左心室衰竭的手术治疗西方的观点-课件幻灯

IrvingL.Kron.M.D.充血性心力衰竭美国的患者人数>5百万每年新增的患者数400,000~700,000发病率升高–人口老龄化每年耗资超过100亿美元其中75%为住院费用心脏移植和心力衰竭

30-天死亡率 37% 3-年存活率 15%HochbergMS,etal.JTCV86:519-27,1983Kron,etal.AnnSurg210:348-54,1989心室功能p<0.05结果院内存活院内死亡预测因子N=88N=8年龄(岁)62.6±0.968.8±2.0*心绞痛稳定型80%(70)75%(6)不稳定型11%(10)12.5%(1)无9%(8)12.5%(1)EF(%)20.3±0.3420.3±2.0*p<0.05comparedtoageofsurvivors结果院内存活院内死亡血管条件N=50N=7好90%(45)0%中等10%(5)0%差0%100%(7)**p<0.05comparedtovesselqualityinsurvivorsLangenbergSA,etal.AnnThorSurg.Nov60(5):1193-6,1995结论Yamaguchietal.AnnThoracSurg.1998;65:434-8存活率和LVESVI心力衰竭和LVESVIDor,etal.JThoracCardiovascSurg1998;116:50-9.Dor,etal.JTCVS116:50-9,1998MaxeyTS,KronIL,etalJThoracCardiovascSurg.2004Feb;127(2):428-34CABG(n=39)CABG+VR(n=56)年龄68.4±5.163.1±6.2性别31M,8F42M,14F手术前EF(%)25.75±0.7422.07±1.12左心室舒张末直径(cm)6.4±0.36.5±0.3NYHA分级III-IV3755二尖瓣返流2230CABG(n=39)CABG+VR(n=56)单纯不稳定型心绞痛2220单纯心力衰竭814心绞痛&心力衰竭916休克06*CABG(n=39)CABG+VR(n=56)#移植物3.4±0.82.6±1.0MV修补2214缺血时间(分钟)81±2290±28CPB时间(分钟)104135手术死亡率00预后数据CABG(n=39)CABG+VR(n=56)手术后EF(%)29.03±0.61(提高5%)33.43±1.22*(提高11%)手术死亡率00住院时间(天)6.9±1.97.9±2.0反复心力衰竭18%4%*远期死亡率5.1%1.8%**p<0.05结论那么哪些是最佳适应症?心室增大前壁无运动或运动减弱远端血管条件好存在心肌缺血的证据主动脉无动脉粥样硬化心室-二尖瓣复合物一场拔河比赛二尖瓣修补

缺血性MR的治疗方法恢复瓣的功能保存瓣下结构从而保持正常的瓣环瓣膜结构关系，以保存其正常功能参数修补术置换术p

值感染5/547/560.586休克2/542/561.00肺部合并症20/5418/560.589肾功能不全8/5410/560.666合并症/患者数1.5±0.21.7±0.20.450Reeceetal,AnnSurg.2004May;239(5):671-5;discussion675-7修补术置换术死亡率1/546/56p<0.05住院时间913p<0.05T.BrettReeceetal,AnnSurg.2004May;239(5):671-5;discussion675-7Tethered瓣叶Anterior

PapillaryMuscleMitralLeafletsAnt.PostNormal

PPMDisplacedPPMMRLALAMRLV复位缝合缺血性MR–结果

n=1050~

1+MR手术后TEE100%30-天死亡率3%5年总存活率87.3%手术后5-年未复发率100%复发性MR5%GazoniLM,etal.AnnThoracSurg2007Sep;84(3):750-7;discussion758心脏移植术(UNOS2须花费$30,000)5.8%CABG4.0%二尖瓣修补联合CABG6.7%左心室成形术4.0%Copeetal,AnnThoracSurg2001;(72)1298-305心脏移植术(UNOS2须花费$30,000)$76,000CABG$25,000二尖瓣修补联合CABG$32,000左心室成形术$27,000Copeetal,AnnThoracSurg2001;(72)1298-305“每一个问题都有一个解答：简单的，明了的，或错误的”-H.L.MenckenSurgeryfortheFailing

LeftVentricle-

PerspectiveWestIrvingL.Kron.M.D.CongestiveHeartFailure>5millionAmericansaffected400,000to700,000newcases/yrIncreasingincidence-elderlypopulationAnnualcostexceeds$10billion75%ofthecostduetohospitalizationTransplantation&HeartFailure“Atanygivenday,thechanceofgettingaheartforamalebloodtypeOislessthangettinghitbylightning.”–C.VanMeter“Theideaoftreatingheartfailurewithtransplantationisliketreatingpovertywiththelottery.”–L.W.StevensonPriortothemid1980’s,CABGinpatientswithEF<20%associatedwithprohibitivemortality

30-daymortality 37% 3-yearsurvival 15%HochbergMS,etal.JTCV86:519-27,1983CABGforlowEF

