左心室衰竭的手術(shù)治療西方的觀點(diǎn)-課件幻燈

1、左心室衰竭的手術(shù)治療 西方的觀點(diǎn)Irving L. Kron. M.D.充血性心力衰竭美國的患者人數(shù)5 百萬每年新增的患者數(shù)400,000700,000發(fā)病率升高 人口老齡化每年耗資超過100億美元其中75% 為住院費(fèi)用 心臟移植和心力衰竭“ 在一天里，一位血型為O型的男性患者得到一個(gè)心臟的幾率低于被閃電擊中的幾率.” C.Van Meter“ 通過心臟移植術(shù)治療心力衰竭患者就好比利用彩票來救濟(jì)窮人.” L.W. Stevenson20世紀(jì)80年代中葉以前， EF 20% 的患者行CABG手術(shù)時(shí)死亡率非常之高，使其成為手術(shù)的禁忌癥30-天死亡率 37%3-年存活率 15%Hochberg MS

2、, et al. J TCV 86:519-27, 1983低射血分?jǐn)?shù)患者的CABG 術(shù)手術(shù)死亡率 = 2.6% (1/39)Kron, et al. Ann Surg 210:348-54, 1989心室功能 23例患者手術(shù)后后期評(píng)估左心室功能手術(shù)前 EF18.6手術(shù)后 EF26.0p0.05結(jié)果院內(nèi)存活院內(nèi)死亡預(yù)測(cè)因子N=88N=8年齡 (歲)62.6 0.968.8 2.0*心絞痛 穩(wěn)定型80% (70)75% (6) 不穩(wěn)定型11% (10)12.5% (1) 無9% (8)12.5% (1)EF (%)20.3 0.3420.3 2.0*p0.05 compared to age o

3、f survivors左心室容積預(yù)測(cè)缺血性心肌病患者的手術(shù)后存活率41例EF 100ml/m2Yamaguchi et al. Ann Thorac Surg. 1998; 65:434-8存活率和 LVESVI心力衰竭和 LVESVI“對(duì)于缺血性心肌病患者，冠狀動(dòng)脈搭橋術(shù)聯(lián)合心室成形術(shù)優(yōu)于單純的冠狀動(dòng)脈搭橋術(shù)”Maxey TS, Kron IL, et al J Thorac Cardiovasc Surg. 2004 Feb;127(2):428-34手術(shù)前比較CABG (n=39)CABG + VR (n=56)年齡68.4 5.163.1 6.2性別31 M, 8 F42 M, 14

4、F手術(shù)前 EF (%)25.75 0.7422.07 1.12左心室舒張末直徑 (cm)6.4 0.36.5 0.3NYHA 分級(jí) III-IV3755二尖瓣返流2230手術(shù)中的資料CABG (n=39)CABG + VR (n=56)# 移植物3.4 0.82.6 1.0MV 修補(bǔ)2214缺血時(shí)間 (分鐘)81 2290 28CPB 時(shí)間 (分鐘)104135手術(shù)死亡率00預(yù)后數(shù)據(jù)CABG (n=39)CABG + VR (n=56)手術(shù)后 EF (%)29.03 0.61(提高5%)33.43 1.22*(提高11%)手術(shù)死亡率00住院時(shí)間 (天)6.9 1.97.9 2.0反復(fù)心力衰竭1

