1 1限制性二尖瓣成型联合限制性二尖瓣成型联合CABG治疗缺血性二尖瓣返流治疗缺血性二尖瓣返流南京医科大学附属南京第一医院南京医科大学附属南京第一医院南京市心血管病医院南京市心血管病医院 陈陈 鑫鑫南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所2 2ll缺血性二尖瓣返流（缺血性二尖瓣返流（ischemic mitral ischemic mitral regurgitation, IMRregurgitation, IMR）-CAD-CAD、心肌缺血心肌缺血/ /心心肌梗塞引起的乳头肌功能不全、左心功能不全、肌梗塞引起的乳头肌功能不全、左心功能不全、瓣环扩大等造成的二尖瓣关闭不全。瓣环扩大等造成的二尖瓣关闭不全。ll这类病人在进行心脏冠状动脉搭桥手术时常常这类病人在进行心脏冠状动脉搭桥手术时常常需要考虑是否同时处理需要考虑是否同时处理IMRIMR。llMVR MVR 是治疗二尖瓣关闭不全的有效手段，但术是治疗二尖瓣关闭不全的有效手段，但术后常需要长期或短期抗凝，出血或后常需要长期或短期抗凝，出血或/ /和血栓栓和血栓栓塞的发生率可达塞的发生率可达2-7%/2-7%/年（年（1 1），人工瓣膜本身），人工瓣膜本身还可能发生心内膜炎、瓣周漏、溶血等，严重还可能发生心内膜炎、瓣周漏、溶血等，严重影响病人的远期效果。影响病人的远期效果。 南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所3 3ll良好的二尖瓣成型技术良好的二尖瓣成型技术-治疗治疗IMRIMR的有效手段，的有效手段，-完全避免与人工瓣相关的并发症完全避免与人工瓣相关的并发症-降低手术死亡率降低手术死亡率-提高患者生存质量和远期效果。提高患者生存质量和远期效果。南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所4 4临床资料临床资料一般资料：一般资料：ll 72 72 例例 伴有中重度伴有中重度IMRIMR（3-4+3-4+，3.50.63.50.6）的）的冠心病人接受了同时冠心病人接受了同时CABG+CABG+限制性二尖瓣成限制性二尖瓣成型型ll男男: :女女 = 59 : 13= 59 : 13ll年龄年龄 55-83 ( 67.25.7) 55-83 ( 67.25.7) 岁，岁，7070岁以上病人岁以上病人3333例例ll心电图心电图: : 陈旧性陈旧性QQ波心肌梗塞波心肌梗塞-66-66例例南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所5 5llTTE : TTE : ll中中- -重度返流重度返流 (3+) 40 (3+) 40 例例ll重度返流重度返流 (4+) 32 (4+) 32 例例llLVEDD 55-81 (64.211.5) mm,LVEDD 55-81 (64.211.5) mm,llLAD 52-74(58.06.2)mmLAD 52-74(58.06.2)mmllLVEF 30% 16LVEF 45% 4145% 41例。例。ll同时合并三尖瓣中重度返流同时合并三尖瓣中重度返流1010例。例。llCAGCAG：双支病变：双支病变7 7例，例，6565例三支病变，同时合例三支病变，同时合并并LMLM狭窄狭窄 1616例。例。 同时合并左心室壁瘤同时合并左心室壁瘤1818例。例。南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所6 6ll手术前心功能手术前心功能 NYHA IINYHA II级级1515例、例、IIIIII和和IVIV级分别级分别为为4242例和例和1515例例ll合并疾病合并疾病: : 高血压病高血压病3737例，糖尿病例，糖尿病2929例，心衰例，心衰史史4141例，慢性心房纤颤例，慢性心房纤颤1010例，肾功能异常例，肾功能异常1717例，例，脑中风史脑中风史1616例。例。ll5 5例严重左主干病变伴术前不稳定心绞痛主动脉例严重左主干病变伴术前不稳定心绞痛主动脉内球囊反搏（内球囊反搏（IABPIABP）1 1：1 1辅助下急诊手术。辅助下急诊手术。南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所7 7方方 法法ll常规放置常规放置Swan-GazeSwan-Gaze导管，监测导管，监测PA, PCWPPA, PCWPll术术中中（TEETEE）：评评价价二二尖尖瓣瓣功功能能状状态态、心心脏脏功功能能和成型效果。和成型效果。ll7272例例均均在在全全麻麻体体外外循循环环下下经经胸胸骨骨正正中中切切口口手手术术。开开胸胸后后先先取取左左乳乳内内动动脉脉，同同时时取取桡桡动动脉脉和和大大隐隐静静脉备用。脉备用。ll常常规规 CPBCPB。阻阻断断主主动动脉脉，心心肌肌保保护护采采用用经经主主动动脉脉根根部部顺顺行行灌灌注注含含血血心心肌肌保保护护液液，结结合合经经“ “桥桥” ”灌灌注注。合合并并主主动动脉脉瓣瓣病病变变者者切切开开升升主主动动脉脉，经经冠冠状状动脉开口直接冷灌。动脉开口直接冷灌。南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所8 8ll手手术术中中先先处处理理室室壁壁瘤瘤，然然后后进进行行冠冠状状动动脉脉远远端端吻吻合合，再再经经右右房房房房间间隔隔途途径径暴暴露露和处理二尖瓣。和处理二尖瓣。ll手术中手术中TEETEE观察二尖瓣膜观察二尖瓣膜成型效果。术中探查结合成型效果。术中探查结合TEETEE见二尖瓣膜返流的原因见二尖瓣膜返流的原因南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所9 9 二二二二尖尖尖尖瓣瓣瓣瓣环环环环扩扩扩扩大大大大引引引引起起起起的的的的IMR-IMR-CarpentieCarpentie I I型型型型- 54- 54例例例例手手术中探查结合术中探查结合术中探查结合术中探查结合TEE-TEE-TEE-TEE-二尖瓣返流原因二尖瓣返流原因二尖瓣返流原因二尖瓣返流原因 心腔明显扩大、乳头心腔明显扩大、乳头肌肉移位引起腱索肌肉移位引起腱索乳头肌功能而导致乳头肌功能而导致二尖瓣返流二尖瓣返流-CarpentierCarpentier IIIbIIIb - -1818例例南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所10101. 1.手术中用二尖瓣成型的测瓣器，根据二尖瓣前后手术中用二尖瓣成型的测瓣器，根据二尖瓣前后叶交界间的距离和前叶的面积，测得所需成型环叶交界间的距离和前叶的面积，测得所需成型环的大小，实际植入的二尖瓣成型环均比测量的小的大小，实际植入的二尖瓣成型环均比测量的小一到二号一到二号2. 2.2-0 2-0 TicronTicron线不带垫片间断褥式缝合植入二尖瓣线不带垫片间断褥式缝合植入二尖瓣成型环，注水实验观察二尖瓣返流矫正情况。成型环，注水实验观察二尖瓣返流矫正情况。3. 3.同时主动脉置换者在升主动脉一次阻断下完成近同时主动脉置换者在升主动脉一次阻断下完成近端吻合，单纯二尖瓣成型者在升主动脉侧壁钳下端吻合，单纯二尖瓣成型者在升主动脉侧壁钳下完成近端吻合。完成近端吻合。4. 4.主动脉开放前先开放乳内动脉桥，并左心排气主动脉开放前先开放乳内动脉桥，并左心排气5. 5.主动脉开放后进行三尖瓣成型。主动脉开放后进行三尖瓣成型。 南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所1111结结 果果ll7272例均放置二尖瓣成型环（例均放置二尖瓣成型环（1616例为例为C C 型环，型环，5656例为例为0 0型全环）型全环）ll冠状动脉远端吻合人均冠状动脉远端吻合人均3.41.33.41.3（3-63-6）个。应用）个。应用左乳内动脉左乳内动脉7171例，例，2121支静脉桥为序贯搭桥。支静脉桥为序贯搭桥。ll同时行主动脉瓣置换同时行主动脉瓣置换9 9例，例，ll三尖瓣成型三尖瓣成型1010例，例，ll室壁瘤线性切除室壁瘤线性切除6 6例，心内补片左室成型例，心内补片左室成型1212例。例。ll主动脉阻断时间主动脉阻断时间55-126 min55-126 min，平均，平均7822 min7822 min；CPBCPB时间时间 78-170 min78-170 min，平均，平均12239 min12239 min。 南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所1212ll手术中成型后手术中成型后TEETEE：二尖瓣无和微量反流：二尖瓣无和微量反流2828和和3535例，轻度返流例，轻度返流6 6例，轻例，轻- -中度返流中度返流3 3例，中例，中- -重重度返流度返流1 1例（再次例（再次CPBCPB下行二尖瓣置换，原位下行二尖瓣置换，原位保留全部二尖瓣装置植入保留全部二尖瓣装置植入27#27#生物瓣）。