二尖瓣修補(bǔ)的方法東方的觀點(diǎn)（中英文）

二尖瓣修補(bǔ)的方法東方的觀點(diǎn)Dr.TimWing-KukAuFRCS,FHKCSConsultantSurgeonHonoraryClinicalAssistantProfessorDepartmentofCardiothoracicSurgeryTheUniversityofHongKong,QueenMaryHospital,HongKongSAR心血管治療領(lǐng)域中的新起點(diǎn)

December2008Shanghai,China

ClevelandClinic無癥狀二尖瓣返流治療結(jié)果的定量分析MauriceEnrique-Saranetal.NEnglJMed2005;352:875-83二尖瓣返流的概述GrigioniF.JACC199934;7:2078-85OttoC.NEnglJMed2001,345;10:740-6Enrique-Saranetal.Circulation.1994;90:830-37Shuhaiberetal.EurJCardThoracSurg.2007;31:267-75ChordsOlivieria1983Survival1.230.384.04Chords1.230.384.04DegenGillinov2003Survival1.671.302.15DegenLee1997Survival1.420.842.40DegenMohty2001Survival1.751.242.46DegenYacoub1981Survival2.340.916.05Degen1.681.392.02IschemicCalifiore2004Survival0.780.193.16IschemicCohn1995Survival0.530.181.53IschemicGrossi2001Survival1.340.921.95IschemicMantovani2004Survival1.480.425.20Ischemic1.180.831.69MixedAdebo1984Survival1.480.336.70MixedAkins1994Survival1.600.763.36MixedCraver1990Survival1.160.393.50MixedEnriguez-Sarano99?Survival1.641.132.38MixedGalloway1989Survival1.551.022.35MixedHausmann1999Survival0.860.581.26MixedKawachi1991Survival4.330.6429.34MixedPerier1984Survival2.391.304.37MixedSand1987Survival1.631.042.57MixedThourani2003Survival1.531.261.86Mixed1.491.241.78RheumaticAntunes1987Survival2.131.283.53RheumaticYau2000Survival2.651.474.78Rheumatic2.331.593.43Overall1.581.411.78危險(xiǎn)比修補(bǔ)

vs

置換

血流動(dòng)力學(xué)更穩(wěn)定

維持心室的功能

避免使用人工瓣膜

不會(huì)出現(xiàn)血栓栓塞和出血

感染機(jī)率降低分型瓣葉運(yùn)動(dòng)描述Ia正常瓣環(huán)擴(kuò)張Ib瓣葉穿孔IIa過度腱索延長IIb腱索破裂IIc乳頭肌梗死/延長IIIa受限瓣葉縮短或粘合或腱索融合IIIb左心室功能異常或動(dòng)脈瘤導(dǎo)致瓣葉圈合IV不定乳頭肌功能失調(diào)

退行性二尖瓣返流的Carpentier分級

前瓣葉–瓣葉轉(zhuǎn)位人工腱索–Gore-Tex5/0

人數(shù)死亡率STS數(shù)據(jù)庫1.5%Gillinov200835440.3%DeBonis20067380.3%Suri*2006641.6%*David20057010.7%Kasegawa20061811.3%Nakajima2005160.0%Cinghatanadgige2003432.3%Song20031841.0%退行性二尖瓣返流

東方

=西方

TEE的重要性

返流束的方向判斷容易出錯(cuò)

鹽水注射試驗(yàn):有或無

Barlow’s–罕見但是很困難分型瓣葉活動(dòng)描述Ia正常瓣環(huán)擴(kuò)張Ib瓣葉穿孔IIa過度腱索延長IIb腱索斷裂IIc乳頭肌

梗死/延長IIIa受限瓣葉縮短或粘合或融合IIIb左心室功能異?；騽?dòng)脈瘤導(dǎo)致的瓣葉圈合IV不定乳頭肌功能失調(diào)

改良Carpentier分級:缺血性MR缺血性二尖瓣返流的機(jī)制–慢性Lveineetal.Circulation112(5)August745-58

Bursi,F.etal.Circulation2005;111:295-301773例MI后患者，根據(jù)超聲心動(dòng)圖檢查MR嚴(yán)重程度的不同分組，30天內(nèi)各組的總存活率

(實(shí)線代表無MR，點(diǎn)線代表輕度MR，虛線代表中度或重度)NILMR50%MildMR38%ModorsevereMR12%亞洲的問題有多嚴(yán)重?中國國家心血管疾病中心2005報(bào)道:

全國缺血性心臟病的發(fā)病率為4.2%

每年新增的MI患者為500,000例

[城市預(yù)測]

預(yù)計(jì)每年新增的缺血性MR患者例數(shù)：60,000院內(nèi)死亡率1.4%修補(bǔ)vs21%置換

P=0.06缺血性二尖瓣返流中二尖瓣修補(bǔ)和二尖瓣置換的比較OsmanO.Al-Radi,MBBS,PeterC.Austin,PhD,JackV.Tu,MD,TironeE.David,MD,andTerrenceM.Yau,MD,MS北京上海年份

1976-971978-03患者45053416女性(%)52.439.6年齡40.540.0風(fēng)濕性(%)8092二尖瓣(%)54.3100機(jī)械瓣100100死亡率(%)3.83.310年存活率(%)9394出血&血栓%患者，年份1.590.85Shuhaiberetal.EurJCardThoracSurg.2007;31:267-75ChordsOlivieria1983Survival1.230.384.04Chords1.230.384.04DegenGillinov2003Survival1.671.302.15DegenLee1997Survival1.420.842.40DegenMohty2001Survival1.751.242.46DegenYacoub1981Survival2.340.916.05Degen1.681.392.02IschemicCalifiore2004Survival0.780.193.16IschemicCohn1995Survival0.530.181.53IschemicGrossi2001Survival1.340.921.95IschemicMantovani2004Survival1.480.425.20Ischemic1.180.831.69MixedAdebo1984Survival1.480.336.70MixedAkins1994Survival1.600.763.36MixedCraver1990Survival1.160.393.50MixedEnriguez-Sarano99?Survival1.641.132.38MixedGalloway1989Survival1.551.022.35MixedHausmann1999Survival0.860.581.26MixedKawachi1991Survival4.330.6429.34MixedPerier1984Survival2.391.304.37MixedSand1987Survival1.631.042.57MixedThourani2003Survival1.531.261.86Mixed1.491.241.78RheumaticAntunes1987Survival2.131.283.53RheumaticYau2000Survival2.651.474.78Rheumatic2.331.593.43Overall1.581.411.78分型瓣葉活動(dòng)描述修補(bǔ)技術(shù)Ia正常瓣環(huán)擴(kuò)張瓣環(huán)成形術(shù)Ib瓣葉穿孔IIa過度腱索延長Gore-Texor縮短術(shù)IIb腱索斷裂IIc乳頭肌梗死/延長Gore-Texor縮短術(shù)IIIa受限瓣葉縮短或粘合或腱索融合心包補(bǔ)片口角成形術(shù)腱索,乳頭肌開窗術(shù)IIIb左心室功能異?；騽?dòng)脈瘤導(dǎo)致瓣葉圈合IV不定乳頭肌功能失調(diào)

風(fēng)濕性二尖瓣返流的病理生理學(xué)MethodsandResults—From1970to1994,951patientswithrheumaticMVinsufficiencywereoperatedonwiththereconstructivetechniqueselaboratedbyAlainCarpentier.Meanagewas25.8years(4to75),andsinusrhythmwaspresentin63%.ThefunctionalclassificationusedwastypeI,normalleafletmotion,71patients(7%);typeII,prolapsedleaflet,311patients(33%);andtypeIII,restrictedleafletmotion,345patients(36%).Thecombinedlesionofprolapseoftheanteriorleafletandrestrictionoftheposteriorwaspresentin224patients(24%).Surgicaltechniquesusedwereimplantationofaprostheticringin95%,shorteningofthechordsandleafletenlargementwithautologouspericardium,andcommissurotomy.Hospitalmortalityratewas2%.Themeanfollow-upwas12years(maximum,29years):8618patientsperyear.Actuarialsurvivalwas89±19%at10yearsand82±18%at20years.Therateofthromboemboliceventswas0.4%patientsperyear(33events),with3deaths.Freedomfromreoperationwas82±19%at10yearsand55±25%at20years.Themaincause(83%)ofreoperationwasprogressivefibrosisoftheMV.Theactuarialrateofreoperationwas2%patientsperyearandwascorrelatedtothedegreeofpreoperativefibrosis.功能分級Ⅰ型，瓣葉活動(dòng)正常的患者有71例（7%）；Ⅱ型，瓣葉脫垂者311例（33%）；Ⅲ型，瓣葉活動(dòng)受限者345例（36%）。二尖瓣前葉脫垂同時(shí)伴后葉受限的患者共224例（24%）。

