瓣下结构成形在缺血性二尖瓣返流外科治疗中应用价值的理论研究

目的：研究瓣环及瓣下结构成形技术治疗缺血性二尖瓣返流（ischemic mitral regurgitation, IMR)的机制，探讨应用瓣下结构成形技术的必要性。方法：使用AUTOCAD软件仿真模拟Carpentier IIIb型以及CarpentierI型IMR的病变特点，进一步分析瓣环成形术及瓣下结构成形术治疗IMR的效果。结果：单纯使用瓣环成形术能够治愈Carpentier I型IMR；对于后乳头肌严重移位的Carpentier IIIb型IMR，当后乳头肌位移超出临界值时，单纯使用瓣环成形术可以促进前后瓣叶对合、缓解返流严重程度，但不能有效治愈返流，同时会加重后叶栓系；对于乳头肌轻度移位的Carpentier IIIb型 IMR，相对于传统的瓣环成形术，应用“瓣环与瓣下结构一体成形”的治疗方式可以避免对“小型号成形环瓣环成形”技术的依赖。结论：应重视瓣下成形技术在IMR二尖瓣成形术中的应用。     

缺血性二尖瓣返流的研究进展

缺血性二尖瓣返流的研究进展同济医科大学心血管病研究所心内科樊红，程龙献综述曹子寿涂源淑审校缺血性二尖瓣返流（ｍｉｔｒａｌｒｅｇｕｒｇｉｔａ－ｔｉｏｎ，ＭＲ）是冠心病常见的并发症之一，急性心肌梗塞并发ＭＲ尤为常见，发生率可高达５０％。本文就其发生机理及...     

心肌梗死后缺血性二尖瓣返流

缺血性二尖瓣返流是急性心梗后的常见并发症,也是一种包括局部和整体左室重构等多因素、多过程参与的疾病,发病率在11%～59%.虽然很多研究在设计、入选标准、随访时间和评估二尖瓣返流的技术各不相同,但是结果都表明心梗后缺血性二尖瓣返流是一种不良预后因素,可导致心衰及死亡发生率增加,并且独立于已知的心梗后危险因素.     

心肌梗死后缺血性二尖瓣返流

缺血性二尖瓣返流是急性心梗后的常见并发症,也是一种包括局部和整体左室重构等多因素、多过程参与的疾病,发病率在11%～59%。虽然很多研究在设计、入选标准、随访时间和评估二尖瓣返流的技术各不相同,但是结果都表明心梗后缺血性二尖瓣返流是一种不良预后因素,可导致心衰及死亡发生率增加,并且独立于已知的心梗后危险因素。     

缺血性二尖瓣返流的外科治疗(附38例临床报告)

目的　介绍外科治疗缺血性二尖瓣返流的手术方法和临床结果。方法　自 1996年 12月至 2 0 0 1年 4月 ,38例缺血性二尖瓣返流患者接受了手术治疗 ,其中男性 33例 ,女性 5例 ,年龄 32～70岁 ,平均 (5 8± 8)岁。术前纽约心脏学会 (NYHA)心功能分级Ⅰ～Ⅱ级 4例 ,Ⅲ～Ⅳ级 34例。轻度二尖瓣返流 6例 ,中度 16例 ,重度 16例。合并室壁瘤 6例。除 6例轻度返流患者只行冠状动脉旁路移植术外 ,其余 32例患者均行冠状动脉旁路移植术加二尖瓣手术。结果　无手术及术后早期死亡 ,无术后早期严重并发症。所有患者均症状消失 ,痊愈出院。出院时心功能均为Ⅰ～Ⅱ级。随访 37例 ,平均随访 (2 0 8± 14 3)个月 ,除 1例远期死亡 ,1例NYHA分级心功能Ⅲ级外 ,心功能均为Ⅰ～Ⅱ级。结论　中度以上的缺血性二尖瓣返流应积极采用手术治疗的方法 ,二尖瓣成形术应为首选 ,术后效果良好。     

经皮球囊二尖瓣成形术后二尖瓣返流

经皮球囊二尖瓣成形术后二尖瓣返流中国人民解放军心血管内外科研究所，沈阳军区总医院心血管内科汤莉莉综述钱武扬，张玉威审校自１９８４年Ｉｎｏｕｅ［１］首次应用经皮球囊二尖瓣成形术（ＰＢＭＶ）以来，已收到了极其显著的效果，成功率达９５％～９９％［２，３］。...     