生物瓣）。ll手术后共手术后共1818例带例带IABPIABP回回ICUICU，IABPIABP支持支持15-11215-112小时。小时。1515例在手术后例在手术后7272小时内拔除小时内拔除IABPIABP。 南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所1313手术后并发症手术后并发症ll二次开胸止血二次开胸止血二次开胸止血二次开胸止血2 2例；例；例；例；ll新发房颤新发房颤新发房颤新发房颤2222例（例（例（例（2020例药物治疗后转成窦性心律）例药物治疗后转成窦性心律）例药物治疗后转成窦性心律）例药物治疗后转成窦性心律）ll9 9例病人拔除气管插管后因低氧血症需无创呼吸例病人拔除气管插管后因低氧血症需无创呼吸例病人拔除气管插管后因低氧血症需无创呼吸例病人拔除气管插管后因低氧血症需无创呼吸机辅助机辅助机辅助机辅助 ，1 1例需再次气管插管呼吸机辅助；例需再次气管插管呼吸机辅助；例需再次气管插管呼吸机辅助；例需再次气管插管呼吸机辅助；ll肾功能损害加重行肾功能损害加重行肾功能损害加重行肾功能损害加重行 CRRT 4 CRRT 4 例；例；例；例；ll脑中风脑中风脑中风脑中风1 1例；下肢切口感染例；下肢切口感染例；下肢切口感染例；下肢切口感染2 2例例例例 ll围手术期死亡围手术期死亡3 3例：例：低心排合并多脏器功能衰竭低心排合并多脏器功能衰竭低心排合并多脏器功能衰竭低心排合并多脏器功能衰竭2 2例，手术后急性肾功能衰竭伴肺部严重感染例，手术后急性肾功能衰竭伴肺部严重感染例，手术后急性肾功能衰竭伴肺部严重感染例，手术后急性肾功能衰竭伴肺部严重感染1 1例，例，例，例，分别在术后分别在术后分别在术后分别在术后3 3、7 7和和和和1414天死亡，手术死亡率天死亡，手术死亡率天死亡，手术死亡率天死亡，手术死亡率4.2%4.2%68例（转成二尖瓣置换1例除外）康复出院。 南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所1414随随 访访ll手术后随访手术后随访6-606-60个月（平均个月（平均 22.822.8月），月），ll 随访满随访满6 6月的月的6666例（死亡例（死亡2 2例，心源性死亡例，心源性死亡1 1例）例）ll 6-126-12月的月的6666例（死亡例（死亡2 2例，非心源性死亡）例，非心源性死亡）ll 1212月的月的5656例（累计心源性死亡例（累计心源性死亡3 3例）例）ll 2424月的月的4040例（累计心源性死亡例（累计心源性死亡5 5例）。例）。ll患患者者心心功功能能改改善善，心心绞绞痛痛均均消消失失。手手术术后后3 3、6 6、1212、2424月月，分分别别经经胸胸超超声声心心动动图图检检查查（表表1 1），手手术术后后IMRIMR均均得得到到明明显显改改善善，左左房房和和左左室室舒舒张张末末期期内内径径明明显缩小，随访期间无二次手术。显缩小，随访期间无二次手术。南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所1515表表1 1 二尖瓣成型手二尖瓣成型手术前后超声前后超声检查结果果 术前 术终 术后2周 3月 6月 12 月 24月 P value病人总数 72 71* 71 71 66 56 40 累计死亡数 - - 3 3 5 7 8 生存率% 96 96 92 88 80二尖瓣反流程度3.30.6 0.40.4 0.40.4 0.50.6 0.50.6 0.70.7 0.70.6 0.01EF% 5014 - 5415 5317 5414 5418 5515 0.01LVEDD 6411 - 5710 5511 569 5712 5514 0.01LA 586 - 535 497 506 486 497 0.01*1例转成二尖瓣置换除外南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所1616讨讨 论论一、手术指征： 与与单单纯纯搭搭桥桥相相比比，同同时时搭搭桥桥和和心心脏脏瓣瓣膜膜手手术术明明显显增增加加手手术术死死亡亡率率22，但但如如果果不不处处理理已已经经存在的明显存在的明显IMRIMR，又明显降低远期生存率。，又明显降低远期生存率。 因因此此手手术术中中决决定定是是否否处处理理IMRIMR明明显显影影响响手手术术效果。效果。 术术中中TEETEE评评价价IMRIMR时时，应应保保证证心心脏脏良良好好的的前前后后负负荷荷，否否则则可可能能低低估估IMRIMR的的程程度度，影影响响手手术术方案方案22。 南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所1717ll 虽然虽然 Seipelt5Seipelt5等的等的262262例病人结果显示搭桥同时例病人结果显示搭桥同时二尖瓣成型置换虽不影响手术后早期效果，但缺二尖瓣成型置换虽不影响手术后早期效果，但缺血性二尖瓣病变组手术死亡率明显高于非缺血组血性二尖瓣病变组手术死亡率明显高于非缺血组（19.5% 19.5% vsvs 6.7%, P=0.002 6.7%, P=0.002）。）。llBonacchiBonacchi等等66分析了分析了180180例伴例伴LVLV功能减退和功能减退和IMRIMR病人，结果显示，对轻病人，结果显示，对轻- -中度中度IMRIMR，单纯搭桥手术，单纯搭桥手术后生存率满意，后生存率满意，IMRIMR也得到明显改善，但远期无也得到明显改善，但远期无事件生存率低于同时事件生存率低于同时MVPMVP病人，提示即使轻病人，提示即使轻- -中中度度IMRIMR，也应该积极处理。，也应该积极处理。南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所1818下壁下壁MI-IMRMI-IMR的重要危险因素的重要危险因素ll本组本组56%56%有明确陈旧性下壁有明确陈旧性下壁QQ波心肌梗塞，主波心肌梗塞，主要是因为下壁心梗后的心室重构，严重影响二要是因为下壁心梗后的心室重构，严重影响二尖瓣装置的几何形状，导致后乳头肌向外侧移尖瓣装置的几何形状，导致后乳头肌向外侧移位，腱索牵拉过紧影响二尖瓣的关闭，产生位，腱索牵拉过紧影响二尖瓣的关闭，产生IMRIMR。llKumanohosoKumanohoso77分析了分析了103103例心肌梗塞病人，例心肌梗塞病人，6161例前壁，例前壁，4242例下壁心梗，虽然下壁例下壁心梗，虽然下壁MIMI对对LVLV功能影响小于前壁功能影响小于前壁MIMI，但下壁心梗病人，但下壁心梗病人IMRIMR的的发生率发生率38%38%（16/4216/42）和返流程度（返流面积）和返流程度（返流面积）（10.1%+7.5%10.1%+7.5%）均明显高于前壁心梗）均明显高于前壁心梗(10%)(10%)（6/616/61，P.0001)P.0001)，（，（4.4%7.0%, 4.4%7.0%, P=.0002P=.0002）。）。南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所1919作者体会作者体会/ /经验经验ll冠冠冠冠心心心心病病病病人人人人伴伴伴伴轻轻轻轻- -中中中中度度度度IMRIMR，如如如如果果果果左左左左房房房房和和和和左左左左室室室室大大大大小小小小正常，左室功能也正常，可以仅行冠状动脉搭桥正常，左室功能也正常，可以仅行冠状动脉搭桥正常，左室功能也正常，可以仅行冠状动脉搭桥正常，左室功能也正常，可以仅行冠状动脉搭桥ll但但但但对对对对中中中中度度度度和和和和中中中中度度度度以以以以上上上上的的的的IMRIMR者者者者，伴伴伴伴心心心心室室室室功功功功能能能能已已已已经经经经减减减减退退退退，特特特特别别别别是是是是心心心心脏脏脏脏已已已已经经经经明明明明显显显显扩扩扩扩大大大大者者者者，需需需需要要要要积积积积极极极极处处处处理；理；理；理；ll对对对对有有有有陈陈陈陈旧旧旧旧性性性性下下下下壁壁壁壁QQ波波波波心心心心梗梗梗梗，左左左左室室室室功功功功能能能能明明明明显显显显减减减减退退退退病病病病人人人人的的的的IMRIMR处处处处理理理理应应应应更更更更加加加加积积积积极极极极，以以以以提提提提高高高高手手手手术术术术后后后后远远远远期期期期的的的的无事件生存率。无事件生存率。无事件生存率。无事件生存率。