二尖瓣瓣环成形技术

2025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity22025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity32025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity4

国内二尖瓣疾病的病理类型特点2025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity5美国多个研究中心二尖瓣疾病的病理情况

WilliamF.Northrup,TheJournalofHeartValveDisease2003;12:14-242025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity6中国和美国二尖瓣疾病的病理原因分布2025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity7国内二尖瓣疾病病因构成趋势变化2025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity82025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity9二尖瓣不同病理改变时的成形机会二尖瓣不同部位成形的机会2025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity10二尖瓣装置不同部位在不同病理改变下的变化

2025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity11二尖瓣环的解剖结构特点2025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity12二尖瓣环解剖

Mitralannulusanatomy

二尖瓣环分为前瓣环和后瓣环。前瓣环约占整个瓣环的三分之一

(1)左纤维三角---位于二尖瓣前叶与主动脉左冠瓣的接合部(2)右纤维三角---是房室膜性间隔，是二尖瓣，三尖瓣和主动脉根部的交合点,

而且也称之为心脏中心纤维体。2025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity13二尖瓣瓣环的纤维不连续性

Disconnectionofmitralannulus

A：二尖瓣环全部为纤维成分组成

B：二尖瓣环仅左右纤维三角为纤维成分组成

C：二尖瓣环的纤维成分非对称性缺失

D：二尖瓣环的纤维成分间断对称性缺失2025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity14二尖瓣瓣环的立体动态结构

Dynamicstructureofmitralannulus二尖瓣环呈马鞍型(或D型或肾型)，水平和垂直面均可以运动和形态改变，瓣环最小直径与最大直径的比值约为0.75。鞍型瓣环的最高点位于二尖瓣前环中点，二尖瓣环水平方向后瓣环在心脏收缩期移向前环而舒张期远离二尖瓣前环。2025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity15二尖瓣环垂直方向，瓣环整体在心脏收缩期移向心尖方向，舒张期移向左心房方向。二尖瓣瓣环的立体动态结构

DynamicstructureofmitralannulusEndsystoleEnddiastole左心房（LA）左心室（LV）2025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity16二尖瓣瓣环形态与功能临床意义

Clinicalsignificanceofmitralannulusanatomy前瓣环形态和长度改变不明显，后瓣环缺乏纤维条索而薄弱，并且是瓣环不完整现象的主要表现区域，是二尖瓣瓣环扩大的主要部位.进行瓣环成型时主要为后瓣环的矫正PosteriormitralannulusenlargemoreobviouslythananteriorannulusandmustberepairedLefttrigonemarkerRighttrigonemarker2025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity17前瓣环为主动脉左/无冠瓣环的延续，成型时此区域人工瓣环应用并非完全必要，使得应用C形或条带（band）瓣环成为可能。另外要注意缝针不宜过深，以免损伤主动脉瓣。

Anteriorannulusisclosetoaorticvalveandrelativelyfixed.Noneedtofixitagainandshouldnotinjuretheaorticvalve.

二尖瓣瓣环形态与功能临床意义

Clinicalsignificanceofmitralannulusanatomy2025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity18二尖瓣瓣环形态与功能临床意义

Clinicalsignificanceofmitralannulusanatomy2025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity192025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity20AB2025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity21二尖瓣瓣环扩大二尖瓣瓣环钙化

MitralannulusenlargementMitralannuluscalcification二尖瓣瓣环的病变Mitralannuluspathology2025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity22有效瓣口面积二尖瓣前后叶完全开启时的瓣口直径小于二尖瓣环的直径，则二尖瓣的面积与二尖瓣环面积是不同的概念，前者称为有效瓣口面积，表明舒张期通过二尖瓣左房血流的截面积；后者则为潜在瓣口面积。有效瓣口面积与潜在瓣口面积二者比例约为1:1.5~1:2.2。正常人的瓣口面积约为4.0~6.0平方厘米.2025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity23二尖瓣对合面积二尖瓣前后叶粗糙部对合面积，在正常情况下约占瓣叶总面积的20%-40%，是二尖瓣体完成闭合功能的主要部位。不同原因的二尖瓣关闭不全时瓣叶对合面积都有不同程度的损害,增大瓣叶的对合面积则是二尖瓣成型的主要目标.2025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity24二尖瓣对合面积黑色代表二尖瓣闭合时不参加闭合的瓣叶部分。浅色的部分则构成了有效闭合面积。充分的二尖瓣对合面积可以保障长期良好的二尖瓣成形效果2025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity252025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity26ABarlow综合症PhysioRing成形，注水试验后前后叶对合缘作染色B吸净水后，探查对合缘标记以下的前瓣叶高度。生理状况下一般在4-10mm。Barlow综合症者如果对合缘下前瓣叶高度大于10mm则有SAM风险。2025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity27A使用Carpentier-McCarthy-Adams环进行缺血性二尖瓣成形，注水后染色B吸净水后，探查染色对合缘下的后瓣叶高度和对合面积AnyanwuandAdams;JThoracCardiovascSurg2007;133(6):16352025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity28二尖瓣修复的理想结果20042008AnyanwuandAdams;JThoracCardiovascSurg2007;133(6):16352025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity292025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity30SizeprominentlydisplayedViewWindowIntertrigonaldistancemarkers2025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity31安置纤维三角缝线用2-0缝线，分别在两个纤维三角缝合一针，跨度为4mm

