实时三维超声在人工腱索二尖瓣成形术中的应用

摘要

目的 评价实时三维超声心动图在人工腱索植入行二尖瓣成形术中的应用价值.方法 31例二尖瓣脱垂病人,采用4-0 Goretex线为材料构建人工腱索行二尖瓣成形术,在术前、术中和术后分别行实时三维超声心动图检查.术前测量病人的正常腱索长度,通常测量二尖瓣前叶A1节段和后叶P1节段的腱索长度,以指导手术方案的制定.术中和术后采用实时三维超声检查以评价手术治疗效果.术中所有病人均同时植入人工二尖瓣成形环.结果 无手术死亡病例,体外循环(142.0±31.2)min、主动脉阻断(98.0±22.5)min.每例病人植入人工腱索1～3根,平均(2.0±1.5)根.术前三维超声测量的人工腱索的预期长度平均为(21.0±2.5)mm,术中实际植入的人工腱索的长度平均为(20.0±2.2)mm,二者比较差异无统计学意义.随访3～30个月,随访率98%.出现轻微反流15例,轻度反流1例,中度反流1例,无需再次手术治疗病例.未发现Goretex线人工腱索断裂,无后期死亡.结论 人工腱索植入二尖瓣成形术可获得良好的近、中期效果,实时三维超声可准确预测人工腱索的长度,对提高手术效果有重要帮助.%Objective To investigate the surgical technique and outcomes of replacement of chordae tendineae in mitral valve repair, and evaluate the value of real-time three-dimensional transesophageal echocardiography in the perioperative period. Methods Thirty-one patients with mitral valve prolapse underwent mitral valve repair using chordae tendineae replacement concomitant with implantation of valveplasty ring. A 4-0 Goretex sutures was used for reconstruction of artificial chordae. Realtime three-dimensional transesophageal echocardiography was performed in all the patients during the preoperative, intraoperatire, and postoperative periods. The length of the chordae tendineae under the A1 section of the anterior leaflet and the P1 section of the posterior leaflet were measured and considered the normal length of chordae tendineae by real-time three-dimensional transesophageal echocardiography preoperatively. These pre-determined normal chordal lengths helped intraoperatively to approximate the length of the artificial chordae used and postoperatively to gauge the success of the procedures. The same values were used again postoperatively to gauge the success of intervention. Full flexible valveplasty rings were used in all the patients.Results There was no operative death. The mean cardiopulmonary bypass (CPB) and aortic cross clamp time were ( 142. 0 ±31.2 ) min and (98.0 ± 22.5 ) min, respectively. One patient' s intraoperative echocardiography upon termination of CPB showed persistent severe mitral regurgitation and was converted to mitral valve replacement. This patient was not included in the study group. The mean number of artificial chordae per patient was (2.0 ± 1.5 ) , range from 1 to 3. The mean preoperatively measured normal chordal length was ( 21.0 ± 2.5 ) mm, and the mean postoperative artificial chordal length was ( 20.0 ± 2.2 )mm. The difference was not significant. The follow-up interval was from 3 to 30 months and the follow-up rate was 98%. During the follow-up period, there was no late death. Trace mitral regurgitation (MR) was detected in 15 patients, mild and moderate MR were detected in 1 for each. No severe MR was detected. The freedom from reoperation was 100% during follow-up.There were no documented artificial chordae ruptures. Conclusion Conclusion Artificial chordal replacement with Gore-tex suture in mitral valve repair in this group of patients with mitral valve prolapse appears to have satisfactory early and mid-term results. Real-time three-dimensional transesophageal echocardiography plays a critical role in this technique. Real-time threedimensional transesophageal echocardiography can exactly predict the length of artificial chordae, which is helpful to improve the outcomes of mitral valve repair. However, longer term follow-up and larger series are required to validate our findings.