ll对对对对存存存存在在在在多多多多种种种种手手手手术术术术危危危危险险险险因因因因素素素素的的的的中中中中度度度度IMRIMR病病病病人人人人，单单单单纯纯纯纯搭搭搭搭桥桥桥桥可可可可能能能能降降降降低低低低手手手手术术术术死死死死亡亡亡亡率率率率8,8,需需需需要要要要综综综综合合合合考考考考虑虑虑虑，决决决决定是否同时处理定是否同时处理定是否同时处理定是否同时处理IMRIMR。南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所2020冠状动脉靶血管的条件也是影响冠状动脉靶血管的条件也是影响手术指征的重要因素手术指征的重要因素ll对对手手术术前前左左心心室室EF30% EF6060岁，两组的远期生存率无明显差异。岁，两组的远期生存率无明显差异。ll本本组组1 1例例病病人人关关胸胸前前TEETEE显显示示成成型型效效果果不不满满意意，再再次次CPBCPB下瓣膜置换，未增加术后并发症。下瓣膜置换，未增加术后并发症。南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所2222限制性二尖瓣成型限制性二尖瓣成型 llBollingBolling 最早提出采用限制性二尖瓣成型治疗终末期心肌最早提出采用限制性二尖瓣成型治疗终末期心肌病伴重度二尖瓣反流，取得了较好的早期效果病伴重度二尖瓣反流，取得了较好的早期效果33ll但关于缺血性心脏病伴中重度二尖瓣反流的病人行冠状但关于缺血性心脏病伴中重度二尖瓣反流的病人行冠状动脉搭桥和限制性二尖瓣成型的报道不多动脉搭桥和限制性二尖瓣成型的报道不多ll本组二尖瓣环扩大引起的本组二尖瓣环扩大引起的IMRIMR即所谓即所谓CarpentieCarpentie I I型型IMRIMR（本组（本组5454例），以及因心腔明显扩大，乳头肌肉移例），以及因心腔明显扩大，乳头肌肉移位引起腱索乳头肌功能而导致二尖瓣返流（位引起腱索乳头肌功能而导致二尖瓣返流（CarpentierCarpentier IIIbIIIb型）（本组型）（本组1818例）病人，在搭桥同时均植入二尖瓣例）病人，在搭桥同时均植入二尖瓣成型环，效果满意。成型环，效果满意。南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所2323ll我们手术中在成型环植入前，先在左右纤维三角处各我们手术中在成型环植入前，先在左右纤维三角处各缝一针褥式缝合，再根据两纤维三角之间的距离和二缝一针褥式缝合，再根据两纤维三角之间的距离和二尖瓣前瓣叶的大小测得成型环大小，实际上采用的成尖瓣前瓣叶的大小测得成型环大小，实际上采用的成型环比测得的小一到二个号，达到限制性二尖瓣成型。型环比测得的小一到二个号，达到限制性二尖瓣成型。GeidelGeidel也强调也强调Downsizing Downsizing 二尖瓣成型可以提高远期效二尖瓣成型可以提高远期效果果1212。ll本组男性病人多采用本组男性病人多采用28#30#28#30#的成型环，女性病人多的成型环，女性病人多采用采用26-28#26-28#的成型环，平均随访的成型环，平均随访22.822.8月，中期临床效果月，中期临床效果满意。满意。llBax11Bax11等报告等报告5151例中例中- -重度重度IMRIMR伴左室功能减退的冠状伴左室功能减退的冠状动脉搭桥病人，手术中采用比正常小两号的成型环，动脉搭桥病人，手术中采用比正常小两号的成型环，手术死亡率手术死亡率5.6%5.6%，手术后左房左室均明显缩小，随访，手术后左房左室均明显缩小，随访两年生存率两年生存率84% 84% 。南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所2424南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所2525二尖瓣成型环的选择二尖瓣成型环的选择ll对对对对称称称称成成成成型型型型环环环环：“O”O”O”O”型型型型和和和和“C”C”C”C”型型型型，虽虽虽虽然然然然在在在在IMRIMRIMRIMR主主主主要要要要是是是是后后后后瓣瓣瓣瓣环环环环扩扩扩扩大大大大，理理理理论论论论上上上上采采采采用用用用“C C C C型型型型环环环环”将将将将后后后后瓣瓣瓣瓣环环环环缩缩缩缩小小小小即即即即能能能能纠纠纠纠正正正正IMRIMRIMRIMR，但但但但二二二二尖尖尖尖瓣瓣瓣瓣的的的的前前前前后后后后径径径径扩扩扩扩大大大大也也也也是是是是导导导导致致致致前前前前后后后后瓣瓣瓣瓣叶叶叶叶不不不不能能能能满满满满意意意意对对对对合合合合的的的的重重重重要要要要原原原原因因因因，因因因因此此此此，“O O O O型型型型”环环环环可可可可以以以以保保保保证证证证更更更更满满满满意意意意的的的的远远远远期期期期效果。效果。效果。效果。ll二二二二尖尖尖尖瓣瓣瓣瓣非非非非对对对对称称称称成成成成型型型型环环环环（ETlogixETlogixETlogixETlogix）用用用用于于于于治治治治疗疗疗疗IMRIMRIMRIMR，解解解解剖剖剖剖上上上上更更更更加加加加符符符符合合合合生生生生理理理理，临临临临床床床床应应应应用用用用的的的的近近近近期期期期效效效效果果果果十分满意，远期效果还需要时间证实。十分满意，远期效果还需要时间证实。十分满意，远期效果还需要时间证实。十分满意，远期效果还需要时间证实。南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所2626“”型型环能环能更好更好的维持二尖瓣环前的维持二尖瓣环前后径距离后径距离南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所2727llIMRIMR的治疗有二尖瓣成型和二尖瓣置换。从发病机制的治疗有二尖瓣成型和二尖瓣置换。从发病机制来看，来看，IMRIMR主要是因为瓣环明显扩大或瓣下装置（腱主要是因为瓣环明显扩大或瓣下装置（腱索、乳头肌）异常，而瓣叶常常无明显异常病变。索、乳头肌）异常，而瓣叶常常无明显异常病变。llReeceReece等等1414报告报告110 IMR110 IMR中，中，5454例病人搭桥例病人搭桥+ +二尖瓣二尖瓣成型，成型，5656例搭桥例搭桥+ +换瓣（保留瓣下装置），但手术死亡换瓣（保留瓣下装置），但手术死亡率有明显差异（率有明显差异（1.9% 1.9% vsvs 10.7% 10.7%），提示即使瓣膜置换），提示即使瓣膜置换病人均保留瓣下装置，瓣膜修复仍有明显优势。病人均保留瓣下装置，瓣膜修复仍有明显优势。ll二尖瓣成型可明显改善左室功能和几何形状，成型组二尖瓣成型可明显改善左室功能和几何形状，成型组的远期生存率明显高于换瓣组的远期生存率明显高于换瓣组66。所以对。所以对IMRIMR病人应病人应尽可能争取行瓣膜成尽可能争取行瓣膜成 南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所2828南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所2929Intraoperative TEEPre-ImplantPost-Implant南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所3030llKangKang等等88分析了分析了107107例中重度例中重度IMRIMR病人，病人，5050例成型，例成型，5757例仅搭桥，成型组手术死亡率例仅搭桥，成型组手术死亡率12%12%，明显高于单纯，明显高于单纯搭桥组搭桥组(2%),(2%),但五年生存率相似（但五年生存率相似（88%5% versus 88%5% versus 87%6%87%6%），多元回归分析显示：高龄、心功能差、房），多元回归分析显示：高龄、心功能差、房颤是手术死亡的独立预测因素颤是手术死亡的独立预测因素(P0.05)(P0.05)。在重度。在重度IMRIMR病人，成型后所有病人病人，成型后所有病人IMRIMR均明显改善，而单纯搭桥均明显改善，而单纯搭桥组仅组仅67%67%病人的病人的IMRIMR得到改善得到改善(P0.001)(P0.001)。但在中度。但在中度IMRIMR病人，两组病人，两组IMRIMR改善率相似改善率相似(75% versus 67%, (75% versus 67%, P=NS)P=NS)，提示二尖瓣成型可以有效改善，提示二尖瓣成型可以有效改善IMRIMR，但对合，但对合并有高龄、房颤等手术高危因素的中度并有高龄、房颤等手术高危因素的中度IMRIMR病人，搭病人，搭桥同时二尖瓣成型可增加手术死亡率。桥同时二尖瓣成型可增加手术死亡率。 