二尖瓣狭窄伴心房纤颤球囊扩张术疗效评价

目的 评价二尖瓣狭窄（MS）伴房颤经皮球囊扩张术（PBMV）的疗效及安全性。方法 对21例伴房颤MS与同期29例窦律MS患者PBMV术后及随诊结果进行分析比较。结果 MS伴房颤PBMV术后血流动力学及心功能显著改善，但其改善程度要略逊于窦律组；均无血管栓塞并发症发生。结论 只要术前充分抗凝，操作仔细，MS伴房颤行PBMV治疗具有与MS伴窦性心律同样的疗效和安全性。     

二尖瓣球囊扩张术对二尖瓣狭窄合并心房颤动患者的近期临床和血液动力学的影响

目的分析二尖瓣球囊扩张成形术(percutaneous balloon mitral valvuloplasty, PBMV)对二尖瓣狭窄(mitral stenosis, MS)合并心房颤动(atrial fibrillation, AF)的近期临床和血液动力学的影响.方法比较45例MS合并AF患者(AF组)和138例窦性心律患者(窦律组)PBMV手术前后的临床和血液动力学参数.结果①AF组年龄大于窦律组[(40.6±8.4) vs (36.7±5.6)岁, P<0.05];AF组NYHA≥Ⅲ级(77.8% vs 48.6%, P<0.05)和瓣膜超声评分≥8(26.7% vs 8.7%, P<0.05)的人数显著高于窦律组;术前AF组存在更大的左房内径[(50.2±7.1) mm vs (45.4±5.2) mm, P<0.05]、更高的肺动脉收缩压[(90.6±20.3) mmHg vs (40.5±6.5) mmHg, P<0.05]和平均左房压[(33.4±6.7) mmHg vs (14.9±4.4) mmHg, P<0.05].②PBMV成功率AF组(88.9%)与窦律组(91.7%)相似,严重并发症AF组也与窦律组相似(9.4% vs 6.7%);术后二尖瓣口面积≥1.5 cm2者窦律组显著高于AF组(71.7% vs 53.3%, P＜0.05);术后两组NYHA心功能明显改善,心功能恶化者AF组和窦律组相似(6.7% vs 5.8%),但术后NYHA≤Ⅱ级者窦律组显著高于AF组(81.2% vs 55.6%, P＜0.05);③术后即刻两组肺动脉收缩压和平均左房压均明显下降,AF组下降幅度更大,但窦律组术后的实际肺动脉压和左房压更低,AF组甚至到术后48 h肺动脉压也未降至正常.结论 PBMV仅能使AF患者获得部分临床和血液动力学改善,PBMV疗效较差的原因可能与AF患者并存多种异常有关,AF本身不影响PBMV成功率和严重并发症发生率.     

心房颤动的经皮二尖瓣球囊扩张术患者的特点和即刻效果

目的：探讨心房颤动（AF）的经皮二尖瓣球囊扩张术（PBMV）患者的特点和即刻效果。方法：回顾性收集405例风湿性二尖瓣狭窄AF的BPMV病人的临床、心脏照片、超声心动图、血流动力学资料，与447例正常窦性心律（NSR）的PBMV病人进行比较。结果：（1）与NSR组相比，AF组的年龄和术前心胸比（HTR）较大，术前二尖瓣口面积（MVA）较小，而且心功能Ⅲ/Ⅳ级，既往二尖瓣分离术史，二尖瓣病变计分＞8，术前二尖瓣反流（I／Ⅱ级）的百分率明显增高。（2）AF组PBMV即刻效果良好率明显低于NSR组，术后MVA明显小于NSR组，而术后肺动脉平均压（PAMP）、左房平均压（LAMP)炕于NSR组。结论：AF的PBMV病人临床和二尖瓣形态学条件都相对较差，同时其PBMV即刻效果亦相对不理想。     

二尖瓣病变合并巨大左心房与慢性房颤的外科治疗

目的评价在二尖瓣置换术同期行改良迷宫术和左房折叠术（LAP）治疗巨大左心房慢性房颤（AF）的临床效果。方法40例左心房容积指数≥55mL／m^2的二尖瓣病变合并慢性AF患者，实施二尖瓣置换术与改良迷宫术，改良迷宫术以Ⅲ型迷宫术为基础进行改良。其中同期加行左房折叠术（LAP组）20例，未加行LAP术的20例为对照组。应用心电图及超声心动图观察手术前后心电活动、心功能、左心房容积指数（LAVI）、左室射血分数（LVEF）的变化。随访1年。结果对照组和LAP组恢复并维持窦性心律分别占55％和85％（P〈0．01）、心功能改善级别分别为1．06±0．63和2．01±0．66（P〈0．01）、手术后LAVI分别为52．25±14．02和39．98±9．05（P〈0．01）、LAEF分别为（55．67±5．33）％和（64．01±7．15）％（P〈0．01）。结论对合并巨大左心房的风湿性二尖瓣病变慢性AF患者，实施二尖瓣置换术和改良迷宫术同期加行左房折叠术，更能有效消除AF，长期维持窦律，进一步改善左心房、心室主动收缩功能，疗效确切。     