瓣环测量把手柄插入塞规，印有“M”的那面朝上。将事先安置好的两个三角区的缝线，分别通过塞规前部的凹槽，用镊子轻轻牵拉前叶，向下推送塞规。如塞规的两个凹槽正好对着两个三角，并且塞规的表面积和前叶的面积相一致，那么这个塞规的大小就是所要选择的人工瓣环的大小。2025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity32安置前瓣环缝线先在两个三角之间的前瓣环间断安置缝线，每针跨度约2mm,缝线上行穿挂人工瓣环的针距宜为2mm,有益前瓣环正常曲度的维持。安置交界和后瓣环缝线在交界处和后瓣环安置缝线，跨度为约4mm。将这些缝线分别穿过人工瓣环，并且在人工瓣环上的跨度为2mm，这样可以起到缩小扩大的后瓣环的作用。通常总共缝合约11-13针，缝合时注意不要缝到回旋支。2025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity33用手柄将人工瓣环向下推到二尖瓣环上，同时向上提缝线,去除手柄后保留瓣环支撑架打结缝线，最后去除瓣环支撑架，完成人工瓣环植入。2025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity34人工瓣膜全环和瓣环塑性带2025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity35

Carpentier-McCarthy-AdamsIMRETlogix瓣膜成形环

Duran人工成形环

国产佰仁思瓣膜成形环

Carpentier-Edwards经典二尖瓣环SJMTailor™Ring2025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity36A.MedtronicDuran瓣环塑形带

B.Cosgrove-Edwards瓣环塑形带

C.SJMTailor®瓣环塑形带

D.CarboMedicsAnnuloFlex®瓣环塑形带2025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity37Carpentier-EdwardsClassicAnnuloplastyRingSolidtitaniumcoreprovidesstrengthanddurability2025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity38Carpentier-EdwardsPhysioAnnuloplastyRingRemodelingpreservesnatural3:4ratiobetweentheanteroposteriordiameterandtransversediameterduringsystole.2025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity39Carpentier-EdwardsPhysioIIAnnuloplastyRing

InventedbyAlainF.Carpentier,MD,PhDandDavidH.Adams,MDDoublesaddleconfiguration

Truesewingcuffdesign

morecircularshape

2025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity40Cosgrove-EdwardsAnnuloplastySystemuseinthemitralortricuspidposition.Flexiblebandadaptstothree-dimensionalcontour2025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity41GeoFormRingRemodelthemitralannulus

Reformtheleftventricle

2025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity42Carpentier-McCarthy-AdamsIMRETlogixAnnuloplastyRingfirstasymmetricringdesignedtotreatasymmetricdilatation.CorrectsforTypeIIIbmitralregurgitation.Decreasedanteroposterior(AP)distanceincreasesleafletcoaptation.IncreasedsewingmarginintheP2-P3region,markedwithsuture,designedtoaccommodateadouble-suturerow.2025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity43MedtronicFullyrigid

Profile3DRing

MedtronicSemi-rigidCGFutureRingandBandSystem2025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity44MedtronicFlexible

DuranAnCoreRingandBandSystem

Thisflexibilityallowsyourrepairedmitralortricuspidvalvetocontinuouslymoveandchangeshapeandsizejustasanaturalvalvedoes.2025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity45SorinMEMO3DTMSemirigidAnnuloplastyRing2025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity46St-JudeflexibleTailor™RingIndicatedforbothmitralandtricuspidvalverepair.RingcaneasilybecustomizedtoaC-ring(band).2025/1/7©2009byDr.MengXu,BeijingAnzhenHospital,CapitalMedicalUniversity47解剖变化

空间构型变化-风湿性 -心肌病

-退行性