南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所3131ll年龄是影响手术效果的重要因素之一年龄是影响手术效果的重要因素之一1515，高龄病人，高龄病人手术后易发生肺部并发症，本组手术后手术后易发生肺部并发症，本组手术后8 8例病人拔除气例病人拔除气管插管后因低氧血症需无创呼吸机辅助，其中管插管后因低氧血症需无创呼吸机辅助，其中6 6例为例为7070岁以上病人。故手术后加强肺部并发症的防止，对高岁以上病人。故手术后加强肺部并发症的防止，对高龄病人更为重要。手术后低心排仍是主要的死亡原因龄病人更为重要。手术后低心排仍是主要的死亡原因（本组两例），对有明显低心排表现，及早应用主动（本组两例），对有明显低心排表现，及早应用主动脉内球囊反搏，帮助稳定血液动力学。本组对手术前脉内球囊反搏，帮助稳定血液动力学。本组对手术前LVEF30%LVEF 70 in 33.Mean age: 67.25.8 (55 to 83), 70 in 33.llECG: old MI with q wave in 56.ECG: old MI with q wave in 56.南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所3838llTTE : TTE : Moderate-severe Moderate-severe (3+) 40 (3+) 40 Severe Severe (4+) 32 (4+) 32 LVEDD 55-81 (64.211.5) mm, LVEDD 55-81 (64.211.5) mm, LAD 52-74(58.06.2)mm LAD 52-74(58.06.2)mm LVEF 30% 16 LVEF 45% 41 45% 41llMorderateMorderate-severe TVR in 10-severe TVR in 10llCAGCAG：double-vessel disease in 7, triple-vessel in 65, double-vessel disease in 7, triple-vessel in 65, severe LM disease in 16 severe LM disease in 16 llLV aneurysm in 18LV aneurysm in 18南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所3939llNYHA: classNYHA: class in 15, class III in 42 and class IV in 15, class III in 42 and class IV in 15. in 15. llCo morbidity: Co morbidity: high blood pressure 37 high blood pressure 37 diabetes mellitus 29 diabetes mellitus 29 history of heart failure 41 history of heart failure 41 history of stroke 16 history of stroke 16 chronic AF 10 chronic AF 10 renal dysfunction 17 renal dysfunction 17llEmergency op in 5 severe LM disease with Emergency op in 5 severe LM disease with unstable angina with IABPunstable angina with IABP南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所4040Methods llSwan-Gaze monitored PA and PCWP Swan-Gaze monitored PA and PCWP llTEE TEE assessed assessed LV LV function function , , degree degree of of MR MR and and effect effect of of MVPMVPllMidline Midline sternotomysternotomy was preferred, IMA and GSV was preferred, IMA and GSV were harvested, RA was used selectivelywere harvested, RA was used selectivelyllCPB with intermittent CPB with intermittent antegradeantegrade cardioplegiacardioplegia combined with “graft” perfusion. Direct CA orifice combined with “graft” perfusion. Direct CA orifice perfusion was performed if AI was presentperfusion was performed if AI was present南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所4141 Ventricular Ventricular aneurysm aneurysm was was first first disposed, disposed, then then distal distal anastomosisanastomosis was was performed, performed, the the right right atrium atrium was was opened opened and and MVR MVR was was performed performed through through a a transseptaltransseptal approach. approach. IntraoperativeIntraoperative exploration exploration and TEE identified the and TEE identified the mechanisms of MR. TEE mechanisms of MR. TEE evaluated the effect of evaluated the effect of MVP.MVP.南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所4242 Annular Annular dilatation dilatation ( (CarpentieCarpentie I) I) in 54in 54Exploration and TEE identify the mechanisms of MR Cardiac chamber dilatation Cardiac chamber dilatation /transposition and /transposition and dysfunction of dysfunction of chordaechordae tendineaetendineae /papillary /papillary muscle (muscle (CarpentierCarpentier type type IIIbIIIb) in 18 ) in 18 南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所4343llMVP MVP ring ring size size was was determined determined by by standard standard measurement measurement of of the the intertrigonalintertrigonal distance distance and and anterior anterior leaflet height. leaflet height. llRestrictive Restrictive annuloplastyannuloplasty was was performed performed with with an an undersized undersized semirigidsemirigid ring (downsizing 1-2 sizes). ring (downsizing 1-2 sizes). llThe The rings rings were were