冠状动脉粥样硬化性心脏病的外科治疗进展

外科治疗冠状动脉粥样硬化性心脏病的传统方式是胸骨正中完全劈开切口、体外循环、心脏停跳下的冠状动脉搭桥术,以大隐静脉作为主要的血管桥。存在的问题是手术创伤大,并发症比较多,医疗费用高,大隐静脉桥的远期通畅率低,且不适用于弥漫性冠状动脉狭窄和远端细小血管病变。近年来,人们对冠状动脉粥样硬化性心脏病外科治疗的技术进行了大量的改进和创新,包括微创伤冠状动脉搭桥术、完全动脉化冠状动脉搭桥术和激光打孔心肌血运重建术等,本文就各种新方法的手术要点、适应证和临床效果等进行了综述。     

老年冠状动脉粥样硬化性心脏病患者外科治疗的特点

目的 观察老年冠状动脉粥样硬化性心脏病(冠心病)患者外科治疗的特点.方法 回顾性分析215例冠心病患者的外科治疗,其中≥70岁75例,＜70岁患者140例.所有患者均行冠状动脉旁路移植术(CABG),108例行非体外循环CABG;107例行体外循环CABG,其中同时行二尖瓣成形术11例,二尖瓣置换术8例,主动脉瓣置换术7例,室壁瘤切除术18例.≥70岁组有2例同期行肿瘤手术.比较两组手术前一般情况、并存疾病、围手术期情况和转归情况. 结果 ≥70岁组和＜70岁组比较,手术前冠状动脉介入治疗两组分别为17.3%和7.1%(P＜0.05),不稳定心绞痛分别为91.4%和78.7%(P＜0.01).吻合动脉桥数分别为(1.1±0.5)支和(0.9±0.5)支(P＜0.01)应用大剂量儿茶酚胺类药物分别为12.0%和4.3%(P＜0.05),术后总并发症发生率分别为49.3%和28.6%(P＜0.01),术后心房颤动发生率分别为12.0%和4.3%(P＜0.05),伤口感染分别为7例和1例(P＜0.01),术后住院时间分别为(24.2±21.5)d和(17.5±7.4)d(P＜0.01);两组病死率(分别为5.3%和2.1%)比较,差异无统计学意义(P＜0.05).结论 70岁以上冠心病患者接受外科治疗安全、有效,但手术并发症发生率高,术后住院时间延长.     

冠心病合并中重度缺血性二尖瓣关闭不全的外科治疗

目的探讨冠心病合并中重度缺血性二尖瓣关闭不全的外科治疗原则。方法选择冠心病合并中重度缺血性二尖瓣关闭不全的手术患者61例,并对患者的临床资料进行回顾性分析。结果 45例行冠状动脉旁路移植术+二尖瓣成形术,16例行冠状动脉旁路移植术+二尖瓣置换术,其中2例患者行二尖瓣置换术,术后早期死于心力衰竭,余59例均治愈岀院。术后复查超声心动图检查显示,左心室舒张末内径从(52.8±11.3)mm降至(47.9±8.9)mm(P<0.01),LVEF从(46±11)%升至(52±12)%,差异有统计学意义(P<0.01)。结论对于冠心病合并中重度缺血性二尖瓣关闭不全的手术患者,同期处理二尖瓣后效果满意。     

缺血性二尖瓣反流

当前,缺血性二尖瓣反流发生率正在增加,其临床重要性受到越来越多的重视。研究发现,缺血性二尖瓣反流与临床预后密切相关,心肌梗死、慢性心力衰竭患者出现二尖瓣反流后,病死率增加一倍。多因素回归分析显示,严重二尖瓣反流(有效反流口面积>20 mm2)为死亡的独立危险因素。运动负     

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。     

二尖瓣关闭不全的外科治疗

目的 总结二尖瓣关闭不全外科治疗的经验.方法 2001年1月至2007年7月共治疗二尖瓣关闭不全56例,男性25例,女性31例.先天性11例,风湿性3例,非风湿性42例,合并先天性心脏病19例.中度关闭不全18例,中度-重度关闭不全17例,重度关闭不全21例.病变类型腱索异常37例,如腱索断裂,缺如,一根或多根腱索延长;腱索和乳头肌异常11例;瓣叶发育异常16例;感染性心内膜炎造成的二尖瓣关闭不全3例;瓣环扩大54例.手术方式单纯腱索短缩13例,乳头肌劈开腱索包埋短缩8例,瓣叶和腱索移植5例,人工腱索再造2例.前瓣叶楔形切除或折叠9例,后叶矩形切除与sliding技术8例,缘对缘技术1例,感染性心内膜炎造成的二尖瓣损害局部修复3例.自制涤纶带环缩2例,二尖瓣环部分环缩38例,置入Duran环16例.结果 全组没有手术死亡病例.有2例在手术后8个月和15个月发生二尖瓣返流行二尖瓣瓣膜置换术;二尖瓣功能正常29例(51.79%),残留轻度关闭不全14例(25.00%),残留轻-中度关闭不全11例(19.64%).随访1～6年(2.3年),结果良好.结论 外科修复是治疗二尖瓣关闭不全的主要方法,该方法是安全,有效的,早期效果良好.     