Carpentier-Edwards環(huán)13265.7口角成形術(shù)10652.7腱索轉(zhuǎn)移2311.4腱索縮短189前葉延長術(shù)147后葉延長術(shù)63%總修補(bǔ)人數(shù)=201例患者二尖瓣修補(bǔ)聯(lián)合主動(dòng)脈瓣置換治療風(fēng)濕性心臟病Huynh-QuangTriHo,MD,Van-PhanNguyen,MD,Kim-PhuongPhan,MD,Nguyen-VinhPham,PhDHeartInstitute,HoChiMinhCity,VietnamMS30% MR37% Mixed33%死亡率修補(bǔ)1.4%置換0.7%AnnThoracSurg2001;71:78–85Vietnam心臟中心Prof.NVPhan

香港大學(xué)二尖瓣置換vs修補(bǔ)↙↙Gore-Tex心包補(bǔ)片環(huán)….何種環(huán)?一覽表房顫是一種嚴(yán)重的疾病十年死亡率Framingham研究62%

58%

30%

21%

Men

Women□不伴房顫■伴有房顫24%

10%

2%3%

50-5960-6970-7980-89房顫患者心梗的發(fā)生率

按年齡分組二尖瓣修補(bǔ)

╬謝謝symptoms

MitralValveRepairStrategiesPerspectiveEASTDr.TimWing-KukAuFRCS,FHKCSConsultantSurgeonHonoraryClinicalAssistantProfessorDepartmentofCardiothoracicSurgeryTheUniversityofHongKong,QueenMaryHospital,HongKongSARNewHorizoninCardiovascularTreatments

December2008Shanghai,China

ClevelandClinicQuantitativeDeterminantsoftheOutcome

ofAsymptomaticMitralRegurgitationMauriceEnrique-Saranetal.NEnglJMed2005;352:875-83FactsaboutMRAsymptomaticMR–5-10yearsSevereMR–annualmortality5%SuddendeathinsevereMRPoorNYHAclassLowLVejectionAtrialfibrillationSevereMR(irrespectiveofetiology)→

Surgery

GrigioniF.JACC199934;7:2078-85OttoC.NEnglJMed2001,345;10:740-6Enrique-Saranetal.Circulation.1994;90:830-37EchocardiographicPredictionofSurvivalAfterSurgicalCorrectionofOrganicMitralRegurgitationShuhaiberetal.EurJCardThoracSurg.2007;31:267-75ChordsOlivieria1983Survival1.230.384.04Chords1.230.384.04DegenGillinov2003Survival1.671.302.15DegenLee1997Survival1.420.842.40DegenMohty2001Survival1.751.242.46DegenYacoub1981Survival2.340.916.05Degen1.681.392.02IschemicCalifiore2004Survival0.780.193.16IschemicCohn1995Survival0.530.181.53IschemicGrossi2001Survival1.340.921.95IschemicMantovani2004Survival1.480.425.20Ischemic1.180.831.69MixedAdebo1984Survival1.480.336.70MixedAkins1994Survival1.600.763.36MixedCraver1990Survival1.160.393.50MixedEnriguez-Sarano99?Survival1.641.132.38MixedGalloway1989Survival1.551.022.35MixedHausmann1999Survival0.860.581.26MixedKawachi1991Survival4.330.6429.34MixedPerier1984Survival2.391.304.37MixedSand1987Survival1.631.042.57MixedThourani2003Survival1.531.261.86Mixed1.491.241.78RheumaticAntunes1987Survival2.131.283.53RheumaticYau2000Survival2.651.474.78Rheumatic2.331.593.43Overall1.581.411.78Repair

vs

Replacement

SuperiorhemodynamicsPreservationofventricularfunction,AvoidanceofprostheticvalveFreedomfromthromboembolism&bleedingLowerinfectionrate

Skillandexperiencecounts

TypeLeafletmotionDescriptionIaNormalAnnulardilatationIbLeafletperforationIIaExcessiveChordalelongationIIbChordalruptureIIcPapillarymuscleInfarction/elongationIIIaRestrictedLeafletretractionorCommissuralorchordalfusionIIIbLeaflettetheringbyLVdysf(x)oraneurysmIVVariablePapillarymuscledysf(x)