5、8%4%*遠(yuǎn)期死亡率5.1%1.8%*p0.05結(jié)論CABG & 心室成形術(shù)能夠改善心肌缺血及心室增大患者的左心室的功能心室成形與單純CABG相比，能夠顯著的改善患者的EF值，而不增加死亡率那么哪些是最佳適應(yīng)癥?心室增大前壁無運(yùn)動(dòng)或運(yùn)動(dòng)減弱遠(yuǎn)端血管條件好存在心肌缺血的證據(jù)主動(dòng)脈無動(dòng)脈粥樣硬化缺血性二尖瓣返流的手術(shù)治療心室-二尖瓣復(fù)合物一場(chǎng)拔河比賽手術(shù)方法置換術(shù)瓣環(huán)成形術(shù)瓣葉延長術(shù)后乳頭肌復(fù)位Dor二尖瓣修補(bǔ)缺血性MR的治療方法恢復(fù)瓣的功能保存瓣下結(jié)構(gòu)從而保持正常的瓣環(huán)瓣膜結(jié)構(gòu)關(guān)系，以保存其正常功能存在冠狀動(dòng)脈疾病時(shí)，二尖瓣修補(bǔ)手術(shù)優(yōu)于置換手術(shù)參數(shù)修補(bǔ)術(shù)置換術(shù)p 值感染5/547/560.586

6、休克2/542/561.00肺部合并癥20/5418/560.589腎功能不全8/5410/560.666合并癥/患者數(shù)1.5 0.21.7 0.20.450Reece et al, Ann Surg. 2004 May;239(5):671-5; discussion 675-7 修補(bǔ)術(shù)置換術(shù)死亡率1/546/56p 0.05住院時(shí)間913p 0.05T. Brett Reece et al, Ann Surg. 2004 May;239(5):671-5; discussion 675-7存在冠狀動(dòng)脈疾病時(shí)，二尖瓣修補(bǔ)手術(shù)優(yōu)于置換手術(shù)Tethered 瓣葉Anterior Papillar

7、y MuscleMitral LeafletsAnt. PostNormal PPMDisplacedPPMMRLALAMRLV復(fù)位縫合缺血性MR 結(jié)果n=1050 1+ MR 手術(shù)后TEE100%30-天死亡率3%5年總存活率87.3%手術(shù)后5-年未復(fù)發(fā)率100%復(fù)發(fā)性 MR5%Gazoni LM, etal. Ann Thorac Surg 2007 Sep; 84(3): 750-7; discussion 758這些手術(shù)與心臟移植術(shù)的比較?治療心肌病的手術(shù)手術(shù)死亡率心臟移植術(shù)(UNOS 2 須花費(fèi) $ 30,000)5.8 %CABG4.0 %二尖瓣修補(bǔ)聯(lián)合 CABG6.7 %左心室成

8、形術(shù)4.0 %p=0.8 心臟移植術(shù) vs. 其他術(shù)式Cope et al, Ann Thorac Surg 2001; (72) 1298-305治療心肌病的手術(shù)費(fèi)用心臟移植術(shù)(UNOS 2 須花費(fèi) $ 30,000)$76,000CABG$25,000二尖瓣修補(bǔ)聯(lián)合 CABG$32,000左心室成形術(shù)$27,000心臟移植術(shù)的平均總費(fèi)用比其他術(shù)式高3倍以上 (p5 million Americans affected400,000 to 700,000 new cases/yrIncreasing incidence - elderly populationAnnual cost exce

9、eds $10 billion 75% of the cost due to hospitalization Transplantation & Heart Failure“ At any given day, the chance of getting a heart for a male blood type O is less than getting hit by lightning.” C.Van Meter“ The idea of treating heart failure with transplantation is like treating poverty with t

10、he lottery.” L.W. StevensonPrior to the mid 1980s, CABG in patients with EF 20% associated with prohibitive mortality30-day mortality37%3-year survival15%Hochberg MS, et al. J TCV 86:519-27, 1983CABG for low EFOperative Mortality = 2.6% (1/39)Kron, et al. Ann Surg 210:348-54, 1989Ventricular Functio

11、n23 patients had late postoperative measurements of left ventricular functionPre-operative EF18.6Post-operative EF26.0p0.05ResultsHospital SurvivorsHospital DeathsPredictorsN=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.