CABG同期二尖瓣置换与二尖瓣成形术治疗冠心病合并Ⅲb型缺血性二尖瓣反流患者的疗效比较

目的 对比分析冠状动脉旁路移植术(coronary artery bypass grafting,CABG)同期行二尖瓣置换术(mitralvalve replacement,MVR)与二尖瓣成形术(mitral valvuloplasty,MVP)治疗冠状动脉粥样硬化性心脏病(冠心病)合并Ⅲb型缺血性二尖瓣反流(is...     

缺血性二尖瓣反流的治疗

缺血性二尖瓣反流（IMR）是冠状动脉粥样硬化性心脏病的常见并发症。左室重构是IMR的主要发生机制。心肌梗死后发生IMR是预后不良的危险因素。对于重度IMR患者,在冠状动脉旁路移植术（CABG）同期处理二尖瓣已形成共识,但对于中度IMR患者,CABG同期是否行二尖瓣成形术尚存争议。该文介绍IMR的发生机制、反流程度的评估及治疗措施。     

冠状动脉旁路移植术治疗冠心病合并中度缺血性二尖瓣反流的近远期疗效分析

目的：评估单纯冠状动脉旁路移植术（CABG）治疗冠心病合并中度缺血性二尖瓣反流的近远期效果,以探讨最佳的治疗方案。方法：2009年1月至2018年12月,共有822例冠心病合并中度缺血性二尖瓣反流的患者在首都医科大学附属北京安贞医院接受治疗,其中750例行单纯冠状动脉旁路移植术（CABG组）,72例同期行二尖瓣修复（MVP）或二尖瓣置换术（MVR）(CABG+MV组),通过倾向性评分匹配后（5:1匹配）,共有384例患者纳入分析,其中CABG组320例,CABG+MV组64例。通过对比,评估两组患者外科治疗术后的效果。结果：两组患者均成功接受了手术治疗。围术期患者死亡19例,其中CABG组17例（5.3%）,CABG+MV组2例（3.1%）,两组间比较差异无统计学意义（P=0.461）。围术期发生MACCE事件21例,其中CABG组18例（5.6%）,CABG+MV组3例（4.7%）,两组间比较差异无统计学意义（P=0.763）。患者术后随访时间为（51.48±21.59）个月,期间死亡59例,其中CABG组50例（15.6%）,CABG+MV组9例（14.1%）,两组间比较差异无统计...     

代谢综合征与冠状动脉粥样硬化性心脏病

代谢综合征(Metabolic syndrome,MS)是一种涉及多种心血管疾病危险因子的聚集状态,据初步研究资料显示我国MS患病率已高达13．25％,随着年龄的增加而增高,55岁以上人群患病率高达20．26％。MS使发生糖尿病和冠心病的危险性明显上升。本文着重对MS与冠状动脉硬化性心脏病(CAD)的相关性作一综述。     

Radiation-induced mitral and tricuspid regurgitation with severe ostial coronary artery disease: A case report with successful surgical treatment

A 71-year-old woman presented with congestive heart failure due to severe mitral and tricuspid regurgitations. In addition, she had significant ostial right coronary stenosis. She received radiation therapy following left radical mastectomy for carcinoma of breast in the past. She underwent successful combined mitral valve replacement, tricuspid annuloplasty, and coronary artery bypass graft for radiation-induced heart disease. © 1995 Wiley-Liss, Inc.     

Association of aortic valve sclerosis and coronary artery disease in patients with severe nonischemic mitral regurgitation

BACKGROUND: The presence of aortic valve sclerosis accounts for a higher rate of ischemic events and increased cardiovascular mortality. It may reflect coronary artery disease (CAD) because of a shared pathologic background. HYPOTHESIS: We aimed to analyze whether the presence of aortic valve sclerosis might help in identifying patients with coronary atherosclerosis among those with severe nonischemic mitral regurgitation (MR), who undergo coronary angiography before surgery for screening, and not because of suspected ischemic heart disease. METHODS: In all, 84 patients (mean age 64 +/- 9 years; 71% men) with mitral valve prolapse and severe regurgitation underwent echocardiography and coronary angiography. Aortic valve sclerosis was defined as focal areas of increased echogenicity and thickening of the leaflets without restriction of leaflet motion on echocardiography. Coronary artery disease was defined by the presence/absence of atherosclerotic plaques, independent of the degree of stenosis. RESULTS: Coronary artery disease was diagnosed in 47.6% of patients with and 15.8% of those without aortic valve sclerosis (p = 0.008). On logistic regression analysis, the presence of aortic valve sclerosis predicted CAD (odds ratio 3.3, 95% confidence interval 1.03-10.5; p = 0.04) independent of age. In female patients, the risk ratio for CAD in the presence of aortic valve sclerosis was 9. CONCLUSIONS: Coronary artery atherosclerosis and aortic valve sclerosis are closely associated in patients with severe nonischemic MR.     

