保留二尖瓣后瓣下结构的二尖瓣置换术对左室构型及功能的影响

1、保留二尖瓣后瓣下结构的二尖瓣置换术对左室构型及功能的影响                   作者：刘进平, 韩涛, 徐驯宇, 郭薇, 黄烽, 李梅珍  【关键词】  二尖瓣;,心脏瓣膜假体置入;,心室重构;,心室功能,左;,心缩期摘要: 目的 评价保留二尖瓣后瓣下结构的二尖瓣置换术对左室构型及功能的影响。方法 选择因慢性风湿性心瓣膜病而行二尖瓣置换术(MVR)者79例,其中保留二尖瓣后瓣下结构组

2、(MVRP)40例,不保留二尖瓣后瓣下结构组(MVRNP)39例,再根据病因不同分为二尖瓣狭窄(MS)组29例(MVRP 14例,MVRNP 15例),二尖瓣关闭不全(MI)组27例(MVRP 15例,MVRNP 12例)和双瓣置换术(DVR)组23例(MVRP 11例,MVRNP 12例)。分别于术前、术后7 d和3月三维超声测量左房面积(LAA)、左室短轴缩短率(FS)、左室舒张期末容积(LVEDV)及收缩期末容积(LVESV)，并计算左室射血分数(LVEF)。 结果 术后3月,MVRP组MI及DVR患者FS、LVESV、LVEF、LAA及LVEDV优于MVRNP组(P<0.05);

3、两组MS患者差别无统计学意义(P>0.05); MVRP组左室构型呈椭圆形,MVRNP组呈偏心形或圆形。结论  与不保留二尖瓣后瓣下结构的MVR术比较,保留二尖瓣后瓣瓣下结构的MVR术对于MI、DVR患者更有利于改善左室构型及左室功能。关键词: 二尖瓣; 心脏瓣膜假体置入; 心室重构; 心室功能,左; 心缩期ABSTRACT: Objective To make an evaluation of the effect of mitral valve replacement(MVR) with the subvalvular preservation on the configu

4、ration and function of left ventricle.        Methods 79 patients with chronic rheumatic valvular disease were taken and divided into two groups according to the form of operations: the mitral valve subvalvular preservation(MVRP) group(n=40) and the non preservatio

5、n(MVRNP) group(n=39).        The mitral valve stenosis(MS) group was 29 cases(including 14 MVRP and 15 MVRNP), the mitral incompetence(MI) group was  27 cases(including 15 MVRP and 12 MVRNP), and the double valve replacement(DVR)group was 23 cases(including 11

6、 MVRP and 12 MVRNP). The left atria area(LAA), fractional shortening(FS), left ventricular enddiastolic volume(LVEDV) and left ventricle endsystolic volume(LVESV) before 7 days and 3 months after the operation were measured with 3D ultrasonometry and the ejection fraction was calculated, respectivel

7、y.Results The FS, LVESV and LVEF of patients in MI and DVR subgroups in MVRP group were more ameliorated than that in MVRNP group(P<0.05) 3 months after the operation.The LAA and LVEDV of patients in MI and DVR subgroups in MVRP group were more ameliorated than in MVRNP group(P<0.05) 3 months

8、after the operation.The configuration in MVRP group of MI and DVR 3 months after operations was ovalshap, but in MVRNP group was offcenter or even globular, although was no significant difference in MS patients between MVRP and MVRNP groups(P>0.05) 3 months after the operation.Conclusion The oper

9、ation of posterior subvalvular preservation are more favorable in improving the configuration and function of left ventricle for MI and DVR patients.KEY WORDS: mitral valve; heart valve prosthesis implantation; ventricular remodeling; ventricular function,left; systole     &

10、#160;          二尖瓣置换术(MVR)为外科治疗风湿性心瓣膜病二尖瓣病变的主要方法,然而对是否保留瓣下结构目前尚存有争议。本研究采用实时三维超声心动图重建左室三维图像技术,测定患者手术前后左室容积、左室功能及左房内径,评价保留二尖瓣后瓣下结构的MVR术是否有利于改善左室构型及功能。1 对象与方法1.1 对象一般资料        选取2005年7月2006年5月因慢性风湿性心瓣膜病在福建省立医院施行MVR术病例79例,男性

11、29例,女性50例,年龄(45.6±8.6)岁(2169岁)。其中保留二尖瓣后瓣下结构MVR术(MVRP)40例,不保留二尖瓣后瓣下结构MVR术(MVRNP)39例。根据病因分为二尖瓣狭窄(MS,二尖瓣口面积<1.2 cm2,反流2)29例,其中MVRP 14例,MVRNP 15例;二尖瓣关闭不全(MI,二尖瓣口面积>1.2 cm2,反流34)27例,其中MVRP 15例,MVRNP 12例;因主动脉瓣和二尖瓣病变行双瓣置换术(DVR)23例,其中MVRP 11例,MVRNP 12例。MVRNP组住院期间死亡1例,死因ARDS(死前床边心脏超声提示左心功能基本正常);MV

12、RP组术后3月猝死1例,死因不明(未尸检)。其他患者术后3个月心功能均恢复至级。MVRP组行MVR时切除前瓣及腱索,原位保留后瓣及腱索1,如果患者因腱索病变严重不宜保留,则以GorTex人工腱索缝于后瓣原腱索附着处,借此保留乳头肌瓣环的连续性2;MVRNP组行传统MVR术,即全部切除二尖瓣后瓣下结构。1.2   三维超声心动图检测彩色超声诊断仪(Sonos 7500型,荷兰Philips公司)及带有4D Cardio View RT容积分析软件的三维工作站(德国Tomtec公司)。患者于术前、术后7 d、3月(随访)行实时三维心脏超声(RT3DE)检查。采集图像后选取多切面测定左房面积(LAA)、左室短轴缩短率(FS)等二维参数,然后用Tomtec Cardio Viewer分析软件进行三维超声左室重建,测定左室收缩末容积(LVESV)、舒张末容积(LVEDV)并计算左室