12、3 2.0*p0.05 compared to age of survivorsResultsHospital SurvivorsHospital DeathsVessel qualityN=50N=7Good90% (45)0%Fair10% (5)0%Poor0%100% (7)*p0.05 compared to vessel quality in survivorsLangenberg SA, et al. Ann Thor Surg. Nov 60(5): 1193-6, 1995ConclusionsCABG for low EF has the best resultsWhen

13、there is evidence of ischemiaWhen distal vessels are of good quality (complete revascularization)As a primary operationLeft Ventricular Volume Predicts Postoperative Survival in Ischemic Cardiomyopathy41 patients undergoing CABG with EF 100ml/m2Yamaguchi et al. Ann Thorac Surg. 1998; 65:434-8Surviva

14、l and LVESVIHeart Failure and LVESVIDor Procedure in Akinetic Scars Centre Cardiothoracique de Monaco (n=100)Akinetic scar (n=51) vs. dyskinetic scar (n=49)Concomitant CABG98%Hospital Mortality12%Patients with either large akinetic or dyskinetic scar and severe LV dysfunction improved early and late

15、 NYHA class and EFDor, et al. J Thorac Cardiovasc Surg 1998;116:50-9.Dor, et al. JTCVS 116:50-9, 1998“Coronary Artery Bypass with Ventricular Remodeling is Superior to Coronary Artery Bypass Alone in Patients with Ischemic Cardiomyopathy”Maxey TS, Kron IL, et al J Thorac Cardiovasc Surg. 2004 Feb;12

16、7(2):428-34Preoperative ComparisonsCABG (n=39)CABG + VR (n=56)Age68.4 5.163.1 6.2Sex31 M, 8 F42 M, 14 FPreoperative EF (%)25.75 0.7422.07 1.12LVED diameter (cm)6.4 0.36.5 0.3NYHA class III-IV3755Mitral regurgitation2230Indication for OperationCABG (n=39)CABG + VR (n=56)Unstable angina alone2220CHF a

17、lone814Angina & CHF916Shock06*Intraoperative DataCABG (n=39)CABG + VR (n=56)# grafts3.4 0.82.6 1.0MV repair2214Ischemic time (min)81 2290 28CPB time (min)104135Operative mortality00Outcome DataCABG (n=39)CABG + VR (n=56)Postoperative EF (%)29.03 0.61(5% increase)33.43 1.22*(11% increase)Operative mo

18、rtality00Hospital stay (days)6.9 1.97.9 2.0Recurrent heart failure18%4%*Long-term mortality5.1%1.8%*p0.05ConclusionsCABG & ventricular remodeling improve left ventricular function in patients with ischemia and ventricular enlargementVentricular remodeling affords significant improvement in EF compar

19、ed to CABG alone, without added mortalitySo who is the best candidate?Large ventricleAnterior akinesis or dyskinesiaGood distal vesselsEvidence of ischemiaLack of aortic atherosclerosisSurgical Therapy for Ischemic Mitral RegurgitationSurgical ApproachesReplacementAnnuloplastyLeaflet extensionPoster

20、ior papillary repositioningDorMitral Valve RepairTechnique for Ischemic MRRestore valvular competencePreservation of subvalvular apparatusThus preservation of natural annulovalvular relationship for functional preservationMitral Repair is Superior to Replacement When Associated with Coronary Artery

21、DiseaseVariableRepairReplacementp valueInfection5/547/560.586Stroke2/542/561.00Pulmonary Complication20/5418/560.589Renal Insufficiency8/5410/560.666Complication/patient1.5 0.21.7 0.20.450Reece et al, Ann Surg. 2004 May;239(5):671-5; discussion 675-7 RepairReplacementMortality1/546/56p 0.05Hospital

22、Stay913p 0.05Mitral Repair is Superior to Replacement When Associated with Coronary Artery DiseaseT. Brett Reece et al, Ann Surg. 2004 May;239(5):671-5; discussion 675-7Tethered LeafletAnterior Papillary MuscleMitral LeafletsAnt. PostNormal PPMDisplacedPPMMRLALAMRLVRepositioning StitchIschemic MR Resultsn=1050 to 1+ MR post-op TEE100%30-day mortality3%Overall 5-year survival87.3%5-year freedom from re-operation100%Recurrent MR5%Gazo