《二尖瓣瓣环成形技术.ppt》由会员分享，可在线阅读，更多相关《二尖瓣瓣环成形技术.ppt（53页珍藏版）》请在三一文库上搜索。
1、二尖瓣瓣环成形技术 Mitral Valve Annuloplasty 首都医科大学附属北京安贞医院 孟 旭,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,2,美国胸心外科协会（STS）MVR/MVP手术死亡率统计 （1994-2003）,二尖瓣成型可以避免二尖瓣置换术后出血栓塞机械瓣失灵等很多并发症, 可以保持心室生理性结构有利于心功能恢复,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Med
2、ical University,3,二尖瓣成形手术技术探讨,国内外二尖瓣疾病的病理类型的差异 二尖瓣环解剖结构的特点 人工瓣环成形技术的发展 缺血性二尖瓣关闭不全的外科成形技术,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,4,国内二尖瓣疾病的病理类型特点,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,5,美国多个研究中心二尖瓣疾病的病理情况,William
3、 F. Northrup, The Journal of Heart Valve Disease 2003;12:14-24,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,6,中国和美国二尖瓣疾病的病理原因分布,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,7,国内二尖瓣疾病病因构成趋势变化,2019/5/16, 2009 by Dr.Meng Xu, Be
4、ijing Anzhen Hospital ,Capital Medical University,8,北京安贞医院近年二尖瓣手术方式分布趋势,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,9,二尖瓣不同病理改变时的成形机会,二尖瓣不同部位成形的机会,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,10,二尖瓣装置不同部位在不同病理改变下的变化,2019/5/
5、16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,11,二尖瓣环的解剖结构特点,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,12,二尖瓣环解剖 Mitral annulus anatomy,二尖瓣环分为前瓣环和后瓣环。前瓣环约占整个瓣环的三分之一 (1)左纤维三角-位于二尖瓣前叶与主动脉左冠瓣的接合部 (2)右纤维三角-是房室膜性间隔，是二尖瓣，三尖瓣和主动脉根部的交合点,
6、 而且也称之为心脏中心纤维体。,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,13,二尖瓣瓣环的纤维不连续性 Disconnection of mitral annulus,A：二尖瓣环全部为纤维成分组成 B：二尖瓣环仅左右纤维三角为纤维成分组成 C：二尖瓣环的纤维成分非对称性缺失 D：二尖瓣环的纤维成分间断对称性缺失,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical Univers
7、ity,14,二尖瓣瓣环的立体动态结构 Dynamic structure of mitral annulus,二尖瓣环呈马鞍型(或D型或肾型)，水平和垂直面均可以运动和形态改变，瓣环最小直径与最大直径的比值约为0.75。鞍型瓣环的最高点位于二尖瓣前环中点，二尖瓣环水平方向后瓣环在心脏收缩期移向前环而舒张期远离二尖瓣前环。,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,15,二尖瓣环垂直方向，瓣环整体在心脏收缩期移向心尖方向，舒张期移向左心房方向。,二尖瓣瓣环的立体动态结构
8、Dynamic structure of mitral annulus,End systole,End diastole,左心房（LA）,左心室（LV）,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,16,二尖瓣瓣环形态与功能临床意义 Clinical significance of mitral annulus anatomy,前瓣环形态和长度改变不明显，后 瓣环缺乏纤维条索而薄弱，并且是瓣环 不完整现象的主要表现区域，是二尖瓣 瓣环扩大的主要部位.进行瓣环成型时 主要为后
9、瓣环的矫正 Posterior mitral annulus enlarge more obviously than anterior annulus and must be repaired,Left trigone marker,Right trigone marker,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,17,前瓣环为主动脉左/无冠瓣环的延续，成型时此区域人工瓣环应用并非完全必要，使得应用C形或条带（band）瓣环成为可能。另外要注意缝针不宜过深，以免损伤主动
10、脉瓣。 Anterior annulus is close to aortic valve and relatively fixed. No need to fix it again and should not injure the aortic valve.,二尖瓣瓣环形态与功能临床意义 Clinical significance of mitral annulus anatomy,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,18,后瓣环近前交界处有左冠状动脉旋支紧邻。
11、左冠脉优势者旋支与后瓣环的间距约为36.5毫米，平均4.1毫米；右冠优势者二者间距为6-11.5毫米，平均8.5毫米；手术进针时应该注意防止旋支及其伴随静脉或冠状静脉窦的损伤。 Posterior annulus is close to LCX and be careful not to injure it.,二尖瓣瓣环形态与功能临床意义 Clinical significance of mitral annulus anatomy,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical Universit