二尖瓣成形与置换术治疗重度缺血性二尖瓣反流近中期疗效比较

目的:比较二尖瓣成形术与二尖瓣置换术治疗重度缺血性二尖瓣反流(IMR)患者的近中期临床结果,探讨其治疗方法的选择。方法:2010年至2017年,成人冠心病合并重度IMR接受冠状动脉旁路移植术及二尖瓣成形/置换术共106例,其中二尖瓣成形56例,二尖瓣置换50例。研究主要终点为左心室收缩末期容积指数(LVESVI),二级终点:死亡、中风、二尖瓣再次手术、心力衰竭、NYHA分级恶化、二尖瓣再次反流、生活质量。结果:两组患者术前基线资料差异无统计学意义。两组患者在术后30 d、1年复合心脏事件终点发生率方面差异无统计学意义(P=0.97)。术后1年LVESVI及LVEF改善、基于SF-12评分的生活质量,差异无统计学意义(P0.05)。术后1年二尖瓣成形组再发中-重度二尖瓣反流明显高于二尖瓣置换组(P=0.002)。结论:对于重度缺血性二尖瓣反流,二尖瓣成形或置换术均可获得较好的近中期临床效果;全瓣保留二尖瓣置换术更低的远期中重度二尖瓣反流发生率可能使患者更多的获益,但要权衡人工瓣膜置换的利弊。     

经皮球囊二尖瓣成形术后二尖瓣返流（附8例报告）

经皮球囊二尖瓣成形术后二尖瓣返流（附８例报告）广西玉林地区人民医院（５３７０００）李平，陈丽芬，张少富，刘强，陈蓉，黄为我院自１９９２年起已完成经皮球囊二尖瓣成形术（ＰＢＭＶ）６０例，其中８例术后并发二尖瓣返流（ＭＲ），本文就共发生的原因、机制作一分...     

预制人工腱索环和二尖瓣成形环置入术治疗二尖瓣脱垂

目的:回顾预制人工腱索环和二尖瓣成形环置入术治疗二尖瓣脱垂,探讨此手术对二尖瓣脱垂的治疗效果。方法:2008年1月至2012年12月间,回顾性分析北京安贞医院收治的15例二尖瓣脱垂患者,其中男性10例,女性5例,年龄(48.5±3.2)岁,SBE后腱索断裂导致关闭不全2例,单纯腱索断裂导致关闭不全8例,腱索延长导致关闭不全5例。术前超声心动图(TEE)显示:根据Carpentier标准,前叶脱垂10例,后叶脱垂3例,前叶合并后叶脱垂2例。所有患者二尖瓣均为重度关闭不全,反流面积(11.0±0.9)cm2,1例合并三尖瓣重度反流。术前射血分数(EF)平均(64.9±1.9)%,左心室舒张末直径(LVDD)平均(54.9±1.4)mm,左心房直径(LA)平均(42.9±1.7)mm。所有患者均经胸正中切口,体外循环下行预制人工腱索环移植,移植腱索数量为(3.6±0.3)根,腱索长度(15.4±1.5)mm,平均体外循环时间(113±11.7)min,平均主动脉阻断时间(86±9.8)min。3例患者置入SJ成形环,12例患者置入爱德华成形环,1例患者同时行三尖瓣成形术。结果:术后无死亡,无恶性心律失常及其他严重并发症。术后复查TEE显示少量反流3例,微量反流8例,未见反流4例。术后EF平均(60.2±2.9)%,未见明显改变。LVDD平均(46.5±1.1)mm,LA平均(32.9±1.2)mm,均较术前明显改善。随访12~57个月,平均(35.7±4.3)个月,少量反流3例,无或微量反流12例。结论:预制人工腱索环和二尖瓣成形环置入术治疗二尖瓣脱垂近中期效果确切,但是远期预后尚需进一步观察。     

