Aubert Stéphane, Barreda Théodoro, Acar Christophe, Leprince Pascal, Bonnet Nicolas, Ecochard René, Pavie Alain, Gandjbakhch Iradj
Department of Cardiovascular Surgery, Pitié Salpêtrière Hospital, 50-52 boulevard Vincent Auriol, 75013 Paris, France.
Eur J Cardiothorac Surg. 2005 Sep;28(3):443-7. doi: 10.1016/j.ejcts.2005.05.005.
The aim of this study was to describe the pattern of lesions responsible for commissural prolapse, the techniques of valve repair and their long-term results.
Between 1992 and 2004, 128 mitral valve repairs were consecutively performed for commissural prolapse. There were 86 males and 42 females, the median age was 57.5 years (range 14-84 years). Forty-six percent of patients were in NYHA III or IV, mean ejection fraction was 61+/-9.4%. The diagnosis of commissural prolapse was recognized by preoperative echocardiography in 32% of the patients and was revealed by intraoperative inspection of the valve in the other cases. The site of the prolapse was the posteriomedial commissure (n=94), the anterior commissure (n=30) or both (n=4). The aetiologies were: infective endocarditis (n=56), degenerative (n=46), ischemic (n=25), congenital mitral regurgitation (n=1). The commissural prolapse was associated with another mitral valvular lesion requiring a specific treatment in 61 cases (47.7%). An associated procedure was carried out in 45 patients.
The operative treatment of the commissural prolapse included: commissural closure 65 (50.8%), leaflet resection 31 (24.2%), transposition or shortening of chordae 19 (14.8%), reimplantation or shortening of papillary muscles 3 (2.3%), and replacement of the commissural area by a partial mitral homograft 10 (8%). In-hospital mortality included three deaths (2.3%) and four patients (3.1%) were reoperated: three pericardial drainages for hemopericardium and one for mediastinitis. During the follow-up, one patient died (0.8%) from myocardial infarction and eight patients (6.3%) were reoperated including six (4.7%) for recurrent mitral regurgitation. After a median follow-up time of 76.9 months (range from 15 days to 160 months), 116 patients (90.1%) were in NYHA I. Echocardiographs showed no or minimal insufficiency in 112 patients (87.5%) and mild or moderate insufficiency in 10 patients (7.8%).
The diagnosis of commissural prolapse is difficult by preoperative echocardiography. The aetiology of the mitral disease is variable (endocarditis, degenerative or ischemic mitral regurgitation). Using a variety of techniques, commissural prolapse can be repaired with excellent clinical and echographic long-term results.
本研究旨在描述导致瓣叶联合脱垂的病变模式、瓣膜修复技术及其长期结果。
1992年至2004年间，连续对128例因瓣叶联合脱垂而行二尖瓣修复术的患者进行研究。其中男性86例，女性42例，年龄中位数为57.5岁（范围14 - 84岁）。46%的患者为纽约心脏协会（NYHA）心功能Ⅲ或Ⅳ级，平均射血分数为61±9.4%。术前超声心动图诊断出瓣叶联合脱垂的患者占32%，其余患者通过术中瓣膜检查确诊。脱垂部位为后内侧瓣叶联合（n = 94）、前瓣叶联合（n = 30）或两者均有（n = 4）。病因包括：感染性心内膜炎（n = 56）、退行性病变（n = 46）、缺血性病变（n = 25）、先天性二尖瓣反流（n = 1）。61例（47.7%）瓣叶联合脱垂患者合并有其他需要特殊治疗的二尖瓣病变。45例患者接受了相关手术。
瓣叶联合脱垂的手术治疗方法包括：瓣叶联合闭合65例（50.8%）、瓣叶切除31例（24.2%）、腱索移位或缩短19例（14.8%）、乳头肌重新植入或缩短3例（2.3%）、用部分二尖瓣同种异体移植物替换瓣叶联合区域10例（8%）。住院期间死亡3例（2.3%），4例患者（3.1%）再次手术：3例因心包积血行心包引流，1例因纵隔炎再次手术。随访期间，1例患者（0.8%）死于心肌梗死，8例患者（6.3%）再次手术，其中6例（4.7%）因复发性二尖瓣反流再次手术。中位随访时间为76.9个月（范围15天至160个月），116例患者（90.1%）为NYHA心功能Ⅰ级。超声心动图显示112例患者（87.5%）无或仅有微量反流，10例患者（7.8%）有轻度或中度反流。
术前超声心动图难以诊断瓣叶联合脱垂。二尖瓣疾病的病因多样（心内膜炎、退行性病变或缺血性二尖瓣反流）。采用多种技术可修复瓣叶联合脱垂，临床及超声心动图长期结果良好。
