠ, 23 patients in classⅡ, 4 patients in classⅢ and 1 patient in classⅣ. All the patients received MVP including 14 patients received MVP in active phase of IE. Concomitantly, 6 patients received aortic valve replacement, 5 patients received tricuspid valvuloplasty, 1 patient received coronary artery bypass grafting, 1 patient received resection of left atrial myxoma and 1 patient received repair of aortic sinus aneurysm. Surgical procedures included pericardial patch closure of leaflet perforation in 5 patients, leaflet excision and suturing in 17 patients, double-orifice method in 3 patients, chordae transfer and artificial chordae implantation in 5 patients, and annuloplastic ring implantation in 15 patients. ResultsOne patient died of acute myocardial infarction 7 days after the operation. All other 32 patients were successfully discharged. Echocardiography before discharge showed left ventricular end-diastolic diameter (LVEDD, 48.9±7.6 mm)and left atrial diameter (LAD, 31.7±7.4 mm)were significantly smaller than preoperative values (P=0.000). Thirty-two patients were followed up for 6-125 (73.0±38.6)months. There was no death, IE recurrence, bleeding or thromboembolism during follow-up. One patient received mitral valve replacement for mitral stenosis 3 years after discharge. There were 25 patients in NYHA func-tional classⅠ, 5 patients in classⅡand 2 patients in classⅢ. There were 4 patients with mild MR, 1 patient with moderate MR, and 26 patients had no MR. One patient had faster mitral inflow at diastolic phase (1.7 m/s). One patient had moderate aortic regurgitation. LVEDD and LAD during follow-up were not statistically different from those before discharge. Left ventricular ejection fraction during follow-up was significantly higher than that before discharge (60.9%±6.6% vs. 57.5%±6.7%, P=0.043). ConclusionMVP is a reliable surgical procedure for patients with IE and MR, and can significantly reduce left atrial and left ventricular diameter and improve cardiac function postoperatively.

心臟瓣膜手術后并發溶血性貧血的治療

目的 探討心臟瓣膜手術后并發溶血性貧血的外科治療方法及效果。方法 1998年1月至2007年12月，廣東省人民醫院廣東省心血管病研究所共治療11例心瓣膜手術后并發溶血性貧血患者，男9例，女2例；年齡15~57歲（40±14歲）。風濕性心瓣膜病6例，退行性心瓣膜病2例，先天性心瓣膜病2例，感染性心內膜炎1例。第一次手術：行二尖瓣置換術（MVR）2例，雙瓣膜置換術（DVR）4例，二尖瓣人工瓣環成形術5例。第二次入院血紅蛋白55~92 g/L（76±14 g/L），紅細胞壓積0.19~0.31（0.25±0.04），網織紅細胞百分比0.08~0.17（0.12±0.04），總膽紅素34.70~91.50 μmol/L（56.00±19.10 μmol/L），非結合膽紅素23.40~54.90 μmol/L（38.60±12.30 μmol/L）。所有患者均先給予內科治療，10例患者經內科治療無效后再次行心瓣膜置換術或心瓣膜成形術治療，另1例給予內科保守治療。結果 再次手術治療10例，術后死亡1例，死于溶血性貧血、腎功能衰竭和多器官功能衰竭；其他9例經再次手術治療后痊愈出院，貧血癥狀消失，血常規檢查正常。內科保守治療治愈1例。隨訪10例，隨訪時間2個月至11年，心功能Ⅰ級8例，Ⅱ級2例，無晚期死亡。1例感染性心內膜炎患者出院時仍有輕度腎功能不全，隨訪3個月時腎功能完全恢復正常，隨訪1年心功能良好，無溶血癥狀。 結論 心瓣膜手術后并發溶血性貧血，如經內科治療無效應盡早行再次心瓣膜手術治療，可獲得良好的效果。