二尖瓣狭窄伴房颤患者经皮球囊扩张术后电复律的临床疗效

目的　评价二尖瓣狭窄 (MS)伴心房颤动 (AF)患者经皮二尖瓣球囊扩张成型术 (PBMV)及术后即刻电复律成功率与安全性。方法　 5 8例MS伴AF患者均行胸前超声心动图 (TTE)及食道超声心动图 (TEE)检查 ,用Wilkin’s法评分 ,术前、术中、术后测定血流动力学及超声心动图指标的改变 ,术后 32例患者在口服胺碘达隆基础上给予同步电复律。结果　 5 8例MS伴AF患者行PBMV均取得良好的血液动力学及超声心动图指标的改变 ,平均左房压力 (MLAP)、二尖瓣跨瓣压差 (MVPG)在术后有显著的降低 (P <0 .0 0 1) ,二尖瓣口面积 (MVA)较术前明显增加 (P<0 .0 0 1) ,左房内经 (LAD)术后也较术前有显著缩小 (P <0 .0 5 )。PBMV术后电复律即刻成功率为 90 .6 %(2 9/32 ) ,平均随访 2 .1年维持率 84.33%。结论　MS伴AF患者行PBMV术效果良好 ,术后电转复律即刻成功率高 ,随访维持率良好 ,心功能改善明显。     

二维彩色多普勒对球囊导管二尖瓣成形术（PBMV）选择病人的研究

为探索确保PBMV手术成功的超声心动图要素和如何选择合适的病人，采用经2D—CDFI术前对149例二尖瓣狭窄病人的诊断和血流动力学监测，与术后的结果进行配对t检验，再结合心功能、二尖瓣返流量的变化，按MS的Witkins计分法对疗效作相应的评价。结果显示大部分病例经PBMV术后心功能及血流动力学指数均有改善。部分禁忌症的病人经PBMV术后可获得成功。PBMV的成功与否与瓣膜评分有关。结论：狭窄的二尖瓣口增厚不显著，交界钙化度不高的病例，PBMV容易产生交界裂开；术前的心功能和血流动力学指数有改善倾向，术后不加重心脏负担的病例，可作为合适的病例行PBMV。     

持续性心房颤动消融前后左心功能的改变及复发相关因素分析

目的分析射频消融手术对于持续性心房颤动(房颤)患者左心功能的影响及复发相关因素。方法选取2016年1月—2017年1月北京阜外医院心律失常中心收住持续性房颤接受射频消融治疗的患者60例,根据术后3个月以上随访结果分为房颤复发组(复发组,19例)和窦律维持组(窦律组,41例)。分别比较2组射频消融手术前后的左心功能指标改变,以及复发的危险因素。结果复发组患者较窦律组患者房颤持续时间明显延长,肺静脉隔离(CPVI)+其他消融比例高于窦律组(t=11.257,χ^(2)=2.121,P<0.01);消融后,窦律组血浆NT-proBNP下降高于复发组(t/P=2.988/0.004);和复发组相比,窦律组左心房内径缩小,左心室内径减小,LVEF增加,6 min步行试验距离增加更为明显,差异具有统计学意义(t=4.543,9.214,8.652,65.325,P<0.01);Logistic多因素回归分析显示,房颤持续时间(OR=1.23,95%CI 1.056~1.558,P=0.012)和术前超声心动图左心房内径大小(OR=2.01,95%CI 0.928~4.347,P=0.023)是消融术后房颤是否复发的预测因素。结论射频消融治疗持续性房颤后能够减少左心房内径和左心室内径,增加左心室射血分数,增加6 min步行试验距离,改善左心功能。术前左心房内径大、房颤持续时间长是持续性房颤射频消融术后复发的危险因素。     

经皮球囊二尖瓣成形术治疗二尖瓣狭窄并左房血栓形成的临床研究

目的评价经皮球囊二尖瓣成形术(PBMV)治疗风湿性心脏病二尖瓣狭窄(MS)合并左心房血栓形成的可行性、安全性和有效性。方法应用华法林抗凝治疗3~6个月后左房血栓仍存的风心病MS合并左心房血栓形成患者共20例,其中男5例,女15例,年龄22~55岁,平均(36.1±8.3)岁。采用常规方法进行PBMV,观察术中及随访1年期间有无体循环血栓栓塞并发症。结果PBMV成功率为100%,术中及术后随访期间血流动力学及心功能明显改善,无血栓栓塞并发症发生。结论对于合并左心房血栓患者经充分的华法林抗凝治疗,PBMV是安全可行且疗效满意的。     