anchored anchored using using multiple multiple (1416) (1416) deep deep U-shaped stitches of 2-0 U-shaped stitches of 2-0 TicronTicron without mattress. without mattress. llPrecise Precise evaluation evaluation of of preserved preserved valve valve symmetry symmetry and and proper proper leaflet leaflet coaptationcoaptation was was obtained obtained by by ventricular ventricular filling with saline solution. filling with saline solution. llother other concomitant concomitant procedures procedures and and proximal proximal CABG CABG anastomosisanastomosis were performed. were performed.南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所4444Results llAll had All had MitralMitral annuloplastyannuloplasty ring (“C” type in 16 ring (“C” type in 16 and “O” type in 56). and “O” type in 56). llAverage number of graft was 3.41.3(range, 3-6). Average number of graft was 3.41.3(range, 3-6). llConcomitant proceduresConcomitant procedures AVR 9 , TVP 10 AVR 9 , TVP 10 linear repair of LV aneurysm 6 linear repair of LV aneurysm 6 SVR (patch SVR (patch endoaneurysmorrhaphyendoaneurysmorrhaphy) 12) 12llMean CPB time 12239 min (range, 78-170) Mean CPB time 12239 min (range, 78-170) mean X-clamp 7822 min (range, 55- 126). mean X-clamp 7822 min (range, 55- 126).南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所4545llIntraoperativeIntraoperative TEE: TEE: no residual MR in 28, minimal 35 no residual MR in 28, minimal 35 1+ in 6, 12+ in 3 1+ in 6, 12+ in 3 2+-3+ MR in 1 (who received a 27# MVP with 2+-3+ MR in 1 (who received a 27# MVP with entire preservation of entire preservation of subvalvularsubvalvular apparatus in situ) apparatus in situ)ll18 cases needed IABP support when entered ICU, 18 cases needed IABP support when entered ICU, IABP time was 15 -112h, 15 cases were supported less IABP time was 15 -112h, 15 cases were supported less than 72h.than 72h.南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所4646Post-op complications llRe-operation for bleeding in 3 casesRe-operation for bleeding in 3 casesllAF in 22 cases, 20 converted to SR by medicationAF in 22 cases, 20 converted to SR by medicationllre-re-intubationintubation in 1, non-invasive breathing machine in 1, non-invasive breathing machine was used in 9, temporary dialysis in 4was used in 9, temporary dialysis in 4llstroke in 1 and wound infection of lower extremities stroke in 1 and wound infection of lower extremities in 2in 2llPerioperativePerioperative mortality was 4.2% (3 patients): mortality was 4.2% (3 patients): LCOS with multi-organ failure in 2 patients, LCOS with multi-organ failure in 2 patients, acute renal failure with severe pulmonary acute renal failure with severe pulmonary infection in 1.infection in 1. 68 cases (except MVR in 1 case) discharged. 南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所4747Follow-up llThe The follow-up follow-up time time was was 6-60 6-60 months months (mean, (mean, 22.8). 22.8). llThe The follow-up follow-up transthoracictransthoracic UCG UCG (3,6,12,24 (3,6,12,24 months months post-op) post-op) showed showed that that the the IMRsIMRs were were rectified rectified satisfactory satisfactory with with an an improved improved cardiac cardiac function (Table 1). function (Table 1). llAll All patients patients were were free free of of angina angina pectoris pectoris and and re-re-operation for recurrent MR . operation for recurrent MR . 