体外循环下行二尖瓣置换术中保留二尖瓣及瓣下结构的安全性及可行性分析

摘要

目的 探讨体外循环下行二尖瓣置换术中保留二尖瓣及瓣下结构的安全性及可行性.方法 选取2006年1月至2014年6月河南科技大学第一附属医院收治行体外循环二尖瓣置换术的患者105例,依据随机数字表法分为A、B、C3组,每组35例.A组患者行二尖瓣置换术切除全部二尖瓣叶及瓣下结构;B组患者行二尖瓣置换术保留全部二尖瓣后叶及瓣下结构;C组患者行二尖瓣置换术保留部分二尖瓣后叶及瓣下结构.对3组患者手术前后超声心动图变化情况、血流动力学指标及并发症发生情况进行统计学分析.结果 术后10d和术后3个月,B组、C组患者的左心室收缩末期内径(LVESD)、左心室舒张末期内径(LVEDD)、左心室部分缩短(LVFS)、左心室射血分数(LVEF)与A组比较,差异均有统计学意义[术后10 d:(41 ±5)、(38 ±5) mm比(45±5)mm,(59 ±6)、(53±7) mm比(61 ±6) mm,(3l±4)％、(34±4)％比(29±4)％,(61±6)％、(62±7)％比(58±6)％;术后3个月:(43±5)、(35 ±5) mm比(42±5)rmm,(61 ±5)、(52 ±4) mm比(59±5)mm,(33±3)％、(36±3)％比(32±3)％,(62±5)％、(66±6)％比(59±5)％,均P＜0.05];术后48 h时,A组患者的平均肺动脉压(MPAP)、肺血管阻力(PVR)明显高于B组、C组[(5.8±0.6)kPa比(4.4±0.9)、(4.5±0.9)kPa;(50±13)kPa·s/L比(34±10)、(36±16) kPa·s/L],心脏指数和左心室每搏功指数(LVSWI)明显低于B组、C组[(2.6±0.5)L/(min·m2)比(3.2±0.4)、(3.1 ±0.5)L/(min·m2);(1.9±0.5)mJ/m2比(3.7±0.9)、(3.3 ±0.4) mJ/m2],差异有统计学意义(P＜0.05);同一时点3组患者的肺动脉楔压(PCWP)比较[术后＜4h时,A、B、C组PCWP分别为(2.2±0.6)、(1.6±0.6)、(1.4±0.4)kPa;术后24 h时分别为(2.4±0.4)、(1.7±0.4)、(1.6 ±0.4)kPa;术后48 h时分别为(2.5±0.4)、(1.5±0.3)、(1.6±0.5) kPa],差异均有统计学意义(P＜0.05).术后24 h时,A组的LVSWI低于B组,差异有统计学意义[(2.2±0.7)mJ/m2比(3.1±1.0) mJ/m2,P ＜0.05].A组患者的术后早期并发症发生率和病死率均明显高于B组、C组[31.4％ (11/35)比17.1％ (6/35)、14.3％ (5/35);11.4％ (4/35)比5.7％ (2/35)、2.9％(1/35)],差异有统计学意义(P＜0.05).结论 体外循环下行二尖瓣置换术中保留二尖瓣及瓣下结构安全可行.%Objective To analyze the safety and feasibility of mitral valve replacement with mitral valve and valve structures reserved under cardiopulmonary bypass.Methods Clinical data of 105 patients who underwent mitral valve replacement under cardiopulmonary bypass from January 2006 to June 2014 were enrolled and randomly divided into group A,B and C.During mitral valve replacement,the mitral valve and valve structures were removed in group A;these structures were reserved in group B and they were partly reserved in group C.The echocardiographic changes,hemodynamic parameters and postoperative complications were statistically analyzed.Results Ten days and 3 months after operation,the left ventricular end systolic diameter,left ventricular enddiastolic diameter,left ventricular fractional shortening and left ventricular ejection fraction in group B and group C were significantly improved compared with those in group A [10 days after operation:(41 ± 5),(38 ± 5) mm vs (45 ±5) mm,(59 ±6),(53 ±7) mm vs (61 ±6) mm,(31 ±4)％,(34 ±4) ％ vs (29 ±4) ％,(61 ±6)％,(62 ±7)％ vs (58 ±6) ％;3 months after operation:(43 ±5),(35 ±5) mm vs (42±5) mm,(61 ±5),(52 ±4) mm vs (59 ±5) mm,(33 ±3)％,(36±3)％ vs (32±3)％,(62±5)％,(66 ±6)％ vs (59 ±5)％](all P ＜0.05).The mean pressures of pulmonary artery and pulmonary vascular resistance were significantly higher and the cardiac index and left ventricular-stroke work index (LVSWI) were significantly lower in group A than those in group B and group C [(5.8 ±0.6) kPa vs (4.4 ±0.9),(4.5 ±0.9) kPa;(50 ± 13) kPa · s/L vs (34 ± 10),(36±16) kPa· s/L;(2.6 ±0.5) L/(min · m2) vs (3.2±0.4),(3.1 ±0.5) L/(min · m2);(1.9±0.5) mJ/m2 vs (3.7±0.9),(3.3 ±0.4) mJ/m2] (P ＜0.05);the pulmonary capillary wedge pressure (PCMP) 4,24 and 48 h after operation was significantly different among the three groups [4 h after operation:(2.2±0.6) kPavs (1.6±0.6) kPavs (1.4±0.4) kPa,24 h after operation:(2.4±0.4) kPavs (1.7±0.4) kPa vs (1.6 ± 0.4) kPa,48 h after operation:(2.5 ± 0.4) kPa vs (1.5 ± 0.3) kPa vs (1.6 ± 0.5) kPa](P ＜ 0.05);24 h after operation,the LVSWI in group A was significantly lower than that in group B [(2.2 ±0.7) mJ/m2 vs (3.1 ± 1.0) mJ/m2] (P ＜0.05).The incidence of early postoperative complications and mortality rate were significantly higher in group A compared with those in group B and group C [31.4％ (11/35) vs 17.1％ (6/35),14.3％ (5/35);11.4％ (4/35) vs 5.7％ (2/35),2.9％ (1/35)] (P ＜0.05).Conclusion Mitral valve replacement with mitral valve and valve structures reserved under cardiopulmonary bypass is safe and feasible.