12、y,19,术中操作时应注意回旋支与二尖瓣环的位置关系 箭头所指可见后叶楔形切除、人工瓣环植入术后导致的回旋支显影中断,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,20,A. 术前冠脉造影; B. 术后冠脉造影 （Tavilla G, Ann Thorac Surg 1998;66:2091-2093）,A,B,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,
13、21,二尖瓣瓣环扩大 二尖瓣瓣环钙化 Mitral annulus enlargement Mitral annulus calcification,二尖瓣瓣环的病变 Mitral annulus pathology,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,22,有效瓣口面积,二尖瓣前后叶完全开启时的瓣口直径小于二尖瓣环的直径，则二尖瓣的面积与二尖瓣环面积是不同的概念，前者称为有效瓣口面积，表明舒张期通过二尖瓣左房血流的截面积；后者则为潜在瓣口面积。有效瓣口面积与潜在瓣
14、口面积二者比例约为1:1.51:2.2。正常人的瓣口面积约为4.06.0平方厘米.,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,23,二尖瓣对合面积,二尖瓣前后叶粗糙部对合面积，在正常情况下约占瓣叶总面积的20%-40%，是二尖瓣体完成闭合功能的主要部位。 不同原因的二尖瓣关闭不全时瓣叶对合面积都有不同程度的损害, 增大瓣叶的对合面积则是二尖瓣成型的主要目标.,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,C
15、apital Medical University,24,二尖瓣对合面积,黑色代表二尖瓣闭合时不参加闭合的瓣叶部分。浅色的部分则构成了有效闭合面积。,充分的二尖瓣对合面积可以保障长期良好的二尖瓣成形效果,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,25,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,26,A Barlow综合症Physio Ring成形，注
16、水试验后前后叶对合缘作染色 B 吸净水后，探查对合缘标记以下的前瓣叶高度。生理状况下一般在4-10mm。Barlow综合症者如果对合缘下前瓣叶高度大于10mm则有SAM风险。,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,27,A 使用Carpentier-McCarthy-Adams环进行缺血性二尖瓣成形，注水后染色 B 吸净水后，探查染色对合缘下的后瓣叶高度和对合面积,Anyanwu and Adams; J Thorac Cardiovasc Surg 2007;133
17、 (6):1635,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,28,二尖瓣修复的理想结果,2004,2008,Anyanwu and Adams; J Thorac Cardiovasc Surg 2007;133 (6):1635,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,29,二尖瓣人工瓣环成形术,2019/5/16, 2009 by Dr.Me
18、ng Xu, Beijing Anzhen Hospital ,Capital Medical University,30,术中确定纤维三角的方法 Identify the Left and right trigone,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,31,安置纤维三角缝线 用2-0缝线，分别在两个纤维三角缝合一针，跨度为4mm,瓣环测量 把手柄插入塞规，印有“M”的那面朝上。将事先安置好的两个三角区的缝线，分别通过塞规前部的凹槽，用镊子轻轻牵拉前叶，向下推送塞
19、规。如塞规的两个凹槽正好对着两个三角，并且塞规的表面积和前叶的面积相一致，那么这个塞规的大小就是所要选择的人工瓣环的大小。,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,32,安置前瓣环缝线 先在两个三角之间的前瓣环间断安置缝线，每针跨度约2mm,缝线上行穿挂人工瓣环的针距宜为2mm,有益前瓣环正常曲度的维持。,安置交界和后瓣环缝线 在交界处和后瓣环安置缝线，跨度为约4mm。将这些缝线分别穿过人工瓣环，并且在人工瓣环上的跨度为2mm，这样可以起到缩小扩大的后瓣环的作用。通常总
20、共缝合约11-13针，缝合时注意不要缝到回旋支。,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,33,用手柄将人工瓣环向下推到二尖瓣环上，同时向上提缝线,去除手柄后保留瓣环支撑架打结缝线，最后去除瓣环支撑架，完成人工瓣环植入。,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,34,人工瓣膜全环和瓣环塑性带,Paul Dagum 等于2001年比较了部分软环组、
21、全软环组和正常对照组之间的结果。发现部分软环和全软环均对二尖瓣环有相同固定作用，即心动周期内二尖瓣环面积、横径和前后径均无明显变化。但是，部分软环保留了与正常对照组一样的二尖瓣环生理性弯曲折叠功能，而这一点对于瓣膜修复术的远期疗效和防止左室流出道梗阻可能非常重要。,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,35,Carpentier-McCarthy-Adams IMR ETlogix 瓣膜成形环,Duran 人工成形环,国产佰仁思瓣膜成形环,Carpentier-Edw
22、ards 经典二尖瓣环,SJM Tailor Ring,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,36,A. Medtronic Duran瓣环塑形带 B. Cosgrove-Edwards瓣环塑形带 C. SJM Tailor瓣环塑形带 D. CarboMedics AnnuloFlex瓣环塑形带,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,37,C
