限制性二尖瓣成型聯(lián)合cabg治療缺血性二尖瓣返流

1、限制性二尖瓣成型聯(lián)合cabg治療缺血性二尖瓣返流缺血性二尖瓣返流（ischemic mitral regurgitation, IMR）-CAD、心肌缺血/心肌梗塞引起的乳頭肌功能不全、左心功能不全、瓣環(huán)擴(kuò)大等造成的二尖瓣關(guān)閉不全。這類病人在進(jìn)行心臟冠狀動脈搭橋手術(shù)時常常需要考慮是否同時處理IMR。MVR 是治療二尖瓣關(guān)閉不全的有效手段，但術(shù)后常需要長期或短期抗凝，出血或/和血栓栓塞的發(fā)生率可達(dá)2-7%/年（1），人工瓣膜本身還可能發(fā)生心內(nèi)膜炎、瓣周漏、溶血等，嚴(yán)重影響病人的遠(yuǎn)期效果。 良好的二尖瓣成型技術(shù)-治療IMR的有效手段，-完全避免與人工瓣相關(guān)的并發(fā)癥-降低手術(shù)死亡率-提高患者生存質(zhì)量

2、和遠(yuǎn)期效果。臨床資料一般資料： 72 例 伴有中重度IMR（3-4+，3.50.6）的冠心病人接受了同時CABG+限制性二尖瓣成型男:女 = 59 : 13年齡 55-83 ( 67.25.7) 歲，70歲以上病人33例心電圖: 陳舊性Q波心肌梗塞-66例TTE : 中-重度返流 (3+) 40 例重度返流 (4+) 32 例LVEDD 55-81 (64.211.5) mm,LAD 52-74(58.06.2)mmLVEF 45% 41例。同時合并三尖瓣中重度返流10例。CAG：雙支病變7例，65例三支病變，同時合并LM狹窄 16例。 同時合并左心室壁瘤18例。手術(shù)前心功能 NYHA II級

3、15例、III和IV級分別為42例和15例合并疾病: 高血壓病37例，糖尿病29例，心衰史41例，慢性心房纖顫10例，腎功能異常17例，腦中風(fēng)史16例。5例嚴(yán)重左主干病變伴術(shù)前不穩(wěn)定心絞痛主動脈內(nèi)球囊反搏（IABP）1：1輔助下急診手術(shù)。方 法常規(guī)放置Swan-Gaze導(dǎo)管，監(jiān)測PA, PCWP術(shù)中（TEE）：評價二尖瓣功能狀態(tài)、心臟功能和成型效果。72例均在全麻體外循環(huán)下經(jīng)胸骨正中切口手術(shù)。開胸后先取左乳內(nèi)動脈，同時取橈動脈和大隱靜脈備用。常規(guī) CPB。阻斷主動脈，心肌保護(hù)采用經(jīng)主動脈根部順行灌注含血心肌保護(hù)液，結(jié)合經(jīng)“橋”灌注。合并主動脈瓣病變者切開升主動脈，經(jīng)冠狀動脈開口直接冷灌。手術(shù)中

4、先處理室壁瘤，然后進(jìn)行冠狀動脈遠(yuǎn)端吻合，再經(jīng)右房房間隔途徑暴露和處理二尖瓣。手術(shù)中TEE觀察二尖瓣膜成型效果。術(shù)中探查結(jié)合TEE見二尖瓣膜返流的原因 二尖瓣環(huán)擴(kuò)大引起的IMR-Carpentie I型- 54例手術(shù)中探查結(jié)合TEE-二尖瓣返流原因 心腔明顯擴(kuò)大、乳頭肌肉移位引起腱索乳頭肌功能而導(dǎo)致二尖瓣返流-Carpentier IIIb -18例手術(shù)中用二尖瓣成型的測瓣器，根據(jù)二尖瓣前后葉交界間的距離和前葉的面積，測得所需成型環(huán)的大小，實(shí)際植入的二尖瓣成型環(huán)均比測量的小一到二號2-0 Ticron線不帶墊片間斷褥式縫合植入二尖瓣成型環(huán)，注水實(shí)驗(yàn)觀察二尖瓣返流矯正情況。同時主動脈置換者在升主動

