中国胸心血管外科临床杂志

中国胸心血管外科临床杂志

全胸腔镜下 loop-in-loop 腱索重建加二尖瓣成形环植入术矫治二尖瓣脱垂患者的临床效果

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目的 总结与分析全胸腔镜下 loop-in-loop 技术腱索重建加二尖瓣成形环植入术治疗二尖瓣脱垂患者的临床治疗效果与经验总结。 方法 收集我院心脏中心自 2012 年 5 月至 2017 年 5 月收治 21 例二尖瓣瓣叶脱垂患者,其中男 12 例、女 9 例,年龄(50.90±9.66)岁,体重(64.81±11.56)kg,术前经胸超声(TTE)及经食管超声心动图(TEE)提示:根据 Carpentier 标准,二尖瓣前叶腱索断裂 12 例,后叶腱索断裂 5 例,前后叶均有断裂 4 例。二尖瓣中-重度关闭不全 13 例,二尖瓣重度关闭不全 8 例,合并三尖瓣关闭不全 11 例,合并心房颤动 3 例,术前心功能(NYHA 分级)Ⅱ~Ⅲ级,平均术前射血分数(EF)61.17%±4.71%,平均左心室舒张末直径(LVDD)(55.39±7.76)mm,左室容积(EDV)(156.67±46.25)ml,平均左心房直径(LAD)(43.56±7.71)mm,肺动脉压(34.00±15.56)mm Hg,心胸比率 0.60±0.08。所有病例均采用股动、静脉插管建立体外循环。顺行性灌注心肌保护液,分别在右侧胸骨右缘第 3 肋间、右侧腋前线第 5 肋间与腋前线第 3 肋间做手术切口。在全胸腔镜下右房-房间隔切口入路,行 loop-in-loop 人工腱索重建加二尖瓣成形环植入术,术中行打水试验与 TEE 评估成形效果。收集术后 1 周、出院前及出院后进行随访的心脏彩超、胸部 X 线片检查资料。 结果 全组手术均顺利、无再次成形或瓣膜置换、无中转开放、无恶性心律失常、围术期死亡及伤口感染等并发症发生。其中 10 例同时行三尖瓣成形术,1 例同时完成三尖瓣成形术+射频消融术,平均体外循环时间(255.57±37.24)min,主动脉阻断时间(162.24±19.61)min,Loop 数 2~5(3.29±0.78)个,成形环大小 28~34(31.11±1.88)mm,呼吸机辅助时间(19.43±14.68)h,住 ICU 时间(58.45±24.60)h,术后住院时间(12.28±3.61)d。术后复查 TTE,3 例患者二尖瓣有微少量反流,术后口服华法林抗凝治疗 6 月,术后 1 个月、3 个月、6 个月、12 个月等定期进行随访,随访 2~51 个月。出院时 LVDD(45.06±2.96)mm、EDV(108.11±17.09)ml、LAD(35.56±6.93)mm、心胸比率(0.53±0.13),均较入院时明显缩小(P<0.05),肺动脉压为(19.22±6.38)mm Hg,较入院时减低(P<0.05),EF 值 62.33%±4.00%,较术前无明显变化(P>0.05)。随访期间左心房内径和左心室舒张期末期内径比术前均明显缩小,心功能较术前均有不同程度改善,无新发二尖瓣脱垂、反流量增加,无感染性心内膜炎、血栓栓塞及抗凝相关并发症。 结论 全胸腔镜下 loop-in-loop 人工腱索技术加二尖瓣成形环植入术矫治二尖瓣脱垂是安全和有效的,创伤小,美容效果好,早、中期效果良好,是值得推广的手术方式。但手术操作时间有待进一步缩短,其长期临床效果需进一步随访与研究。