自制软质人工二尖瓣成形环在二尖瓣修复术中的应用

目的评价自行研制的新型人工二尖瓣成形环（佰仁思环）的临床应用效果。方法应用二维和彩色血流显像超声技术研究了8例接受自制软质二尖瓣环成形术（软环组）和6例硬质二尖瓣环成形术者（硬环组）术后心功能的变化。结果术后早期软环组左室峰值充盈率（PFR）、左室峰值排空率（PER）、最小容积变化率（dV／dTmin）、左心室收缩期快速射血时间与射血总时间比值（FET／ET）与硬环组比较有统计学差异（P〈0．05）;术后3—6个月软环组射血分数（EF）、FET／ET与硬环组比较有统计学差异（P〈0．05）。结论软质环顺应性好,有利于临床心功能的恢复。     

应用Carpentier-Edwards生理环治疗退行性二尖瓣反流的二尖瓣成形术后的二尖瓣狭窄

Repair durability for degenerative mitral regurgitation is excellent. Although the main reason for reoperation is residual or recurrent regurgitation, Postoperative mitral stenosis is extremely rare.     

Recurrent mitral regurgitation late after annuloplasty for ischemic mitral regurgitation

In 106 patients who had mitral annuloplasty for ischemic mitral regurgitation (MR), 71 patients (67%) had satisfactory outcomes with <2+ MR (grade 0-4) throughout the follow-up period (44 ± 31 months), while 35 patients (33%) had significant recurrent MR (≥2+) late after annuloplasty (≥6 months) during the follow-up period (45 ± 30 months). Compared to those with recurrent MR, the success group had a significantly higher proportion of patients whose left ventricular (LV) ejection fraction (EF) stayed stable or increased over the follow-up period postoperatively (47/70 = 67% vs. 14/35 = 40%, P < 0.01). The success group had a higher proportion of patients whose LV end-systolic volume stayed stable or decreased (37/63 = 59% vs. 6/35 = 17%, P < 0.01) and lower LV sphericity in systole (0.46 ± 0.096 vs. 0.60 ± 0.10, P < 0.01). In conclusion, recurrent ischemic MR after annuloplasty is associated with increasing LV size, decreasing LVEF, and increasing sphericity of the LV.     

Mitral stenosis after mitral valve repair using the duran flexible annuloplasty ring for degenerative mitral regurgitation

The case is presented of a 47-year-old woman who had undergone mitral valve repair using the Duran annuloplasty ring four years earlier, and who was diagnosed with mitral stenosis owing to fibrous tissue overgrowth. In this patient, dense whitish fibrous tissue covered the annuloplasty ring and extended onto both leaflets of the mitral valve, narrowing its orifice and rendering the leaflets stiff and immobile. The pannus covering the mitral valve could not be stripped off without damaging the leaflets, making mitral valve replacement necessary. Mitral valve replacement with a St. Jude Medical mechanical heart valve prosthesis was successfully performed, and no major perioperative complications were encountered.     

Mitral suture annuloplasty corrects both annular and subvalvular geometry in acute ischemic mitral regurgitation