胺碘酮、普罗帕酮治疗房颤临床对比观察

心房颤动（房颤）是临床上极为常见的一种心律失常，如伴快速心室率时可引起明显心悸及血流动力学改变，持续时间过长尚可形成左心房附壁血栓，增加脑卒中的发生率，故必须积极转为窦律。胺碘酮和普罗帕酮均是房颤转复的有效药物，而且安全可靠，但两者的适应证是不同的，有器质性心脏病、心功能不全的患者首选胺碘酮，没有器质性心脏病的患者首选普罗帕酮。     

PBMV治疗二尖瓣狭窄伴中-重度肺动脉高压

目的　评价经皮二尖瓣球囊扩张术(PBMV)治疗二尖瓣狭窄伴中或重度肺动脉高压的疗效。方法　用Inoue球囊导管行PBMV治疗二尖瓣狭窄伴肺动脉收缩压≥60mmHg(8．00kPa)患者101例。用超声心动图和心导管法观察血流动力学效应。结果　术后血流动力学明显改善,二尖瓣瓣口面积增加(P<0．01);肺动脉收缩压及肺循环阻力明显降低(P<0．001),这些变化在心房颤动患者中尤为明显。结论　 PBMV治疗严重二尖瓣狭窄伴中-重度肺动脉高压患者具有良好的临床和血流动力学效应。     

二尖瓣成形术治疗二尖瓣关闭不全的临床研究

目的总结25例二尖瓣关闭不全患者行二尖瓣成形术的手术方法及效果。方法患者均在全麻低温体外循环下施行,采用瓣叶切除修复、瓣裂修复、交界缝合、腱索缩短、双孔二尖瓣成形、人工瓣环植入。手术前、后应用食道内超声心动图判断二尖瓣反流的原因和部位及手术治疗效果,术中采用左室注水加压试验初步判断二尖瓣成形的效果。术后随访主要依靠超声心动图。结果围术期死亡1例,死于恶性心律失常。术后心脏彩超显示,15例(60.00%)无二尖瓣返流,9例(36.00%)为轻微～轻度返流,左房、左室较术前明显缩小,心功能较术前明显改善。结论严格掌握手术适应征,针对不同瓣膜病变,运用合理的瓣膜成形技术,行二尖瓣外科修复疗效确切,术中左室注水试验及经食道超声心动图可为二尖瓣成形提供良好的技术支持。     

Role of closed mitral commissurotomy for mitral restenosis

Out of 1184 consecutive cases of rheumatic mitral stenosis treated surgically by closed mitral commissurotomy (CMC) at NRS Medical College and Hospital, Calcutta, 20 (1.68%) were mitral valve restenosis. Twelve cases (60%) were females, The median age was 32 years. Duration between the first operation and reappearance of symptoms varied with a mean of 8 years. The previous operations were digital dilatation and instrumental dilatation in 6 and 14 cases respectively. History of thromboembolism was present in 4 cases. On echocardiography, calcification of the mitral valve was present in 2 cases, left atrial clot in 4 cases, associated mild to moderate mitral regurgitation in 6 cases and mild aortic regurgitation in 4 cases. All cases presented with New York Heart Association (NYHA) III and IV symptoms. Critical stenosis (mitral valve orifice less than 0.5 cm2) was present in 12 cases. Re-do CMC was undertaken in all cases with Tubb's dilator. Median operating time was 2.5 hours. Satisfactory split was achieved in 13 cases. One patient died during surgery. Four cases having less than satisfactory split were asymptomatic on follow-up. In one case no split was possible and in another, gross mitral regurgitation was noted postoperatively. These 2 cases had to undergo open heart surgery. It is concluded that re-do CMC is a feasible and suitable alternative in mitral restenosis even in the presence of complications.     

“钮扣状”转移保留二尖瓣全装置瓣膜置换的初步探讨

目的 :探讨二尖瓣狭窄病人采用“钮扣状”转移保留全瓣装置二尖瓣置换的方法及对左心功能的影响。方法 :对 5 6例二尖瓣狭窄需行二尖瓣置换的患者 ,分为 :A组 (术中“钮扣状”保留全部二尖瓣瓣下结构 ) ,B组(术中仅保留二尖瓣后瓣及瓣下结构 )和C组 (术中未保留瓣下结构 ) ;于术前 ,术后监测血流动力学指标 ;术前、术后出院前、术后 3～ 6个月行超声心动图检查 ,监测心功能指标。结果 :A组术后心排指数、每搏指数、左室收缩功指数、肺毛细血管楔压、左室舒张末、收缩末内径、左室射血分数、短轴缩短率及左室长轴舒张末内径均优于B ,C组 ,且EF值恢复优于B ,C组。A组主动脉阻断时间较B ,C组延长 ,但总转流时间比较 ,差异无显著性 (P >0 .0 5 )。结论 :以二尖瓣狭窄为主的病人行瓣膜置换时可采用“纽扣状”转移保留全部瓣下装置 ;病人术后早期心功能的改善优于部分保留组和不保留组。     