Objective To analyze the effect of loop-in-loop technique and annuloplasty ring for the treatment of mitral valve prolapse under total thoracoscopy. Methods Between May 2012 to May 2017, 21 patients with mitral valve prolapse (MVP) underwent mitral valve repair at our hospital. There were 12 males and 9 females with a mean age of 50.90±9.66 years and the mean weight of 64.81±11.56 kg. Rupture of anterior chordae occured in 12 patients, upture of posterior chordae in 5 patients, and rupture of anterior and posterior chordae in 4 patients according to Carpentier criteria. There were 13 patients of moderate-severe mitral insufficiency, 8 patients of severe mitral insufficiency, 11 patients of tricuspid insufficiency, 3 patients of atrial fibrillation, preoperative cardiac function (NYHA classification) grade Ⅱ-Ⅲ, the mean preoperative left ventricular ejection fraction (EF) was 61.17%±4.71%, left ventricular end-diastolic diameter (LVDD) was 55.39±7.76 mm, left ventricular volume (EDV) was 156.67±46.25 ml, left atrial diameter (LAD) (43.56±7.71) mm, pulmonary artery pressure was 34.00±15.56 mm Hg and cardiothoracic ratio was 0.60±0.08. Cardiopulmonary bypass was established with right femoral artery and a single 2 stage venus cannula in the right atrium. The ascending aorta was cross-clamped and myocardium was protected by coronary perfusion with cold blood-crystalloid cardioplegia. The incisions were made between the right third intercostal of the sternum, the fifth intercostal of the right anterior axillary line and the third intercostal of the anterior axillary line. Loop-in-loop artificial chordae tendonae reconstruction and mitral annuloplasty were performed through the right atrial-atrial septal incision under total thoracoscopy. The water test and transesophageal echocardiography were performed during the operation to evaluate the effect of mitral annuloplasty. Data of echocardiography and chest radiography were collected postoperatively one week, before discharge and after discharge. Results All the operations were successful without reoplasty or valve replacement, conversion to median thoracotomy, malignant arrhythmia, perioperative death and wound infection. Among them, 10 patients underwent tricuspid valvuloplasty, 1 patient underwent tricuspid valvuloplasty plus radiofrequency ablation simultaneously. The mean cardiopulmonary bypass time was 255.57±37.24 minutes, aortic occlusion time was 162.24±19.61 minutes, the number of loop was 2–5 (3.29±0.78), the size of ring was 28–34 (31.11±1.88) mm, ventilator assistance time was (19.43±14.68) hours, ICU time was (58.45±24.60) hours and postoperative hospital stay was (12.28±3.61) days. Transthoracic echocardiography was re-examined postoperatively. Mild-tral regurgitation was found in 3 patients. Warfarin anticoagulant therapy was given orally for 6 months postoperatively. The patients were followed up regularly for 2–51 months at 1, 3, 6 and 12 months postoperatively. LVDD was 45.06±2.96 mm, EDV 108.11±17.09 ml, LAD 35.56±6.93 mm and cardiothoracic ratio 0.53±0.13 at discharge which were significantly smaller than those at admission (P<0.05). Pulmonary artery pressure was 19.22±6.38 mm Hg which was significantly lower than that at admission (P<0.05), but EF (62.33%±4.00%) had no significant change (P>0.05). The left atrial diameter and left ventricular end-diastolic diameter were significantly smaller than those before operation, and the cardiac function improved to some extent during the follow-up. No new mitral valve prolapse, increased regurgitation, infective endocarditis, thromboembolism or anticoagulation-related complications were found during the follow-up. Conclusion Loop-in-loop artificial chordae tendon implantation combined with mitral annuloplasty is a safe and effective method for mitral valve prolapse under total thoracoscopy with minimal trauma, satisfactory cosmetic effect, and good early- and medium-term results. It is worth of popularizing. However, the operation time needs to be further shortened, and its long-term clinical effect needs further follow-up and other researches to confirm.

关键词: 全胸腔镜; 二尖瓣脱垂; 人工腱索; 二尖瓣修复; 微创

Key words: Total thoracoscopy; mitral valve prolapse; artificial chordae; mitral valve repair; minimally invasive surgery

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