5、脈一次阻斷下完成近端吻合，單純二尖瓣成型者在升主動脈側(cè)壁鉗下完成近端吻合。主動脈開放前先開放乳內(nèi)動脈橋，并左心排氣主動脈開放后進(jìn)行三尖瓣成型。 結(jié) 果72例均放置二尖瓣成型環(huán)（16例為C 型環(huán)，56例為0型全環(huán)）冠狀動脈遠(yuǎn)端吻合人均3.41.3（3-6）個。應(yīng)用左乳內(nèi)動脈71例，21支靜脈橋?yàn)樾蜇灤顦颉Ｍ瑫r行主動脈瓣置換9例，三尖瓣成型10例，室壁瘤線性切除6例，心內(nèi)補(bǔ)片左室成型12例。主動脈阻斷時間55-126 min，平均7822 min；CPB時間 78-170 min，平均12239 min。 手術(shù)中成型后TEE：二尖瓣無和微量反流28和35例，輕度返流6例，輕-中度返流3例，中-重度

6、返流1例（再次CPB下行二尖瓣置換，原位保留全部二尖瓣裝置植入27#生物瓣）。手術(shù)后共18例帶IABP回ICU，IABP支持15-112小時。15例在手術(shù)后72小時內(nèi)拔除IABP。 手術(shù)后并發(fā)癥二次開胸止血2例；新發(fā)房顫22例（20例藥物治療后轉(zhuǎn)成竇性心律）9例病人拔除氣管插管后因低氧血癥需無創(chuàng)呼吸機(jī)輔助 ，1例需再次氣管插管呼吸機(jī)輔助；腎功能損害加重行 CRRT 4 例；腦中風(fēng)1例；下肢切口感染2例 圍手術(shù)期死亡3例：低心排合并多臟器功能衰竭2例，手術(shù)后急性腎功能衰竭伴肺部嚴(yán)重感染1例，分別在術(shù)后3、7和14天死亡，手術(shù)死亡率4.2%68例（轉(zhuǎn)成二尖瓣置換1例除外）康復(fù)出院。 隨 訪手術(shù)后隨

7、訪6-60個月（平均 22.8月）， 隨訪滿6月的66例（死亡2例，心源性死亡1例） 6-12月的66例（死亡2例，非心源性死亡） 12月的56例（累計心源性死亡3例） 24月的40例（累計心源性死亡5例）?；颊咝墓δ芨纳?，心絞痛均消失。手術(shù)后3、6、12、24月，分別經(jīng)胸超聲心動圖檢查（表1），手術(shù)后IMR均得到明顯改善，左房和左室舒張末期內(nèi)徑明顯縮小，隨訪期間無二次手術(shù)。表1 二尖瓣成型手術(shù)前后超聲檢查結(jié)果 術(shù)前 術(shù)終 術(shù)后2周 3月 6月 12 月 24月 P value病人總數(shù) 72 71* 71 71 66 56 40 累計死亡數(shù) - - 3 3 5 7 8 生存率% 96 96 9

8、2 88 80二尖瓣反流程度3.30.6 0.40.4 0.40.4 0.50.6 0.50.6 0.70.7 0.70.6 0.01EF% 5014 - 5415 5317 5414 5418 5515 0.01LVEDD 6411 - 5710 5511 569 5712 5514 0.01LA 586 - 535 497 506 486 497 0.01*1例轉(zhuǎn)成二尖瓣置換除外討 論一、手術(shù)指征： 與單純搭橋相比，同時搭橋和心臟瓣膜手術(shù)明顯增加手術(shù)死亡率2，但如果不處理已經(jīng)存在的明顯IMR，又明顯降低遠(yuǎn)期生存率。 因此手術(shù)中決定是否處理IMR明顯影響手術(shù)效果。 術(shù)中TEE評價IMR時，應(yīng)