142例二尖瓣关闭不全患者行二尖瓣修复成形术的手术经验

目的　分析、总结 14 2例行二尖瓣修复成形术的二尖瓣关闭不全患者的临床疗效。方法　 1994年 1月～ 2 0 0 3年 12月 ,连续对 14 2例二尖瓣关闭不全患者行修复成形术 ,男 88例 ,女 5 4例 ,平均年龄为 (38.5± 7.8)岁。病因诊断 :二尖瓣腱索断裂 74例 ,二尖瓣黏液变性伴瓣叶脱垂 36例 ,冠心病二尖瓣乳头肌功能不全15例 ,二尖瓣瓣环扩大 11例 ,感染性心内膜炎伴二尖瓣穿孔 4例 ,扩张型心肌病伴二尖瓣关闭不全 2例 ;7例患者合并非风湿性主动脉瓣病变。手术在体外循环、中低温下施行 ,采用瓣叶切除缝合、瓣环成形、穿孔修补、腱索转移、edgetoedge技术及人工腱索成形技术 ,术中以食道超声监测成形效果。 结果　死亡 2例 ,1例术后第 6天死于脑出血 ,另 1例术后第 5天死于多器官功能衰竭。 5例患者术中转为瓣膜置换手术 ;其余患者术毕二尖瓣无返流或轻度返流。在平均为 (34.5± 4 .8)个月的随访中 ,有 2例二尖瓣返流加剧至中度而行二尖瓣置换手术。其余患者二尖瓣返流未见加剧 ,心功能恢复良好。结论　选择适当的患者、运用合理的瓣膜成形技术 ,二尖瓣关闭不全患者行瓣膜成形术可取得满意的疗效。     

“钮扣状”转移保留二尖瓣全装置瓣膜置换的初步探讨

OBJECTIVE: To evaluate the surgical technique and the effect of preservation of the entire mitral subvalvular apparatus during mitral valve replacement (MVR) in patients with mitral stenosis. METHODS: MVR was performed on 56 patients with mitral stenosis. Of them, 11 had complete preservation of the entire mitral subvalvular apparatus (group A) with the technique of preservation of 'button-shaped' transplantation, 25 had the preservation of the posterior leaflet only (group B), and the other 20 underwent the conventional MVR (group C). Pre- and postoperative hemodynamic parameters were measured to determine the left ventricular performance. Echocardiography was performed preoperatively, at the time of discharge, and 3 to approximately 6 months postoperatively to determine the dimensions and ejection function. RESULTS: Cardiac index, stroke volume index and left ventricular stroke work index postoperatively in group A were better than those in group B and C (P < 0.05). Echocardiographic measurements postoperatively showed the increase of LVESD, LVEDD in group B and C, but a better LVL and LVFS in group A (P < 0.05), and LVEF was more pronounced in group A (P < 0.05). There appeared a long cross-clamp time in group A, but the total CPB time was not significant among the three groups. CONCLUSION: The surgical skills of preservation with 'button-shaped' transplantation may be a practical choice for patients with mitral stenosis. The preservation of entire mitral subvalvular apparatus improves the left ventricular functions after MVR in patients with mitral valve stenosis.     

A comparative study of balloon mitral valvuloplasty and closed mitral commissurotomy in patients with rheumatic mitral stenosis

Rheumatic mitral stenosis is frequently encountered in our country. It affects younger population and is a major cause of morbidity Mitral valvotomy is the definitive therapy for this disease and can be achieved by closed mitral commissurotomy (CMC), open mitral commissurotomy (OMC) or by percutaneous transluminal mitral valvuloplasty (PTMV). Compared to CMC, PTMV is less invasive but more expensive at this moment. With the reduction of cost, PTMV may become the procedure of choice for the treatment of rheumatic mitral stenosis in future.     

Non-surgical mitral valvotomy

Percutaneous transseptal mitral valvotomy was performed on 14 occasions in 13 patients; in one patient, the procedure was unsuccessful at the first attempt, but was repeated successfully. All other attempts were successful, giving a procedure success rate of 93% and a patient success rate of 100%. The only complication was transient diplopia in one patient, presumably due to a small cerebral embolus. This early experience confirms that this procedure is easily learnt, and can be performed with good results and low risk in selected patients with mitral stenosis.