Mitral valvoplasty: 112 cases report

Objective To study the clinical results and operative methods of mitral valvoplasty in patients of congenital heart disease with mitral insufficiency. Methods One hundred and twelve patients of congenital heart disease with mitral insufficiency had been treated with valve repair procedure. The surgery was performed under extracorporeal circulation and moderate hypothermia. Most of the patients were diagnosed atrioventricular septal defects (29 cases), ventricular septal defect (25 cases), patent ductus arteriosus (14 cases), and atrial septal defect (14 cases) before operation. The main pathologic characters of mitral valve were mitral valve annular dilatation (58 cases), leaflet lesions (37cases), anterior and posterior leaflet prolapse (36 cases). The surgery consisted of complex methods to repair mitral valves, including rings annuloplasty (22 cases), closure of the commissure (18 cases), double-orifice method (14 cases), chords reimplantation and so on. Results Seventy two patientshad 0 to I class mitral valve regurgitation and 26 patients had Ⅱ class mitral valve regurgitation during the retrial period by echocardiography, only one case needed re-operation. The patients with left ventricular end diastolic diameter (LVEDD) more than 45mm had a reduction of left atrial diameter (from 45.8±10.7mm to 34.4±8.9mm, t=6.53, 7.89,(Plt;)0.001) and left ventricular diameter (from 58.6±10.9 mm to 44.3±8.5 mm, t=7.89, Plt;0.001) after operation. Conclusions Surgical operation on mitral valve regurgitation of congenital heart defect is a benefit and a compound method and transesophageal echocardiography may help the surgeon in estimating the surgical efficacy during operation.

Efficacy Analysis of Valvuloplasty for Anterior Leaflet Prolapse

Abstract： Objective To summarize the experiences and analyze the efficacy of mitral valvuloplasty in treating anterior leaflet prolapse. Methods A total of 152 consecutive nonrheumatic heart disease patients including 96 males and 56 females with anterior leaflet prolapse who underwent mitral valvuloplasty from February 1997 to March 2007 were analyzed retrospectively. The age of these patients ranged from 10 to 73 years old (38.54±17.22 years). There were 119 cases of mitral degenerative prolapse or chordae rupture, 24 of ongenital heart disease, 3 of ischemic mitral insufficiency, and 6 of native valve endocarditis. Echocardiography before operation showed the degree of mitral regurgitation was severe in 19, moderate to severe in 63, and moderate in 70 patients. Among the patients, 87 had anterior prolapse and 65 had bilateral prolapse. All patients underwent mitral valve repair under standard cardiopulmonary bypass. Results During the operation, transesophageal echocardiography and saline injection test showed satisfying results in all the patients. No early death occurred after operation. Followup was done to 135 patients for 3 months to 8.5 years with a followup rate of 88.82%. During the follow up, 93 patients were in New Yoke Heart Association（NYHA）class Ⅰ, 35 in Class Ⅱ, 3 in class Ⅲ and 4 in class Ⅳ. The Echocardiography showed that postoperative left atrium diameter (41.09±10.40 mm vs. 45.32±10.07 mm, t=4.186, P=0.000) and left ventricular enddiastolic dimension (52.04±7.74 mm vs. 60.70±7.72 mm,t=9.676, P=0.000) were significantly smaller than that before operation. No or trace mitral regurgitation (MR) was found in 36 patients, mild MR in 45 patients, mild to moderate MR in 38 patients, moderate MR in 9 patients, and moderate to severe MR in 7 patients. Mitral valve replacement was performed in 5 patients after valvuloplasty. Three died during the follow-up. Two of them died of heart failure and one of unknown cause. Conclusion In spite of the complexity, the longterm results of mitral valve repair for anterior leaflet prolapse are satisfactory if the best surgery method is chosen.