9、保證心臟良好的前后負(fù)荷，否則可能低估IMR的程度，影響手術(shù)方案2。 雖然 Seipelt5等的262例病人結(jié)果顯示搭橋同時二尖瓣成型置換雖不影響手術(shù)后早期效果，但缺血性二尖瓣病變組手術(shù)死亡率明顯高于非缺血組（19.5% vs 6.7%, P=0.002）。Bonacchi等6分析了180例伴LV功能減退和IMR病人，結(jié)果顯示，對輕-中度IMR，單純搭橋手術(shù)后生存率滿意，IMR也得到明顯改善，但遠(yuǎn)期無事件生存率低于同時MVP病人，提示即使輕-中度IMR，也應(yīng)該積極處理。下壁MI-IMR的重要危險因素本組56%有明確陳舊性下壁Q波心肌梗塞，主要是因?yàn)橄卤谛墓：蟮男氖抑貥?gòu)，嚴(yán)重影響二尖瓣裝置的幾何形

10、狀，導(dǎo)致后乳頭肌向外側(cè)移位，腱索牽拉過緊影響二尖瓣的關(guān)閉，產(chǎn)生IMR。Kumanohoso7分析了103例心肌梗塞病人，61例前壁，42例下壁心梗，雖然下壁MI對LV功能影響小于前壁MI，但下壁心梗病人IMR的發(fā)生率38%（16/42）和返流程度（返流面積）（10.1%+7.5%）均明顯高于前壁心梗(10%)（6/61，P.0001)，（4.4%7.0%, P=.0002）。作者體會/經(jīng)驗(yàn)冠心病人伴輕-中度IMR，如果左房和左室大小正常，左室功能也正常，可以僅行冠狀動脈搭橋但對中度和中度以上的IMR者，伴心室功能已經(jīng)減退，特別是心臟已經(jīng)明顯擴(kuò)大者，需要積極處理；對有陳舊性下壁Q波心梗，左室功能

11、明顯減退病人的IMR處理應(yīng)更加積極，以提高手術(shù)后遠(yuǎn)期的無事件生存率。對存在多種手術(shù)危險因素的中度IMR病人，單純搭橋可能降低手術(shù)死亡率8,需要綜合考慮，決定是否同時處理IMR。冠狀動脈靶血管的條件也是影響手術(shù)指征的重要因素對手術(shù)前左心室EF60歲，兩組的遠(yuǎn)期生存率無明顯差異。本組1例病人關(guān)胸前TEE顯示成型效果不滿意，再次CPB下瓣膜置換，未增加術(shù)后并發(fā)癥。限制性二尖瓣成型 Bolling 最早提出采用限制性二尖瓣成型治療終末期心肌病伴重度二尖瓣反流，取得了較好的早期效果3但關(guān)于缺血性心臟病伴中重度二尖瓣反流的病人行冠狀動脈搭橋和限制性二尖瓣成型的報道不多本組二尖瓣環(huán)擴(kuò)大引起的IMR即所謂Ca

12、rpentie I型IMR（本組54例），以及因心腔明顯擴(kuò)大，乳頭肌肉移位引起腱索乳頭肌功能而導(dǎo)致二尖瓣返流（Carpentier IIIb型）（本組18例）病人，在搭橋同時均植入二尖瓣成型環(huán)，效果滿意。我們手術(shù)中在成型環(huán)植入前，先在左右纖維三角處各縫一針褥式縫合，再根據(jù)兩纖維三角之間的距離和二尖瓣前瓣葉的大小測得成型環(huán)大小，實(shí)際上采用的成型環(huán)比測得的小一到二個號，達(dá)到限制性二尖瓣成型。Geidel也強(qiáng)調(diào)Downsizing 二尖瓣成型可以提高遠(yuǎn)期效果12。本組男性病人多采用28#30#的成型環(huán)，女性病人多采用26-28#的成型環(huán)，平均隨訪22.8月，中期臨床效果滿意。Bax11等報告51例中

