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1、542例二尖瓣成形临床疗效及随访结果分析,中国医学科学院 阜外心血管病医院成人中心 许建屏,背景,二尖瓣成形手术优点 避免长期抗凝 保护左心功能 减少心内膜炎风险 降低术后栓塞、溶血等换瓣风险,临床资料,阜外医院1996.102008.7542例MVP 男性 359 例；女性 183 例年龄 783（42.6）岁病种分类,临床资料,术前超声二尖瓣返流量,临床资料,术前超声左心房内径 左心室舒张期末径 EF49.5213.50mm 59.218.05mm 62.3110.06 ,临床资料,术前心功能( NYHA),手术方法,CPB 正中开胸 房间隔径路 瓣膜病变单纯前叶病变 144例单纯后叶病变
2、 290例前叶后叶病变 108例,手术方法,手术方法,平均体外循环时间97.8237.92 min 平均主动脉阻断时间 66.9332.14 min 术中检测二尖瓣瓣口注水试验食道超声,手术方法,TVP,CABG,AVP,结果 并发症,结果,术后早期死亡2例术后低心排 1例顽固室颤 1例 随访 504 例 3月11年（平均37月） 晚期死亡 4 例心律失常 2 例 脑血管意外 1 例原因不明 1 例,结果,术后行MVR 5例3例术后3年1例术后4年1例4个月 发生溶血 1例2个月后再次手术成形,结果,术后NYHA 分级,结果,二尖瓣反流,结果,UCG 结果比较,左心房内径 左心室舒张期末径 E
3、F,49.5213.50mm,59.218.05mm,62.3110.06 ,38.215.22mm,49.837.21mm,57.087.09,术前,术后,值,0.05,0.05,0.05,讨论,退行性瓣膜病 95可实行MVP 本组病例 退行性变比例80% 病变区域 多为局部腱索断裂或过长合并瓣环扩大比例较高（12%）,讨论,经典成形技术楔/矩形切除瓣环折叠术,讨论,经典技术人工环,2006.7-2008.7人工环（175例）73%,讨论,经典成形技术楔形切除 瓣环环缩 人工成形环 技术易掌握 成形效果好 大多数患者采用88 （477例）,讨论,Edge to edge 辅助成形,A2-P2
4、,讨论,Edge-to-edge,交界缝合,讨论,本组中应用 “缘对缘” 技术共计108例 7例术中食道超声 少量反流 术后二尖瓣瓣口流速 1.140.28m/s压差 4.763.07mmHg 二尖瓣均无明显狭窄 合并前叶病变的主要辅助成形技术,讨论,腱索转移 腱索缩短,讨论,本组 单纯前叶病变 前、后叶病变 腱索缩短技术10例腱索转移13例 超声结果：中量反流 2例 少中量反流 2例 国外文献：腱索缩短 失败率最高11.5%腱索转移技术效果良好5年免除再手术率96%,讨论,人工腱索,国外文献报道应用GORE-TEX 腱索 15年随访免于再手术率 92，反流无再发 85,讨论,先天性二尖瓣发育
5、异常瓣叶裂,讨论,先天性二尖瓣发育异常,后瓣异常,瓣环过度增生,讨论,先天性二尖瓣发育不良,双孔二尖瓣,降落伞状二尖瓣,讨论,先天性二尖瓣发育异常畸形复杂手术无定式多种手术成形方法的组合根据病变部位、程度灵活 选用,前乳头肌缺如,讨论,风湿性二尖瓣病变 手术难度大 严格把握手术适应症 75的RHD 病例可成形 本组24例 瓣叶改变轻2例少中量反流无再次手术换瓣,讨论,国内文献报道闭式扩张术后再手术年限12.56.7年，再狭窄率1035球囊扩张术结果与闭扩结果相近似直视下对瓣叶质地较软，无显著卷曲，融合二尖瓣成形应有良好的效果,结论,经典成形方法适用于大多数病例，效果好 复杂先天性二尖瓣发育不良
6、病例多种组合 灵活运用 风心病成形 严格把握适应症不拘泥于成法，不执着于成形,谢谢,Outcome of 542 cases Mitral Valve Repair,Chinese academy of medical sciences FuWai hospital Xu JianPing,Preface,Advantage of MVP Avoid long time anticoagulation Protect the function of left ventricular Decrease the risk of SBE Lower the risk of embolism and
7、hemolysis postoperatiom,Material and method,FuWai hospital 1996.102008.7542cases MVP male 359 ；female 183Age 7Ms-83(42.6)YsAetiology,Meterial,Degree of MI in UCG Preoperation,Material,UCG preoperationLA LVED EF49.5213.50mm 59.218.05mm 62.3110.06 ,Material,NYHA preoperation,Surgical Technique,CPB atr
8、ial spect incision Damage part of Mitral valveAnterior leaflet 144 casesPosterior leaflet 290 casesboth 108 cases,Surgical techniques,Surgical techniques,CPB time97.8237.92 min Aorta clamp time 66.9332.14 min Intraoperative testinfusion water to lv through MVtransesophageal echocardiography,Surgical
9、 techniques,TVP,CABG,AVP,AVP,CABG,TVP,(united operation ）,vntricular aneurysm ectomy,Complications,Results,Early postoperation death 2 caseslow output 1caseventricular fibrillation 1case Follow-up 504 cases 3Ms-11Ys(37Ms) Advanced stage death 4 casesarhythmia 2 cases cerebral accident 1 caseunknown
10、aetiology 1 case,Results,After MVP operation Re-do MVR 5cases3cases postoperation 3years1case postoperation 4years1case postoperation 4months Hemolysis 1casere-MVP after 2 months,Results,NYHA postoperation (follow-up),Results,Mitral regurgitation (follow-up),Results,UCG,LA LVED EF,49.5213.50mm,59.21
11、8.05mm,62.3110.06 ,38.215.22mm,49.837.21mm,57.087.09,preoperative,p valve,0.05,0.05,0.05,postoperative,Comment,Retrogression valve disease 95 patients can be done MVP Our cases ,80% cases were retrogression Reason rupture of chordae or excess of chordartogether with annulus dilatation (12%),Comment,
12、Classic MVP techniques-cuniform incision+annuloplasty,Comment,Classic MVP techniques-cuniform ring (soft),2006.7-2008.7 ring 73%,Comment,Classic techniquescuniform incisionannuloplasty ring Easy to grasp Good effect Most patinents 88 （477cases）,Comment,Edge to edge assist method,A2-P2,Comment,Edge-t
13、o-edge,Commissure suture,Comment,In our cases “edge to edge” 108 cases 7cases ITEE mild MI；follow-up mild MI MVflow velocity 1.140.28m/spressure 4.763.07mmHg MV no significant stenosis Together with anterior leaflet damage: mainly assist repair technique,Comment,chordae transposition shorten,Comment
14、,In our cases anterior leaflet damage chordae shorten 10 casestransposition 13 cases UCG：Moderate MI 2 casesMild to moderate 2 cases literatures：chordae shorten 11.5% failurechordae transposition have good effect 5 years free from re-do 96%,Comment,Artificial chordae,Literature:GORE-TEX artificial c
15、hordae 15years follow-up,free from re-do 92，free from MI 85,Comment,Congenital MV malformationMV leaflet cleft,Comment,Congenital mitral valve malformations,Annula dilataion,Supravalvular ring,Comment,Congenital mitral valve malformations,Double orifice,Parachute mitral valve,Comment,Congenital mitral valve malformationsmalformation complexsurgical techniques should be choosed due to valve malformation,
