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1、,二尖瓣修补的方法 东方的观点,Dr. Tim Wing-Kuk Au FRCS , FHKCS Consultant Surgeon Honorary Clinical Assistant Professor Department of Cardiothoracic Surgery The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR,心血管治疗领域中的新起点 December 2008 Shanghai, China,Cleveland Clinic,无症状二尖瓣返流治疗结果的定量分析,Maurice Enrique
2、-Saran et al. N Engl J Med 2005;352:875-83,二尖瓣返流的概述,无症状的 MR 5 - 10 年 严重的MR 年死亡率 5 % 严重MR患者中的猝死 NYHA 分级很差 左心室射血分数很低 房颤 严重 MR (不论何种病因 ) 手术,Grigioni F. JACC 1999 34;7:2078-85 Otto C. N Engl J Med 2001, 345;10:740-6,Enrique-Saran et al. Circulation. 1994;90:830-37,超声心动图预测器质性二尖瓣返流患者手术治疗后的存活率,根据手术前超声心动图检查
3、的EF值预测MR患者手术治疗后的远期存活率,Shuhaiber et al. Eur J Card Thorac Surg. 2007;31:267-75,危险比,修补 vs 置换,血流动力学更稳定 维持心室的功能 避免使用人工瓣膜 不会出现血栓栓塞和出血 感染机率降低,技术和经验至关重要,退行性二尖瓣返流的Carpentier分级,退行性二尖瓣疾病的修补手术,后瓣叶- 公认的标准修补术 前瓣叶 技术难度更高，结果差异较大 联合脱垂 Carpentiers 修补术,后瓣叶 Q 形切除术,前瓣叶 瓣叶转位,人工腱索 Gore-Tex 5/0,退行性MV修补术的结果 西方 vs 东方,退行性二尖瓣
4、返流,东方 = 西方 TEE的重要性 返流束的方向判断容易出错 盐水注射试验: 有或无 Barlows 罕见但是很困难,改良Carpentier 分级 : 缺血性 MR,缺血性二尖瓣返流的机制 慢性,Lveine et al. Circulation 112(5) August 745-58,Bursi, F. et al. Circulation 2005;111:295-301,773例MI后患者，根据超声心动图检查MR严重程度的不同分组， 30天内各组的总存活率 (实线代表无MR，点线代表轻度MR，虚线代表中度或重度),NIL MR 50 %,Mild MR 38 %,Mod or se
5、vere MR 12 %,亚洲的问题有多严重?,中国国家心血管疾病中心 2005 报道 : 全国缺血性心脏病的发病率为4.2% 每年新增的MI患者为500,000例 城市预测 预计每年新增的缺血性MR患者例数：60,000,院内死亡率 1.4 % 修补 vs 21 % 置换 P = 0.06,5 年再次手术率 修补 14 % vs 置换 3 % P = 0.003,缺血性二尖瓣返流中二尖瓣修补和二尖瓣置换的比较 Osman O. Al-Radi, MBBS, Peter C. Austin, PhD, Jack V. Tu, MD, Tirone E. David, MD, and Terre
6、nce M. Yau, MD, MS,慢性缺血性MR的各种修补技术,瓣环成形术 瓣口过小 Bolling (n=140) Carpentier 法 Acar (n=44) 第二腱索松解 David (n=30) LV成形术，比如: Dors Mericanti (n=46) 后乳头肌复位术 Kron (n=18) 缘对缘修补术 Bhudia (n=146)*,中国二尖瓣手术的回顾,Shuhaiber et al. Eur J Card Thorac Surg. 2007;31:267-75,风湿性二尖瓣返流的病理生理学,风湿性二尖瓣返流重建手术的远期预后（29年） Sylvain Chauva
7、ud, MD; Jean-Franois Fuzellier, MD; Alain Berrebi, MD; Alain Deloche, MD;Jean-Nol Fabiani, MD; Alain Carpentier, MD, PhD,Methods and ResultsFrom 1970 to 1994, 951 patients with rheumatic MV insufficiency were operated on with the reconstructive techniques elaborated by Alain Carpentier. Mean age was
8、 25.8 years (4 to 75), and sinus rhythm was present in 63%. The functional classification used was type I, normal leaflet motion, 71 patients (7%); type II, prolapsed leaflet, 311 patients (33%); and type III, restricted leaflet motion, 345 patients (36%). The combined lesion of prolapse of the ante
9、rior leaflet and restriction of the posterior was present in 224 patients (24%). Surgical techniques used were implantation of a prosthetic ring in 95%, shortening of the chords and leaflet enlargement with autologous pericardium, and commissurotomy. Hospital mortality rate was 2%. The mean follow-u
10、p was 12 years (maximum, 29 years): 8618 patients per year. Actuarial survival was 89 19% at 10 years and 82 18% at 20 years. The rate of thromboembolic events was 0.4% patients per year (33 events), with 3 deaths. Freedom from reoperation was 82 19% at 10 years and 55 25% at 20 years. The main caus