CarpentierClassificationofMitralDegenerativeRegurgitationMitralrepairfordegenerativediseasesPosteriorleaflet-universalstandardrepairAnteriorleaflet–moretechnicaldifficultandvariableresultsCommissuralprolapse–Carpentier’srepairPosteriorleaflet–QresectionAnteriorleaflet–leaflettransferArtificialChordae–Gore-Tex5/0ResultsofdegenerativeMVrepair

WestvsEastnumbermortalitySTSdatebase1.5%Gillinov200835440.3%DeBonis20067380.3%Suri*2006641.6%*David20057010.7%Kasegawa20061811.3%Nakajima2005160.0%Cinghatanadgige2003432.3%Song20031841.0%DegenerativeMitralRegurgitationEast=WestImportanceofTEEPitfallsofregurgitantjetdirectionSalinejettest:yesornoBarlow’s–rarebutdifficultTypeLeafletmotionDescriptionIaNormalAnnulardilatationIbLeafletperforationIIaExcessiveChordalelongationIIbChordalruptureIIcPapillarymuscleInfarction/elongationIIIaRestrictedLeafletretractionorCommissuralorchordalfusionIIIbLeaflettetheringbyLVdysf(x)oraneurysmIVVariablePapillarymuscledysf(x)

ModifiedCarpentierClassification:IschemicMR

MechanismofIschemicMitralRegurgitation-ChronicLveineetal.Circulation112(5)August745-58

Bursi,F.etal.Circulation2005;111:295-301OverallsurvivalaccordingtodegreeofMRin773patientswhounderwentechocardiographywithin30daysafterMI(solidlineindicatesnoMR,dottedlinemildMR,anddashedlinemoderateorsevereMR)NILMR50%MildMR38%ModorsevereMR12%HowbigistheprobleminAsia?ChinaNationalCenterforCardiovascularDisease2005Report:PrevalenceofIHDwas4.2%inthecountry500,000newcasesofMIeachyear[urbanestimate]EstimatednewcasessevereIschemicMRannually:60,000In-hospitalmortality1.4%repairvs21%replacementP=0.065yrre-operationraterepair14%vsreplacement3%P=0.003MitralRepairVersusReplacementforIschemicMitralRegurgitationOsmanO.Al-Radi,MBBS,PeterC.Austin,PhD,JackV.Tu,MD,TironeE.David,MD,andTerrenceM.Yau,MD,MSVariousRepairTechniquesforChronicIschemicMRAnnuloplasty–Undersized Bolling(n=140)Carpentiermethods Acar(n=44)2ndChordaeReleases David(n=30)LVRestorationeg:Dor’s Mericanti(n=46)RelocationofPost.PM Kron(n=18)Edge-to-Edge Repair Bhudia(n=146)*BeijingShanghaiYear1976-971978-03Patients45053416Female(%)52.439.6Age40.540.0Rheumatic(%)8092Mitral(%)54.3100Mechanicalvalve100100Mortality(%)3.83.310yrsurvival(%)9394Bleeding&thrombosis%patient.year1.590.85

MitralValveSurgeryreviewinChina

Shuhaiberetal.EurJCardThoracSurg.2007;31:267-75ChordsOlivieria1983Survival1.230.384.04Chords1.230.384.04DegenGillinov2003Survival1.671.302.15DegenLee1997Survival1.420.842.40DegenMohty2001Survival1.751.242.46DegenYacoub1981Survival2.340.916.05Degen1.681.392.02IschemicCalifiore2004Survival0.780.193.16IschemicCohn1995Survival0.530.181.53IschemicGrossi2001Survival1.340.921.95IschemicMantovani2004Survival1.480.425.20Ischemic1.180.831.69MixedAdebo1984Survival1.480.336.70MixedAkins1994Survival1.600.763.36MixedCraver1990Survival1.160.393.50MixedEnriguez-Sarano99?Survival1.641.132.38MixedGalloway1989Survival1.551.022.35MixedHausmann1999Survival0.860.581.26MixedKawachi1991Survival4.330.6429.34MixedPerier1984Survival2.391.304.37MixedSand1987Survival1.631.042.57MixedThourani2003Survival1.531.261.86Mixed1.491.241.78RheumaticAntunes1987Survival2.131.283.53RheumaticYau2000Survival2.651.474.78Rheumatic2.331.593.43Overall1.581.411.78TypeLeafletmotionDescriptionRepairtechniqueIaNormalAnnulardilatationAnnuloplastyIbLeafletperforationIIaExcessiveChordalelongationGore-TexorshorteningIIbChordalruptureIIcPapillarymuscleInfarction/elongationGore-TexorshorteningIIIaRestrictedLeafletretractionorCommissuralorchordalfusionPericardialpatchCommissuroplastyChordal,PMfenestrationIIIbLeaflettetheringbyLVdysf(x)oraneurysmIVVariablePapillarymuscledysf(x)