OperativeMortality=2.6%(1/39)Kron,etal.AnnSurg210:348-54,1989VentricularFunction23patientshadlatepostoperativemeasurementsofleftventricularfunction Pre-operativeEF 18.6 Post-operativeEF 26.0p<0.05ResultsHospitalSurvivorsHospitalDeathsPredictorsN=88N=8Age(years)62.6±0.968.8±2.0*Angina

Stable80%(70)75%(6)

Unstable11%(10)12.5%(1)

None9%(8)12.5%(1)EF(%)20.3±0.3420.3±2.0*p<0.05comparedtoageofsurvivorsResultsHospitalSurvivorsHospitalDeathsVesselqualityN=50N=7Good90%(45)0%Fair10%(5)0%Poor0%100%(7)**p<0.05comparedtovesselqualityinsurvivorsLangenbergSA,etal.AnnThorSurg.Nov60(5):1193-6,1995ConclusionsCABGforlowEFhasthebestresultsWhenthereisevidenceofischemiaWhendistalvesselsareofgoodquality(completerevascularization)AsaprimaryoperationLeftVentricularVolumePredicts

PostoperativeSurvivalinIschemicCardiomyopathy41patientsundergoingCABGwithEF<30%TwooperativedeathsSixlatedeaths16patientsfoundtohaveLVend-systolicvolumeindices(LVESVI)>100ml/m2Yamaguchietal.AnnThoracSurg.1998;65:434-8SurvivalandLVESVIHeartFailureandLVESVIDorProcedureinAkineticScars

CentreCardiothoraciquedeMonaco(n=100)Akineticscar(n=51)vs.dyskineticscar(n=49)

ConcomitantCABG 98% HospitalMortality 12%PatientswitheitherlargeakineticordyskineticscarandsevereLVdysfunctionimprovedearlyandlateNYHAclassandEFDor,etal.JThoracCardiovascSurg1998;116:50-9.Dor,etal.JTCVS116:50-9,1998“CoronaryArteryBypasswithVentricularRemodelingisSuperiortoCoronaryArteryBypassAloneinPatientswithIschemicCardiomyopathy”MaxeyTS,KronIL,etalJThoracCardiovascSurg.2004Feb;127(2):428-34PreoperativeComparisonsCABG(n=39)CABG+VR(n=56)Age68.4±5.163.1±6.2Sex31M,8F42M,14FPreoperativeEF(%)25.75±0.7422.07±1.12LVEDdiameter(cm)6.4±0.36.5±0.3NYHAclassIII-IV3755Mitralregurgitation2230IndicationforOperationCABG(n=39)CABG+VR(n=56)Unstableanginaalone2220CHFalone814Angina&CHF916Shock06*IntraoperativeDataCABG(n=39)CABG+VR(n=56)#grafts3.4±0.82.6±1.0MVrepair2214Ischemictime(min)81±2290±28CPBtime(min)104135Operativemortality00OutcomeDataCABG(n=39)CABG+VR(n=56)PostoperativeEF(%)29.03±0.61(5%increase)33.43±1.22*(11%increase)Operativemortality00Hospitalstay(days)6.9±1.97.9±2.0Recurrentheartfailure18%4%*Long-termmortality5.1%1.8%**p<0.05ConclusionsCABG&ventricularremodelingimproveleftventricularfunctioninpatientswithischemiaandventricularenlargementVentricularremodelingaffordssignificantimprovementinEFcomparedtoCABGalone,withoutaddedmortalitySowhoisthebestcandidate?LargeventricleAnteriorakinesisordyskinesiaGooddistalvesselsEvidenceofischemiaLackofaorticatherosclerosisSurgicalTherapyforIschemicMitralRegurgitationSurgicalApproachesReplacementAnnuloplastyLeafletextensionPosteriorpapillaryrepositioningDorMitralValveRepair

TechniqueforIschemicMRRestorevalvularcompetencePreservationofsubvalvularapparatusThuspreservationofnaturalannulovalvularrelationshipforfunctionalpreservationMitralRepairisSuperiortoReplacementWhenAssociatedwithCoronaryArteryDiseaseVariableRepairReplacementpvalueInfection5/547/560.586Stroke2/542/561.00PulmonaryComplication20/5418/560.589RenalInsufficiency8/5410/560.666Complication/patient1.5±0.21.7±0.20.450Reeceetal,AnnSurg.2004May;239(5):671-5;discussion675-7

RepairReplacementMortality1/546/56p<0.05HospitalStay913p<0.05MitralRepairisSuperiortoReplacementWhenAssociatedwithCoronaryArteryDiseaseT.BrettReeceetal,AnnSurg.2004May;239(5):671-5;discussion675-7TetheredLeafletAnterior

PapillaryMuscleMitralLeafletsAnt.PostNormal

PPMDisplacedPPMMRLALAMRLVRepositioningStitchIschemicMR–Results

n=1050to1+MRpost-opTEE100%30-daymortality3%Overall5-yearsurvival87.3%5-year