南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所4848Table 1. Follow-up outcomes and pre- /post-op UCG Pre- post- 2w post- 6m 12m 24m P N 72 71* 71 71 66 56 40 N of death - - 3 3 5 7 8 Survival(%) 96 96 92 88 80IMR 3.30.6 0.40.4 0.40.4 0.50.6 0.50.6 0.70.7 0.70.6 0.01EF% 4514 - 5415 5317 5414 5418 5515 0.01LVEDD 6411 - 5710 5511 569 5712 5514 0.01LA 586 - 535 497 506 486 497 0.01*1 case converted to MVR was excluded南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所4949DiscussionIndicationsIndications for IMR for IMR:llCABG Combined with CABG Combined with valvularvalvular procedure had procedure had a higher mortality; but CABG alone came out a higher mortality; but CABG alone came out with a lower long-term survival rate.with a lower long-term survival rate.llIMR effected surgical outcomes. IMR effected surgical outcomes. llPreload and Preload and afterloadafterload conditions influenced conditions influenced the severity of MR presented on TEE. the severity of MR presented on TEE. 南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所5050llSeipeltSeipelt et al. et al. reported on a retrospective analysis of 262 reported on a retrospective analysis of 262 patients who received either CABG and MVP or CABG patients who received either CABG and MVP or CABG alone, the former had a higher alone, the former had a higher motalitymotality (19.5% (19.5% vsvs 6.7%, 6.7%, P=0.002). P=0.002). llBonacchiBonacchi et al et al. analyzed 180 patients with IMR and LV . analyzed 180 patients with IMR and LV dysfunction, in mild-moderate IMR group, CABG dysfunction, in mild-moderate IMR group, CABG brought a low mortality and a low IMR grade, but long-brought a low mortality and a low IMR grade, but long-term survival rate without cardiac event was lower than term survival rate without cardiac event was lower than those received combined CABG and those received combined CABG and annuloplastyannuloplasty, , which indicated that even mild-moderate IMR should be which indicated that even mild-moderate IMR should be rectified aggressively. rectified aggressively. 南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所5151Posterior MI -an important risk factor of IMRllIn this study, 56% cases had posterior MI with q wave. In this study, 56% cases had posterior MI with q wave. llThe mechanisms:The mechanisms: LV remodeling after posterior MI LV remodeling after posterior MI had a more severe negative impact on the geometry had a more severe negative impact on the geometry of of mitralmitral apparatus, especially on the posterior apparatus, especially on the posterior papillary muscles and papillary muscles and chordachorda tendineaetendineae which were which were dragged laterally, any forms of dragged laterally, any forms of mis-coaptationmis-coaptation of MV of MV might lead to the presence of regurgitation. might lead to the presence of regurgitation. llKumanohosoKumanohosos s report about 103 MI patients (61 report about 103 MI patients (61 anterior MI and 42 posterior MI ) indicated that anterior MI and 42 posterior MI ) indicated that posterior MI had a less impact on LV function but a posterior MI had a less impact on LV function but a higher impact on IMR (rate: 38%, 16/42 Vs 10%, 6/61, higher impact on IMR (rate: 38%, 16/42 Vs 10%, 6/61, P.0001; degree: 10.17.5% Vs 4.47.0%, P=0.0002) P.0001; degree: 10.17.5% Vs 4.47.0%, P=0.0002) 南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所5252Kang: 107 3-4+ IMR.llsevere IMR was attenuated dramatically by CABG combined with MVP, llonly 67% in CABG alone (P0.001); llbut to moderate IMR, the rate was similar (75% Vs 67%, P=NS).-Only 4+ IMR need MVP-Only 4+ IMR need MVP南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所5353Our experiencesllCAD CAD patient patient with with a a normal normal LV LV chamber chamber and and function function who has a mild-moderate IMR-CABG who has a mild-moderate IMR-CABG llModerate-severe Moderate-severe IMR IMR with with decreased decreased LV LV function, function, especially especially with with dilated dilated cardiac cardiac chambers, chambers, CABG+ CABG+ annuloplastyannuloplastyllModerate-severe Moderate-severe IMR IMR with with an an old old posterior posterior q q wave wave MI MI and and with with a a severe severe decreased decreased LV LV function, function, CABG+ CABG+ MVP MVP or MVR must be performedor MVR must be performedllFor For high high risk risk patient patient with with moderate moderate IMR, IMR, CABG CABG alone alone had had a a lower lower motalitymotality, , an an overall overall evaluation-Balance evaluation-Balance the risk and the risk and benifitsbenifits. . 