BACKGROUND AND AIM OF THE STUDY: Papillary muscle displacement is an important element in the pathogenesis of ischemic mitral regurgitation (IMR). The effects of standard ring annuloplasty on subvalvular geometry are incompletely understood. The hypothesis was tested that annular reduction with a Panethtype suture annuloplasty would correct both annular and papillary muscle geometric abnormalities during acute left ventricular (LV) ischemia. METHODS: Eight adult sheep underwent insertion of an adjustable, double-suture Paneth-type mitral annuloplasty and radiopaque markers on the left ventricle, mitral annulus, leaflet edges, and anterior (APM) and posterior (PPM) papillary muscle tips. Immediately after surgey, 3-D marker coordinates were determined during Control conditions and during proximal left circumflex occlusion before and after tightening the annuloplasty suture. RESULTS: Acute IMR (MR grade 0.3 +/- 0.3 to 2.1 +/- 0.4, Control versus Ischemia) was associated with end-systolic LV dilatation (+27 +/- 16 ml, change relative to Control), greater septal-lateral (+4.6 +/- 3.1 cm) and commissure-commissure (+3.3 +/- 1.6 cm) mitral annular diameters, longer anterior (+1.5 +/- 0.9 cm) and posterior (+0.6 +/- 0.9 cm) papillary muscle tethering distances, greater distance from the APM to the anterior commissure (+0.9 +/- 0.8 cm), and shorter distance from the PPM to the poslerior commissure (-1.3 +/- 1.5 cm). Suture annuloplasty corrected the annular and subvalvular changes, and IMR returned to Control levels (0.5 +/- 0.5); only LV end-systolic volume (ESV) was different from Control (+25 +/- 18 ml) (mean +/- SD, p < 0.05 versus Control by RMANOVA and Dunnett's test). CONCLUSION: Suture annuloplasty corrected ischemia-induced end-systolic distortions of the entire valvular-ventricular complex (i.e. inter-leaflet separation, mitral annular dilatation in both axes, and papillary muscle displacements), and abolished acute IMR, independent of any change in ESV. A better understanding of the effects of annular reduction on papillary muscle geometry may lead to improved subvalvular mitral repair techniques.     

Mitral ring annuloplasty: An incomplete correction of functional mitral regurgitation associated with left ventricular remodeling

Functional mitral regurgitation (FMR) occurs commonly in patients undergoing left ventricular (LV) remodeling. It is ubiquitous in patients referred to cardiac transplantation for LV systolic dysfunction and predicts a poor prognosis. The LV remodeling that is responsible for FMR is well understood and involves regional LV dysfunction Mitral annular dilatation is present in patients with idiopathic dilated cardiomyopathy but most often absent in patients with ischemic cardiomyopathy. Nonrandomized observations indicate that implantation of a mitral undersized flexible mitral ring reduces the amount of FMR, reverses LV remodeling, and improves symptoms in patients with endstage cardiomyopathy and severe FMR. Whether a surgical procedure that does not correct the major LV alterations leading to FMR can have long-lasting effects on the amount of FMR and the reversal of LV remodeling remains to be demonstrated in randomized trials.     

BNP in mitral valve restrictive annuloplasty for ischemic mitral regurgitation

Restrictive annuloplasty with undersized mitral rings is used to correct functional mitral regurgitation (MR) in patients with ischemic left ventricular dysfunction. Seventeen patients with severe coronary artery disease, previous myocardial infarction, moderate/severe functional MR and heart failure symptoms were prospectively evaluated. All patients received CABG associated with restrictive annuloplasty. Preoperatively and 6 months after the operation, clinical evaluation, echocardiography and blood sampling for BNP measurement were performed. Operative mortality occurred in 1 patient. MR degree decreased from 3.8+/-0.3 to 1.0+/-0.7 (p<0.01), LVEF increased from 36+/-11% to 43+/-8% (p<0.05), left ventricular end diastolic diameters changed from 54.7+/-5.2 mm to 51.5+/-5.8 mm (p=0.51). NYHA class improved from 2.94+/-1.02 to 1.21+/-0.42 (p<0.01). Mean plasma BNP levels decreased from 471+/-248 pmol/l to 55.6+/-52.8 pmol/l (p<0.05). Restrictive mitral annuloplasty is a safe procedure to be associated to CABG operation. We demonstrated mid-term reduction of BNP plasma values after MR correction thus suggesting the effectiveness of surgical treatment in modifying natural history of the disease.