重度主动脉瓣关闭不全合并中度功能性二尖瓣反流的临床研究

目的 探讨中度功能性二尖瓣反流（FMR）在重度主动脉瓣关闭不全患者中的处理原则及其近中期疗效。方法 分析2019年10月至2020年10月南京医科大学附属南京医院心胸血管外科16例重度主动脉瓣关闭不全合并中度功能性二尖瓣反流患者经手术治疗的临床资料。结果 所有术后患者围手术期无死亡,术后随访（2.9±1.7）个月,术后超声心动图提示FMR程度与术前相比较有所减轻,同时左心房内径（LAD）（P=0.01）、左心室舒张末期内径（LVEDD）（P=0.025）及左心室收缩末期内径（LVESD）（P=0.045）明显缩小,但LVEF较术前反而有所下降,但无统计学意义（P=0.259）。术后3~6个月随访,所有患者无复发,无需再次手术,复查超声心动图与术前比较LAD（P=0.022）、LVEDD（P=0.006）、LVESD（P=0.043）呈进行性缩小, 接近正常水平,EF较术前相比明显改善,有显著统计学差异（P=0.029） ,且FMR同步明显减轻。截至最后一次随访,5例二尖瓣无反流,7例微量反流,4例少量反流,手术成形效果满意。结论 重度主动脉瓣关闭不全合并中度的FMR建议积极行二尖瓣成形术处理,能够保留二尖瓣瓣膜的持久性和功能性,可获得较满意的近中期疗效。     

Different mechanisms of mitral regurgitation in acute and chronic forms of coronary heart disease

Contradictory two-dimensional echocardiographic findings havebeen reported in relation to the role of prolapse of the mitralvalve and lack of systolic leaflet coaptation in mitral regurgitationsecondary to coronary heart disease. A prospective study of22 patients with chronic coronary heart disease and mitral regurgitationshowed the following: Inferior akinesia was detected in 14 (64%),fibrosis of the posteromedial papillary muscle in 10 (45%),and prolapse of the mitral valve in nine (41%). A combinationof the three signs was seen in six patients (27%). Lack of systolicleaflet coaptation was seen in only two patients, both withanterior myocardial infarction. When these results are comparedwith those reported in the literature, it is apparent that inacute coronary heart disease, lack of leaflet coaptation isfrequently visualized (P <0.0l) and fibrosis of the postero-medialpapillary muscle and prolapse of the mitral valve are lacking(P<0.01). A unitary explanation of all forms of mitral regurgitation incoronary heart disease is misleading; mechanisms of mitral regurgitationin coronary heart disease depend on the clinical presentation-acuteor chronic, the site of infarction, and the presence of cardiacdilatation.     

The clinical and hemodynamic significance of mitral regurgitation in coronary artery disease

To evaluate the significance of mitral regurgitation in coronary artery disease (CAD), clinical, electrocardiographic, and angiographic data in 100 coronary artery disease patients with mitral regurgitation were compared to data in 100 coronary artery disease patients without mitral regurgitation. Mitral regurgitation was mild (1+) to moderate (2+) in 94 patients. Heart failure, cardiomegaly, and anterior myocardial infarction were more common in mitral regurgitation patients than in controls (33 vs 4; 47 vs 8; 22 vs 5, respectively, P <0.001). The frequency of inferior myocardial infarction was equal in both groups. Significant left anterior descending and circumflex disease was equally frequent; however, right coronary disease was more frequent in patients with mitral regurgitation (87 vs 68, P <0.001). Total vessel occlusions and triple-vessel disease were more frequent in patients with mitral regurgitation (113 vs 78, P <0.01; 60 vs 40, P <0.001, respectively). No localized area of asynergy was more common in patients or controls, but left ventricular aneurysms and generalized hypokinesis were more common in patients with mitral regurgitation (6 vs 0; 23 vs 2; P <0.001). These data suggest that mitral regurgitation is most often mild, but is associated with significant left ventricular dysfunction and advanced CAD.     

二尖瓣疾病相关的三尖瓣反流

二尖瓣疾病患者常常有三尖瓣反流(TR),后者与不良预后有关。风湿性二尖瓣置换术后如果没有同期处理三尖瓣病变,则TR很常见。纠正二尖瓣病变后TR可能不会消失,可在二尖瓣手术后很多年出现。对三尖瓣疾病患者应详细评估三尖瓣,包括测量三尖瓣环直径。在二尖瓣手术同期用成形环进行三尖瓣环成形是纠正或预防TR的最好方法,可改善生存,预防晚期TR和心力衰竭。