13、-重度IMR伴左室功能減退的冠狀動脈搭橋病人，手術(shù)中采用比正常小兩號的成型環(huán)，手術(shù)死亡率5.6%，手術(shù)后左房左室均明顯縮小，隨訪兩年生存率84% 。二尖瓣成型環(huán)的選擇對稱成型環(huán)：“O”型和“C”型，雖然在IMR主要是后瓣環(huán)擴(kuò)大，理論上采用“C型環(huán)”將后瓣環(huán)縮小即能糾正IMR，但二尖瓣的前后徑擴(kuò)大也是導(dǎo)致前后瓣葉不能滿意對合的重要原因，因此，“O型”環(huán)可以保證更滿意的遠(yuǎn)期效果。二尖瓣非對稱成型環(huán)（ETlogix）用于治療IMR，解剖上更加符合生理，臨床應(yīng)用的近期效果十分滿意，遠(yuǎn)期效果還需要時間證實(shí)。“”型環(huán)能更好的維持二尖瓣環(huán)前后徑距離IMR的治療有二尖瓣成型和二尖瓣置換。從發(fā)病機(jī)制來看，IMR

14、主要是因?yàn)榘戥h(huán)明顯擴(kuò)大或瓣下裝置（腱索、乳頭?。┊惓?，而瓣葉常常無明顯異常病變。Reece等14報告110 IMR中，54例病人搭橋+二尖瓣成型，56例搭橋+換瓣（保留瓣下裝置），但手術(shù)死亡率有明顯差異（1.9% vs 10.7%），提示即使瓣膜置換病人均保留瓣下裝置，瓣膜修復(fù)仍有明顯優(yōu)勢。二尖瓣成型可明顯改善左室功能和幾何形狀，成型組的遠(yuǎn)期生存率明顯高于換瓣組6。所以對IMR病人應(yīng)盡可能爭取行瓣膜成 Intraoperative TEEPre-ImplantPost-ImplantKang等8分析了107例中重度IMR病人，50例成型，57例僅搭橋，成型組手術(shù)死亡率12%，明顯高于單純搭橋組

15、(2%),但五年生存率相似（88%5% versus 87%6%），多元回歸分析顯示：高齡、心功能差、房顫是手術(shù)死亡的獨(dú)立預(yù)測因素(P0.05)。在重度IMR病人，成型后所有病人IMR均明顯改善，而單純搭橋組僅67%病人的IMR得到改善(P0.001)。但在中度IMR病人，兩組IMR改善率相似(75% versus 67%, P=NS)，提示二尖瓣成型可以有效改善IMR，但對合并有高齡、房顫等手術(shù)高危因素的中度IMR病人，搭橋同時二尖瓣成型可增加手術(shù)死亡率。 年齡是影響手術(shù)效果的重要因素之一15，高齡病人手術(shù)后易發(fā)生肺部并發(fā)癥，本組手術(shù)后8例病人拔除氣管插管后因低氧血癥需無創(chuàng)呼吸機(jī)輔助，其中6

16、例為70歲以上病人。故手術(shù)后加強(qiáng)肺部并發(fā)癥的防止，對高齡病人更為重要。手術(shù)后低心排仍是主要的死亡原因（本組兩例），對有明顯低心排表現(xiàn)，及早應(yīng)用主動脈內(nèi)球囊反搏，幫助穩(wěn)定血液動力學(xué)。本組對手術(shù)前LVEF 70 in 33.ECG: old MI with q wave in 56.TTE : Moderate-severe (3+) 40 Severe (4+) 32 LVEDD 55-81 (64.211.5) mm, LAD 52-74(58.06.2)mm LVEF 45% 41Morderate-severe TVR in 10CAG：double-vessel disease in 7