11、e (83%) of reoperation was progressive fibrosis of the MV. The actuarial rate of reoperation was 2% patients per year and was correlated to the degree of preoperative fibrosis.,功能分级型，瓣叶活动正常的患者有71例（7%）；型，瓣叶脱垂者311例（33%）；型，瓣叶活动受限者345例（36%）。二尖瓣前叶脱垂同时伴后叶受限的患者共224例（24%）。,随访12年（最长29年）：每年8618例患者。10年的实际存活率为8
12、919%，20年为8218%。每年血栓栓塞事件的发生率为0.4%（33例），其中3例患者死亡。10年内无需再次手术的患者占8219%，20年为5525%。再次手术的主要原因为二尖瓣进行性纤维化,%,总修补人数 = 201 例患者,二尖瓣修补联合主动脉瓣置换治疗风湿性心脏病 Huynh-Quang Tri Ho, MD, Van-Phan Nguyen, MD, Kim-Phuong Phan, MD, Nguyen-Vinh Pham, PhD Heart Institute, Ho Chi Minh City, Vietnam,MS 30% MR 37% Mixed 33%,死亡率 修补 1
13、.4 % 置换 0.7 %,1组中9年内无需再次二尖瓣手术者占84.2 13% ，2组为 92 7.4% (log-rank test: p = 0.42),戊二醛处理的自体心包补片瓣膜修补术治疗复杂性二尖瓣病变 Choi-Keung Ng, MD, Joachim Nesser, MD, Christian Punzengruber, MD, Otmar Pachinger, MD, Johannes Auer, MD, Herbert Franke, MD, and Peter Hartl, MD,Ann Thorac Surg 2001;71:7885,63例患者超过10年 院内死亡率为
14、 5 年内无再次手术 95 %,技术 扩大50 % 戊二醛0.625% - 30 分钟 6/0 或 7/0 Gore-Tex 缝线,风湿性二尖瓣修补术后无再次手术患者的存活率,风湿性 MR 10 年无再次手术的存活率 85 90 % 风湿性联合瓣膜病变 10年无再次手术的存活率 70 80 %,机械瓣膜 10年无再次手术的存活率 90 95 %,第一次MV修补手术到再次手术的时间间隔, 技术相关 = 6.04 7.18 瓣膜相关 = 45.44 33.65,手术相关的并发症: - 手术指征错误 严重的瓣膜疾病 瓣膜修补几率低 - 技术错误 修补技术不恰当 操作错误 - 第一次修补手术不完善 -
15、 修补技术不稳定 瓣膜相关的并发症 : - 疾病的自然进展,Vietnam 心脏中心 Prof. NV Phan,风湿性瓣膜病手术修补的技术要领,风湿性返流 80 % 成功率 腱索增粗开窗术或切除术+Gore-Tex 瓣叶缩短心包补片 第二腱索松解术 瓣膜成形术风湿性瓣膜病中瓣环扩张非常常见 口角成形术,风湿性联合瓣膜病变 成功率存在差异 腱索增粗切除腱索/PM+ Gore-Tex 置换 腱索缩短心包补片 第二腱索松解术 瓣膜成形术心包补片技术能够使用更长的环 口角成形术+ 去除钙化,（1）瓣叶显著增厚或（2）双侧连合部钙化或（3）瓣环受限时应避免使用修补术,香港大学二尖瓣置换 vs 修补,G
16、ore-Tex,心包补片,环 . 何种环 ?,一览表,房颤是一种严重的疾病,十年死亡率 Framingham 研究,房颤患者心梗的发生率,按年龄分组,手术 - Maze 手术,二尖瓣修补,谢谢,symptoms,ESC 2007: 严重慢性器质性二尖瓣返流的手术指征 Eur Heart J 2007 28:230-268,有症状的患者伴 LVEF 30% and ESD 45 mm and/or LVEF 55 mm) 对药物治疗反映不佳，且能够修补的可能性高，死亡率较低 无症状的患者伴左心室功能正常， IIbB 且能够修补的可能性高，手术风险低,Mitral Valve Repair Str
17、ategies Perspective EAST,Dr. Tim Wing-Kuk Au FRCS , FHKCS Consultant Surgeon Honorary Clinical Assistant Professor Department of Cardiothoracic Surgery The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR,New Horizon in Cardiovascular Treatments December 2008 Shanghai, China,Cleveland Cli
18、nic,Quantitative Determinants of the Outcome of Asymptomatic Mitral Regurgitation,Maurice Enrique-Saran et al. N Engl J Med 2005;352:875-83,Facts about MR,Asymptomatic MR 5 - 10 years Severe MR annual mortality 5 % Sudden death in severe MR Poor NYHA class Low LV ejection Atrial fibrillation Severe
19、MR (irrespective of etiology ) Surgery,Grigioni F. JACC 1999 34;7:2078-85 Otto C. N Engl J Med 2001, 345;10:740-6,Enrique-Saran et al. Circulation. 1994;90:830-37,Echocardiographic Prediction of Survival After Surgical Correction of Organic Mitral Regurgitation,Shuhaiber et al. Eur J Card Thorac Sur
20、g. 2007;31:267-75,Repair vs Replacement,Superior hemodynamics Preservation of ventricular function, Avoidance of prosthetic valve Freedom from thromboembolism & bleeding Lower infection rate,Skill and experience counts,Carpentier Classification of Mitral Degenerative Regurgitation,Mitral repair for