南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所5454The condition of target vessels is an important factorllFor For CAD CAD patients patients with with low low LVEF LVEF (30%), (30%), revascularization revascularization was was preferred preferred aggressively aggressively if if patients patients had had good good target target vessels, vessels, but but if if diffused diffused coronary coronary was was present, present, revascularization revascularization should should be be performed performed cautiously. cautiously. 南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所5555llOperative experiences: important in choosing operative approach ll For aged cases, MVR was a good alternative if MVP was not reliable. llIn this study, 1 patient was converted to MVR since TEE showed that the annuloplasty was unsatisfactory. Thouranis reported that cThouranis reported that combinedombined procedures increased operative procedures increased operative risks, but in risks, but in 60 years group, long-term survival rate was of no 60 years group, long-term survival rate was of no difference between MVP and MVR groups.difference between MVP and MVR groups.南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所5656Restrictive annuloplasty llBollingBolling - - fristfrist introduced for end-stage introduced for end-stage cardiomyopathycardiomyopathy with severe MR- with a good with severe MR- with a good short-term results. short-term results. llThe reports about the treatment of ischemic The reports about the treatment of ischemic cardiomyopathycardiomyopathy by CABG combined with by CABG combined with restrictive MVP are scare.restrictive MVP are scare.llIn this study, IMR was divided 2 groups : In this study, IMR was divided 2 groups : annular dilatation (annular dilatation (CarpentierCarpentier type I in 54 type I in 54 cases); dilatation of cardiac chamber, cases); dilatation of cardiac chamber, displacement of papillary muscles and displacement of papillary muscles and dysfunction of dysfunction of chordaechordae tendineaestendineaes ( (CarpentierCarpentier type type IIIbIIIb in 18 cases). in 18 cases). AnnuloplastyAnnuloplasty ring was ring was applied in each case.applied in each case.南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所5757llMVP ring - downsizing by 1 to 2 ring sizes.MVP ring - downsizing by 1 to 2 ring sizes.llIn this study, 28#-30# rings for men and 26#-28# In this study, 28#-30# rings for men and 26#-28# for female. for female. llThe mean follow-up 22.8 months with good mid-The mean follow-up 22.8 months with good mid-term resultsterm resultsllBaxBax analyzed 51 cases undergoing CABG and analyzed 51 cases undergoing CABG and restrictive restrictive annuloplastyannuloplasty with stringent downsizing of with stringent downsizing of the the mitralmitral annulus (by 2 sizes). Early operative annulus (by 2 sizes). Early operative mortality was 5.6%, left atrium and LV dimension mortality was 5.6%, left atrium and LV dimension reduced dramatically; during 2-year follow-up, only reduced dramatically; during 2-year follow-up, only 1 patient needed re-operation for recurrent MR; 2-1 patient needed re-operation for recurrent MR; 2-year survival rate was 84%.year survival rate was 84%.