17、, triple-vessel in 65, severe LM disease in 16 LV aneurysm in 18NYHA: class in 15, class III in 42 and class IV in 15. Co morbidity: high blood pressure 37 diabetes mellitus 29 history of heart failure 41 history of stroke 16 chronic AF 10 renal dysfunction 17Emergency op in 5 severe LM disease with

18、 unstable angina with IABPMethods Swan-Gaze monitored PA and PCWP TEE assessed LV function , degree of MR and effect of MVPMidline sternotomy was preferred, IMA and GSV were harvested, RA was used selectivelyCPB with intermittent antegrade cardioplegia combined with “graft” perfusion. Direct CA orif

19、ice perfusion was performed if AI was present Ventricular aneurysm was first disposed, then distal anastomosis was performed, the right atrium was opened and MVR was performed through a transseptal approach. Intraoperative exploration and TEE identified the mechanisms of MR. TEE evaluated the effect

20、 of MVP. Annular dilatation (Carpentie I) in 54Exploration and TEE identify the mechanisms of MR Cardiac chamber dilatation /transposition and dysfunction of chordae tendineae /papillary muscle (Carpentier type IIIb) in 18 MVP ring size was determined by standard measurement of the intertrigonal dis

21、tance and anterior leaflet height. Restrictive annuloplasty was performed with an undersized semirigid ring (downsizing 1-2 sizes). The rings were anchored using multiple (1416) deep U-shaped stitches of 2-0 Ticron without mattress. Precise evaluation of preserved valve symmetry and proper leaflet c

22、oaptation was obtained by ventricular filling with saline solution. other concomitant procedures and proximal CABG anastomosis were performed.Results All had Mitral annuloplasty ring (“C” type in 16 and “O” type in 56). Average number of graft was 3.41.3(range, 3-6). Concomitant procedures AVR 9 , T

23、VP 10 linear repair of LV aneurysm 6 SVR (patch endoaneurysmorrhaphy) 12Mean CPB time 12239 min (range, 78-170) mean X-clamp 7822 min (range, 55- 126).Intraoperative TEE: no residual MR in 28, minimal 35 1+ in 6, 12+ in 3 2+-3+ MR in 1 (who received a 27# MVP with entire preservation of subvalvular

24、apparatus in situ)18 cases needed IABP support when entered ICU, IABP time was 15 -112h, 15 cases were supported less than 72h.Post-op complications Re-operation for bleeding in 3 casesAF in 22 cases, 20 converted to SR by medicationre-intubation in 1, non-invasive breathing machine was used in 9, t

25、emporary dialysis in 4stroke in 1 and wound infection of lower extremities in 2Perioperative mortality was 4.2% (3 patients): LCOS with multi-organ failure in 2 patients, acute renal failure with severe pulmonary infection in 1. 68 cases (except MVR in 1 case) discharged. Follow-up The follow-up tim

26、e was 6-60 months (mean, 22.8). The follow-up transthoracic UCG (3,6,12,24 months post-op) showed that the IMRs were rectified satisfactory with an improved cardiac function (Table 1). All patients were free of angina pectoris and re-operation for recurrent MR . Table 1. Follow-up outcomes and pre-

27、/post-op UCG Pre- post- 2w post- 6m 12m 24m P N 72 71* 71 71 66 56 40 N of death - - 3 3 5 7 8 Survival(%) 96 96 92 88 80IMR 3.30.6 0.40.4 0.40.4 0.50.6 0.50.6 0.70.7 0.70.6 0.01EF% 4514 - 5415 5317 5414 5418 5515 0.01LVEDD 6411 - 5710 5511 569 5712 5514 0.01LA 586 - 535 497 506 486 497 0.01*1 case