21、degenerative diseases,Posterior leaflet - universal standard repair Anterior leaflet more technical difficult and variable results Commissural prolapse Carpentiers repair,Posterior leaflet Q resection,Anterior leaflet leaflet transfer,Artificial Chordae Gore-Tex 5/0,Results of degenerative MV repair
22、 West vs East,Degenerative Mitral Regurgitation,East = West Importance of TEE Pitfalls of regurgitant jet direction Saline jet test : yes or no Barlows rare but difficult,Modified Carpentier Classification : Ischemic MR,Mechanism of Ischemic Mitral Regurgitation - Chronic,Lveine et al. Circulation 1
23、12(5) August 745-58,Bursi, F. et al. Circulation 2005;111:295-301,Overall survival according to degree of MR in 773 patients who underwent echocardiography within 30 days after MI (solid line indicates no MR, dotted line mild MR, and dashed line moderate or severe MR),NIL MR 50 %,Mild MR 38 %,Mod or
24、 severe MR 12 %,How big is the problem in Asia ?,China National Center for Cardiovascular Disease 2005 Report : Prevalence of IHD was 4.2% in the country 500,000 new cases of MI each year urban estimate Estimated new cases severe Ischemic MR annually: 60,000,In-hospital mortality 1.4 % repair vs 21
25、% replacement P = 0.06,5 yr re-operation rate repair 14 % vs replacement 3 % P = 0.003,Mitral Repair Versus Replacement for Ischemic Mitral Regurgitation Osman O. Al-Radi, MBBS, Peter C. Austin, PhD, Jack V. Tu, MD, Tirone E. David, MD, and Terrence M. Yau, MD, MS,Various Repair Techniques for Chron
26、ic Ischemic MR,Annuloplasty Undersized Bolling (n=140) Carpentier methods Acar (n=44) 2nd Chordae Releases David (n=30) LV Restoration eg: Dors Mericanti (n=46) Relocation of Post. PM Kron (n=18) Edge-to-Edge Repair Bhudia (n=146)*,Mitral Valve Surgery review in China,Shuhaiber et al. Eur J Card Tho
27、rac Surg. 2007;31:267-75,Pathophysiology of Rheumatic Mitral Regurgitation,Long-Term (29 Years) Results of Reconstructive Surgery in Rheumatic Mitral Valve Insufficiency Sylvain Chauvaud, MD; Jean-Franois Fuzellier, MD; Alain Berrebi, MD; Alain Deloche, MD;Jean-Nol Fabiani, MD; Alain Carpentier, MD,
28、 PhD,Methods and ResultsFrom 1970 to 1994, 951 patients with rheumatic MV insufficiency were operated on with the reconstructive techniques elaborated by Alain Carpentier. Mean age was 25.8 years (4 to 75), and sinus rhythm was present in 63%. The functional classification used was type I, normal le
29、aflet motion, 71 patients (7%); type II, prolapsed leaflet, 311 patients (33%); and type III, restricted leaflet motion, 345 patients (36%). The combined lesion of prolapse of the anterior leaflet and restriction of the posterior was present in 224 patients (24%). Surgical techniques used were impla
30、ntation of a prosthetic ring in 95%, shortening of the chords and leaflet enlargement with autologous pericardium, and commissurotomy. Hospital mortality rate was 2%. The mean follow-up was 12 years (maximum, 29 years): 8618 patients per year. Actuarial survival was 89 19% at 10 years and 82 18% at
31、20 years. The rate of thromboembolic events was 0.4% patients per year (33 events), with 3 deaths. Freedom from reoperation was 82 19% at 10 years and 55 25% at 20 years. The main cause (83%) of reoperation was progressive fibrosis of the MV. The actuarial rate of reoperation was 2% patients per yea