PathophysiologyofRheumaticMitralRegurgitationLong-Term(29Years)ResultsofReconstructiveSurgeryinRheumaticMitralValveInsufficiencySylvainChauvaud,MD;Jean-Fran?oisFuzellier,MD;AlainBerrebi,MD;AlainDeloche,MD;Jean-No?lFabiani,MD;AlainCarpentier,MD,PhDMethodsandResults—From1970to1994,951patientswithrheumaticMVinsufficiencywereoperatedonwiththereconstructivetechniqueselaboratedbyAlainCarpentier.Meanagewas25.8years(4to75),andsinusrhythmwaspresentin63%.ThefunctionalclassificationusedwastypeI,normalleafletmotion,71patients(7%);typeII,prolapsedleaflet,311patients(33%);andtypeIII,restrictedleafletmotion,345patients(36%).Thecombinedlesionofprolapseoftheanteriorleafletandrestrictionoftheposteriorwaspresentin224patients(24%).Surgicaltechniquesusedwereimplantationofaprostheticringin95%,shorteningofthechordsandleafletenlargementwithautologouspericardium,andcommissurotomy.Hospitalmortalityratewas2%.Themeanfollow-upwas12years(maximum,29years):8618patientsperyear.Actuarialsurvivalwas89±19%at10yearsand82±18%at20years.Therateofthromboemboliceventswas0.4%patientsperyear(33events),with3deaths.Freedomfromreoperationwas82±19%at10yearsand55±25%at20years.Themaincause(83%)ofreoperationwasprogressivefibrosisoftheMV.Theactuarialrateofreoperationwas2%patientsperyearandwascorrelatedtothedegreeofpreoperativefibrosis.

Carpentier-Edwardsring13265.7Commissurotomy10652.7Chordaltransfer2311.4Chordalshortening189Anteriorleafletextension147Posteriorleafletextension63%Totalrepair=201patientsMitralValveRepairwithAorticValveReplacementinRheumaticHeartDisease

Huynh-QuangTriHo,MD,Van-PhanNguyen,MD,Kim-PhuongPhan,MD,Nguyen-VinhPham,PhDHeartInstitute,HoChiMinhCity,VietnamMS30% MR37% Mixed33%MortalityRepair1.4%Replacement0.7%Freedomfrommitral

valvere-operationat9yearswas84.2±13%forgroup

1and92±7.4%forgroup2(log-ranktest:p=0.42)

ValvuloplastyWithGlutaraldehyde-TreatedAutologousPericardiuminPatientsWithComplexMitralValvePathologyChoi-KeungNg,MD,JoachimNesser,MD,ChristianPunzengruber,MD,OtmarPachinger,MD,JohannesAuer,MD,HerbertFranke,MD,andPeterHartl,MDAnnThoracSurg2001;71:78–85

63patientsover10yearsZeroin-hospitalmortality5yrsre-opfreeinterval–95%Technique–50%enlargementGlutaldehyde0.625%-30mins6/0or7/0Gore-TexsuturesRe-operationFreeSurvivalAfterRheumaticMitralRepairRheumaticMR10yearsre-opfreesurvival85–90%RheumaticMixedMitral10yearsre-opfreesurvival70–80%MechanicalProsthesis10yearsre-opfreesurvival90–95%TimeIntervalbetweenInitialMVRepairandReoperation●

Procedurerelated=6.04±7.18●

Valverelated=45.44±33.65Procedurerelatedcomplication:-Wrongindicationseverityofvalvelesionpoorlylikehoodofvalverepair-Technicalerrorunsuitabletechniquewrongmanipulation-Inadequateinitialrepair-Instabilityofrepairtechnique

Valverelatedcompli