23、arpentier-Edwards Classic Annuloplasty Ring,Solid titanium core provides strength and durability,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,38,Carpentier-Edwards Physio Annuloplasty Ring,Remodeling preserves natural 3:4 ratio between the anteroposterior diamet
24、er and transverse diameter during systole.,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,39,Carpentier-Edwards Physio II Annuloplasty Ring Invented by Alain F. Carpentier, MD, PhD and David H. Adams, MD,Double saddle configuration,True sewing cuff design,more cir
25、cular shape,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,40,Cosgrove-Edwards Annuloplasty System,use in the mitral or tricuspid position. Flexible band adapts to three-dimensional contour,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical Un
26、iversity,41,GeoForm Ring,Remodel the mitral annulus Reform the left ventricle,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,42,Carpentier-McCarthy-Adams IMR ETlogix Annuloplasty Ring,first asymmetric ring designed to treat asymmetric dilatation.,Corrects for Type
27、 IIIb mitral regurgitation. Decreased anteroposterior (AP) distance increases leaflet coaptation. Increased sewing margin in the P2-P3 region, marked with suture, designed to accommodate a double-suture row.,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,43,Medtro
28、nic Fully rigid Profile 3D Ring,Medtronic Semi-rigid CG Future Ring and Band System,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,44,Medtronic Flexible Duran AnCore Ring and Band System,This flexibility allows your repaired mitral or tricuspid valve to continuous
29、ly move and change shape and size just as a natural valve does.,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,45,Sorin MEMO 3DTM Semirigid Annuloplasty Ring,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,46,St-Jude flexible Tai
30、lor Ring,Indicated for both mitral and tricuspid valve repair. Ring can easily be customized to a C-ring (band).,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,47,解剖变化 空间构型变化 - 风湿性 - 心肌病 - 退行性 - 缺血性 - 心内膜炎 - 先天性 瓣膜性 心室性 真实大小 较一般小的 瓣环成形 瓣环成形,二尖瓣返流成形环的选择,2019/5/16,
31、2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,48,Adams DH et al. Ann Thorac Surg 2006; 82 (6): 2096-101,二尖瓣Barlow疾病的修复采用大的人工瓣环成型技术,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,49,AHA 2005: 完整性的硬环 ! 软环治疗缺血性 MR 复发率增大5倍,Its a ventricular p
32、roblem !,缺血性MR的瓣环成形,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,50,治疗MR：减少40%的AP间距 双环马鞍状：改变左室构型,Miller JCTVS 2003 Maisano, Alfieri et al JCTVS 2005,治疗缺血性二尖瓣关闭不全 的新型成形环GeoForm ring : - eliminate MR - remodel LV !,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,51,使左心室向上和向内重新塑形,Geometric distortion “out & down”,2019/5/16, 2009 by Dr.Meng Xu, Beijing Anzhen Hospital ,Capital Medical University,52,小 结,人工瓣环成型技术是二尖瓣疾病重要的外科修复治疗基础。 保持良好的瓣叶对合面积是二尖瓣环成形根本要求。,THANKS FOR YOUR ATTENTION,