32、r and was correlated to the degree of preoperative fibrosis.,%,Total repair = 201 patients,Mitral Valve Repair with Aortic Valve Replacement in Rheumatic Heart Disease Huynh-Quang Tri Ho, MD, Van-Phan Nguyen, MD, Kim-Phuong Phan, MD, Nguyen-Vinh Pham, PhD Heart Institute, Ho Chi Minh City, Vietnam,M
33、S 30% MR 37% Mixed 33%,Mortality Repair 1.4 % Replacement 0.7 %,Freedom from mitral valve re-operation at 9 years was 84.2 13% for group 1 and 92 7.4% for group 2 (log-rank test: p = 0.42),Valvuloplasty With Glutaraldehyde-Treated Autologous Pericardium in Patients With Complex Mitral Valve Patholog
34、y Choi-Keung Ng, MD, Joachim Nesser, MD, Christian Punzengruber, MD, Otmar Pachinger, MD, Johannes Auer, MD, Herbert Franke, MD, and Peter Hartl, MD,Ann Thorac Surg 2001;71:7885,63 patients over 10 years Zero in-hospital mortality 5 yrs re-op free interval 95 %,Technique 50 % enlargement Glutaldehyd
35、e 0.625% - 30 mins 6/0 or 7/0 Gore-Tex sutures,Re-operation Free Survival After Rheumatic Mitral Repair,Rheumatic MR 10 years re-op free survival 85 90 % Rheumatic Mixed Mitral 10 years re-op free survival 70 80 %,Mechanical Prosthesis 10 years re-op free survival 90 95 %,Time Interval between Initi
36、al MV Repair and Reoperation, Procedure related = 6.04 7.18 Valve related = 45.44 33.65,Procedure related complication : - Wrong indication severity of valve lesion poorly likehood of valve repair - Technical error unsuitable technique wrong manipulation - Inadequate initial repair - Instability of
37、repair technique Valve related complication : - Progresstion of disease process,Vietnam Heart Center Prof. NV Phan,Technical Tips for Rheumatic Repair,Rheumatic Regurgitation 80 % success Thickened chordae - fenestration or resection + Gore-Tex Leaflet retraction - pericardial patch 2nd chordae rele
38、ase Annuloplasty definitely as annular dilatation common in rheumatic Commissuroplasty,Mixed Rheumatic Disease variable success rate Thickened chordae - resection of chordae/PM + Gore-Tex replacement Leaflet retraction - pericardial patch 2nd chordae release Annuloplasty - pericardial patch to allow
39、 larger Ring Commissuroplasty + decalcification,Avoid Repair if significant (1) leaflet thickening or (2) bilateral commissural Ca+ or (3) annular restriction,University of Hong Kong Mitral Replacement vs Repair,Gore-Tex,Pericardial patch,Ring . What Ring ?,Atrial Fib is a Serious Disease,Ten-Year M
40、ortality Framingham Study,% of AFib Patients Experiencing Stroke,By Age Groups,Surgical - Maze Operation,Mitral Repair,Thank You,symptoms,ESC 2007: Indications for surgery in severe chronic organic mitral regurgitation Eur Heart J 2007 28:230-268,Symptomatic patients with LVEF 30% and ESD 45 mm and/or LVEF 55 mm) refractory to medical therapy with high likelihood of durable repair, and low morbidity Asymptomatic patients with preserved LV function, high IIbB likelihood of durable repair, and low risk for surgery,