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二尖瓣置換同期射頻消融術后延遲左心室破裂一例

直視雙極射頻消融損傷右冠狀動脈主干合并左心室后壁破裂一例

Clinical Outcomes of Preservation of Posterior Leaflet and Subvalvular Structures in Mitral Valve Replacement

Abstract： Objective To summarize our experience and clinical outcomes of preservation of posterior leaflet and subvalvular structures in mitral valve replacement（MVR）. Methods We retrospectively analyzed the clinical data of 1 035 patients who underwent MVR in Beijing An Zhen Hospital from January 2006 to March 2011. There were 562 male patients and 473 female patients with their age of 37-78（53.84±13.13）years old. There were 712 patients with rheumatic valvular heart disease and 323 patients with degenerative valve disease, 389 patients with mitral stenosis and 646 patients with mitral regurgitation. No patient had coronary artery disease in this group. For 457 patients in non-preservation group, bothleaflets and corresponding chordal excision was performed, while for 578 patients in preservation group, posterior leafletand subvalvular structures were preserved. There was no statistical difference in demographic and preoperative clinical characteristics between the two groups. Postoperative mortality and morbidity, and left ventricular size and function were compared between the two groups. Results There was no statistical difference in postoperative mortality（2.63% vs. 1.21%, P =0.091）and morbidity （8.53% vs. 7.44%, P=0.519）between the non-preservation group and preservation group, except that the rate of left ventricular rupture of non-preservation group was significantly higher than that of preservation group（1.09% vs. 0.00%, P=0.012）. The average left ventricular end-diastolic dimension （LVEDD）measured by echocardiography 6 months after surgery decreased in both groups, but there was no statistical difference between the two groups. The average left ventricular ejection fraction (LVEF) 6 months after surgery was significantly improved compared with preoperative average LVEF in both groups. The average LVEF 6 months after surgery in patients with mitral regurgitation in the preservation group was significantly higher than that in non-preservation group （56.00%±3.47% vs. 53.00%±3.13%，P =0.000）, and there was no statistical difference in the average LVEF 6 months after surgery in patients with mitral stenosis between the two groups（57.00%±5.58% vs. 56.00%±4.79%，P =0.066）. Conclusion Preservation of posterior leaflet and subvalvular structures in MVR is a safe and effective surgical technique to reduce the risk of left ventricle rupture and improve postoperative left ventricular function．

二尖瓣置換術后左心室破裂的防治方法

摘要： 目的 探討二尖瓣置換術后發生左心室破裂的預防及處理方法，總結治療經驗。 方法 1998年1月至2007年12月第二軍醫大學長海醫院救治7例二尖瓣置換術后發生左心室破裂患者，男2例，女5例；年齡49～72歲（60.0±8.4歲）。術中發生左心室破裂3例，其中1例予以心外修補，2例予以心內、心外聯合修補；術后發生左心室破裂4例，立即床旁開胸，在ICU內行心外修補2例；重返手術室1例；放棄救治1例。 結果 圍術期死亡5例（71.43％），其中1例術后發生低心排血量綜合征和腎功能衰竭，術后3 d死亡；術后發生左心室破裂的3例均未搶救成功而死亡，另1例放棄救治死亡。生存的2例患者采用主動脈內球囊反搏分別支持6 d和8 d，出院前超聲心動圖提示：左室后壁運動幅度減小。隨訪2例，隨訪時間分別為2年和6年，均生存，心功能Ⅰ~Ⅱ級，無假性室壁瘤形成。 結論  左心室破裂的預防至關重要，應在體外循環心臟停搏下修復裂口，術后主動脈內球囊反搏支持有助于提高救治的成功率。

二尖瓣置換術后左心室破裂的原因分析

目的 探討二尖瓣置換術（MVR）后發生左心室破裂的原因，以明確MVR術后除了手術操作引起左心室破裂外，尚有左心室自發性破裂的因素存在。 方法 10例二尖瓣病變患者在MVR后發生左心室破裂，立即檢查破裂口局部情況改變，并在體外循環下行二次手術修補破裂口。根據正常心動周期中心肌運動時幾何形態改變及切除二尖瓣后破壞了左心室縱向環完整性的論點，結合10例患者MVR術后發生左心室破裂心臟局部病變情況，分析心臟破裂的原因。 結果 術中所見10例MVR患者術后發生左心室破裂的部位均在左心室后壁瓣環下方0.3~1.0 cm處，而不在人工瓣膜植入的瓣環處。 因修補心臟破裂口無效，出血導致失血性休克或心臟壓塞死亡9例。 對1例生存患者進行了隨訪，隨訪時間1個月，患者無臨床癥狀，心功能Ⅱ級，超聲心動圖提示：人工瓣膜功能良好，未見瓣周漏。 結論 MVR后發生左心室破裂的原因與左心室心肌運動幾何形態學發生改變，以及局部解剖結構有密切關系。