Mitral Valve Repair for Mitral Bileaflet Prolapse

ObjectiveTo conclude the outcomes of mitral valve repair for mitral bileaflet prolapse. MethodsWe retrospectively analyzed the clinical data of 14 patients with mitral bileaflet prolapse in our hospital between June 2010 and March 2013. There were 10 males and 4 females with at age of 46.9±12.0 years. We used one technique in 4 patients, two techniques in 9 patients, three techniques in 1 patient. ResultsMean follow-up time was 13.1±7.2 months. There was no perioperative death. No reoperation occurred. No or trace mitral regurgitation (MR) was found in 13 patients. Slight MR was found in one patient. ConclusionThe early metaphase results of mitral valve repair for mitral bileaflet prolapse are satisfactory if the appropriate surgery method is chosen.

Echocardiographic evaluation of the relationship between pattern of left ventricular dilation and functional mitral regurgitation

Objective To evaluate the relationship between pattern of left ventricular dilation and functional mitral regurgitation (FMR) by echocardiography. Methods A single-center retrospective observational study was conducted on 117 patients with age of 31-77 years and left ventricular end diastolic dimension≥60 mm treated in our hospital from January 2013 through May 2016. These patients were divided into four groups by FMR degree: FMR-None/Trace (FMR-N/T group,n=33), FMR-Minor (FMR-Mi group,n=37), FMR-Moderate (FMR-Mo group,n=34) and FMR-Severe (FMR-Se group,n=13). We analyzed their basic information and echocardiographic parameters including left ventricular dimension, volume, systolic function, spherical index, regional wall motion score index, tenting height and area of mitral vavle as well as anterior/posterior angle. Results The incidences of inferior/posterior/lateral myocardial infarction and basal myocardial dyskinesia/aneurysm increased with the increase of FMR degree (FMR-N/T vs. FMR-Mi vs. FMR-Mo vs. FMR-Se: 12.1% vs. 18.9% vs. 44.1% vs. 46.2%,P=0.001 and 12.1% vs. 27.0% vs.47.1% vs. 53.8%,P=0.005, respectively). The tenting height and area of mitral valve, anterior/posterior angle, regional wall score index of the left ventricle where the papillary muscle was attached to had a positive correlation with FMR degree (P＜0.05). Conclusion There is a relationship between regional left ventricular dilation and FMR. Evaluating and improving those parameters is very important when we choose the treatment strategy of functional mitral regurgitaion.

Leaflet foldoplasty of mitral valvuloplasty for mitral regurgitation in children

ObjectiveTo report the short-term outcomes of a standardized, simplified and reproducible strategy of mitral valvuloplasty (MVP), which was focused on leaflet foldoplasty and anatomic anomalies of congenital mitral regurgitation (MR).MethodsConsecutive 74 patients who underwent MVP by our standardized strategy in our institution from 2016 to 2018 were included retrospectively. There were 30 males and 44 females with a median age of 18.5 (6-146) months and weight of 15.4 (7-51) kg.ResultsAnatomic anomalies of MR included: (1) subvalvular apparatus: 72 (97.3%) patients with mal-connected chordae tendineae, 31 (41.9%) with absent chordae tendineae and 14 (18.9%) with fused or dysplastic papillary muscle; (2) leaflet: 10 (13.5%) patients with cleft of anterior leaflet, 61 (82.4%) with leaflet prolapse including 56 (91.8%) with anterior leaflet prolapse; (3) annulus: 71 (95.9%) patients with annular dilatation. Leaflet foldoplasty was performed in 61 (82.4%) patients with leaflet prolapse. All patients were successfully discharged and 4 (5.4%) patients were with moderate MR. The follow-up time was 22.0 (9.1-41.8) months. During the follow-up period, 3 patients had moderate MR and 1 patient had reoperation for severe MR. All patients were in normal cardiac function with a mean left ventricular ejection fraction of 66.0%±6.1%. In addition, the mean left ventricular end-diastolic dimension was 31.8±6.0 mm, which was significant smaller than that before the operation (t=6.090, P<0.000 1).ConclusionThe standardized leaflet foldoplasty with resection of mal-connected chordae tendineae and posterior annuloplasty technique is safe and feasible with favorable short-term outcomes in MR patients.