Ben Farhat M, Boussadia H, Gandjbakhch I, Mzali H, Chouaieb A, Ayari M, Ben Salah K
Department of Medicine, Fattouma Bourguiba Hospital, University of Monastir, Tunisia.
J Thorac Cardiovasc Surg. 1990 Apr;99(4):639-44.
Controversy persists regarding whether the efficacy of closed instrumental mitral commissurotomy compares well enough with that of open commissurotomy to warrant its continued use. The purpose of this study was to compare the results of operation as determined by catheterization studies in 63 patients with pure, severe, and noncalcified mitral stenosis. The patients were randomly assigned to one of two groups: thirty-two patients were operated on by the closed technique (group I) and 31 by the open technique (group II). All patients underwent left-sided and right-sided catheterization before and 4 months after operation. Preoperatively the two groups were statistically similar with regard to major clinical data and hemodynamic findings. There were no deaths at operation or systemic embolism in the two groups. The prevalence of surgically induced mitral regurgitation was similar in the two groups (12.4% versus 12.9%). Pulmonary arterial pressure and arteriolar and total pulmonary vascular resistance decreased significantly in the two groups. Pulmonary capillary wedge pressure decreased from 23.3 +/- 8.5 to 15.8 +/- 7 mm Hg in group I (p less than 0.001) and from 23.7 +/- 6 to 14 +/- 5.8 mm Hg in group II (p less than 0.001). Cardiac index increased from 2.86 +/- 0.84 to 3.14 +/- 0.78 L/min/m2 in group I, but this increase did not reach statistical significance. In group II cardiac index increased from 2.89 +/- 0.6 to 3.6 +/- 0.6 L/min/m2 (p less than 0.005). The mean and end-diastolic transmitral pressure gradients decreased significantly in the two groups, but the decrease was statistically greater in the open mitral commissurotomy group (p less than 0.001). Mitral valve area increased from 0.82 +/- 0.18 to 1.4 +/- 0.40 cm2 in group I (p less than 0.01) and from 0.84 +/- 0.15 to 2.14 +/- 0.53 cm2 in group II (p less than 0.001). The mean increase in mitral valve area was 0.61 cm2 in group I and 1.34 cm2 in group II (p less than 0.001). At exercise, in patients with resting pulmonary capillary wedge pressures of 18 mm Hg or less, cardiac index increased by 36% in group I (23 patients) and 48% in group II (24 patients), because of a smaller mitral valve area in group I (1.61 +/- 0.39 cm2) than in group II (2.45 +/- 0.65 cm2). Thus open commissurotomy improved hemodynamic values to a greater extent than closed commissurotomy at both rest and exercise.(ABSTRACT TRUNCATED AT 400 WORDS)
关于闭式二尖瓣交界分离术的疗效与直视交界分离术相比是否足够好，从而值得继续使用，争议仍然存在。本研究的目的是比较63例单纯、重度和非钙化二尖瓣狭窄患者经心导管检查确定的手术结果。患者被随机分为两组：32例患者采用闭式技术手术（第一组），31例采用直视技术手术（第二组）。所有患者在手术前和手术后4个月均接受了左右心导管检查。术前，两组在主要临床数据和血流动力学结果方面在统计学上相似。两组均无手术死亡或全身性栓塞。两组手术引起的二尖瓣反流发生率相似（12.4%对12.9%）。两组的肺动脉压、小动脉和总肺血管阻力均显著降低。第一组肺毛细血管楔压从23.3±8.5降至15.8±7 mmHg（p<0.001），第二组从23.7±6降至14±5.8 mmHg（p<0.001）。第一组心脏指数从2.86±0.84升至3.14±0.78 L/min/m²，但这一升高未达到统计学意义。第二组心脏指数从2.89±0.6升至3.6±0.6 L/min/m²（p<0.005）。两组的平均和舒张末期二尖瓣压力阶差均显著降低，但直视二尖瓣交界分离术组的降低在统计学上更大（p<0.001）。第一组二尖瓣瓣口面积从0.82±0.18增至1.4±0.40 cm²（p<0.01），第二组从0.84±0.15增至2.14±0.53 cm²（p<0.001）。第一组二尖瓣瓣口面积平均增加0.61 cm²，第二组增加1.34 cm²（p<0.001）。在运动时，静息肺毛细血管楔压为18 mmHg或更低的患者中，第一组（23例患者）心脏指数增加36%，第二组（24例患者）增加48%，因为第一组的二尖瓣瓣口面积（1.61±0.39 cm²）小于第二组（2.45±0.65 cm²）。因此，直视交界分离术在静息和运动时比闭式交界分离术在更大程度上改善了血流动力学值。（摘要截短于400字）