28、converted to MVR was excludedDiscussionIndications for IMR:CABG Combined with valvular procedure had a higher mortality; but CABG alone came out with a lower long-term survival rate.IMR effected surgical outcomes. Preload and afterload conditions influenced the severity of MR presented on TEE. Seipe

29、lt et al. reported on a retrospective analysis of 262 patients who received either CABG and MVP or CABG alone, the former had a higher motality (19.5% vs 6.7%, P=0.002). Bonacchi et al. analyzed 180 patients with IMR and LV dysfunction, in mild-moderate IMR group, CABG brought a low mortality and a

30、low IMR grade, but long-term survival rate without cardiac event was lower than those received combined CABG and annuloplasty, which indicated that even mild-moderate IMR should be rectified aggressively. Posterior MI -an important risk factor of IMRIn this study, 56% cases had posterior MI with q w

31、ave. The mechanisms: LV remodeling after posterior MI had a more severe negative impact on the geometry of mitral apparatus, especially on the posterior papillary muscles and chorda tendineae which were dragged laterally, any forms of mis-coaptation of MV might lead to the presence of regurgitation.

32、 Kumanohosos report about 103 MI patients (61 anterior MI and 42 posterior MI ) indicated that posterior MI had a less impact on LV function but a higher impact on IMR (rate: 38%, 16/42 Vs 10%, 6/61, P.0001; degree: 10.17.5% Vs 4.47.0%, P=0.0002) Kang: 107 3-4+ IMR.severe IMR was attenuated dramatic

33、ally by CABG combined with MVP, only 67% in CABG alone (P0.001); but to moderate IMR, the rate was similar (75% Vs 67%, P=NS).-Only 4+ IMR need MVPOur experiencesCAD patient with a normal LV chamber and function who has a mild-moderate IMR-CABG Moderate-severe IMR with decreased LV function, especia

34、lly with dilated cardiac chambers, CABG+ annuloplastyModerate-severe IMR with an old posterior q wave MI and with a severe decreased LV function, CABG+ MVP or MVR must be performedFor high risk patient with moderate IMR, CABG alone had a lower motality, an overall evaluation-Balance the risk and ben

35、ifits. The condition of target vessels is an important factorFor CAD patients with low LVEF (30%), revascularization was preferred aggressively if patients had good target vessels, but if diffused coronary was present, revascularization should be performed cautiously. Operative experiences: importan

36、t in choosing operative approach For aged cases, MVR was a good alternative if MVP was not reliable. In this study, 1 patient was converted to MVR since TEE showed that the annuloplasty was unsatisfactory. Thouranis reported that combined procedures increased operative risks, but in 60 years group,

37、long-term survival rate was of no difference between MVP and MVR groups.Restrictive annuloplasty Bolling - frist introduced for end-stage cardiomyopathy with severe MR- with a good short-term results. The reports about the treatment of ischemic cardiomyopathy by CABG combined with restrictive MVP ar

38、e scare.In this study, IMR was divided 2 groups : annular dilatation (Carpentier type I in 54 cases); dilatation of cardiac chamber, displacement of papillary muscles and dysfunction of chordae tendineaes (Carpentier type IIIb in 18 cases). Annuloplasty ring was applied in each case.MVP ring - downs

39、izing by 1 to 2 ring sizes.In this study, 28#-30# rings for men and 26#-28# for female. The mean follow-up 22.8 months with good mid-term resultsBax analyzed 51 cases undergoing CABG and restrictive annuloplasty with stringent downsizing of the mitral annulus (by 2 sizes). Early operative mortality

40、was 5.6%, left atrium and LV dimension reduced dramatically; during 2-year follow-up, only 1 patient needed re-operation for recurrent MR; 2-year survival rate was 84%.Alternative of MVP ringSymmetrical ring-“O” and “C type: Although annular dilatation is mainly caused by posterior annular dilatation and “C” type ring would rectify the IMR through diminishing posterior annulus, increased A-P distance is also one of the important risk factors that lead to the failure of leaflets coaptation, so “O” type may guarantee be