南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所5858南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所5959Alternative of MVP ringllSymmetrical ring-“O” and “C type:Symmetrical ring-“O” and “C type: Although Although annular annular dilatation dilatation is is mainly mainly caused caused by by posterior posterior annular annular dilatation dilatation and and “C” “C” type type ring ring would would rectify rectify the the IMR IMR through through diminishing diminishing posterior annulus, posterior annulus, increased increased A-P A-P distance distance is is also also one one of of the the important important risk risk factors factors that that lead lead to to the the failure failure of of leaflets leaflets coaptationcoaptation, , so so “O” “O” type type may may guarantee guarantee better better long-long-term outcome.term outcome. llUnsymmetrical Unsymmetrical ringring （ETlogixETlogix)-)-long-term long-term long-term long-term result is not clear.result is not clear.result is not clear.result is not clear.南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所6060“ “” ” type is better type is better at at diminishing diminishing posterior annulus posterior annulus and A-P distanceand A-P distance 南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所6161MVP or MVR for IMRllIMR is caused mostly by annular dilatation or IMR is caused mostly by annular dilatation or abnormality of abnormality of subvalvularsubvalvular apparatus with apparatus with normal leaflets. normal leaflets. llReece et al.Reece et al. compared 54 cases of (CABG compared 54 cases of (CABG +MVP) with 56 cases of (CABG +MVR, +MVP) with 56 cases of (CABG +MVR, preservation of preservation of subvalvularsubvalvular apparatus), the apparatus), the MVP mortality was dramatically lower than MVP mortality was dramatically lower than that of MVR (1.9% that of MVR (1.9% vsvs 10.7%), although MVR 10.7%), although MVR preserved the preserved the subvalvularsubvalvular apparatus. apparatus.llMVP had more advantages in recovering LV MVP had more advantages in recovering LV geometry and improving LV function.geometry and improving LV function.南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所6262南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所6363Intraoperative TEEPre-ImplantPost-Implant南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所6464Risk factorsll AHA announced that the mortality of combined IMR and CABG procedure was as 3-6 times as that of CABG alone. llAdvanced age, triple vessel diseases, LVEF35%, MVR, residual MR were independent risk factors effecting long-term survival rate. 南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所6565llAge is an important risk factor-more Age is an important risk factor-more susceptible to pulmonary morbidity. susceptible to pulmonary morbidity. llIn this study, 6 of 8 patients aged more than In this study, 6 of 8 patients aged more than 70 years needed non-invasive breathing 70 years needed non-invasive breathing machine after machine after extubationextubation because of because of hypoxemia hypoxemia lllow LVEF (30%): IABP, but 2 of 4 patients low LVEF (30%): IABP, but 2 of 4 patients died of LCOSdied of LCOS南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所6666ConclusionsllIMR - indication depends onIMR - indication depends on（degree of degree of regurgitation, condition of target vessel, regurgitation, condition of target vessel, LVEF, etc. LVEF, etc. ）llRestrictive MVP - simple, effective, Restrictive MVP - simple, effective, feasiblefeasiblell“O” type ring- perhaps better “O” type ring- perhaps better llGood Short- and mid-term resultsGood Short- and mid-term results南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所6767Thank You 南京医科大学附属南京第一医院南京医科大学附属南京第一医院 南京市心血管病研究所南京市心血管病研究所