后瓣环缩短增加缺血性二尖瓣关闭不全的瓣叶对合：一种新的有效技术。
Posterior annulus shortening increases leaflet coaptation in ischemic mitral incompetence: a new and valid technique.
机构信息
Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany.
出版信息
Ann Cardiothorac Surg. 2015 May;4(3):238-48. doi: 10.3978/j.issn.2225-319X.2015.04.07.
BACKGROUND
We introduce a technique of posterior annulus shortening to augment leaflet coaptation which addresses the restrictive mitral leaflet mobility in ischemic mitral incompetence (IMI), and report its long-term outcome.
METHODS
Between 1992 and 2012, 75 patients (mean age, 64.6±10.4 years; median, 66.0 years; range, 35.0-86.1 years) underwent repair of IMI by posterior annulus shortening to augment leaflet coaptation surface area. This technique reduces the annular diameter to between 23 and 25 mm and decreases the valve orifice to between 3.5 to 4.5 cm(2), which is sufficient to ensure an adequate leaflet coaptation area. An untreated pericardial strip is used to reinforce the shortened annulus in order to avoid redilatation. This augments the posterior leaflet by increasing the ratio of leaflet area/valve orifice where the coaptation gap is the greatest. The tissue strip increases and heightens the area which the posterior leaflet offers to the anterior leaflet for coaptation during closure, making valve closure possible in advanced leaflet restriction.
RESULTS
During a mean follow-up of 7.62±0.66 (median 8.53, range, 3.6-20.9) years, New York Heart Association (NYHA) functional class significantly improved, left ventricular ejection fraction (LVEF) increased and there was a tremendous abatement of MI (P<0.01). Annular area was reduced from 9.2 to 5.8 cm(2). Coaptation area was increased from a complete lack thereof to 6.6 mm(2) post-repair. CT showed posterior annulus size reduction from 70.4 to 54 mm and an increase in posterior leaflet length from 15.9 to 19.6 mm. A remarkable CT finding was the increase in coaptation length from 5.2 to 8.2 mm. Eighteen-year freedom from moderate MI, freedom from reoperation and survival rates were 80.7%±9%, 84.9%±4.2% and 65.1%±6.3%, respectively.
CONCLUSIONS
Posterior annulus shortening with pericardial strip augmentation addressing the lack of leaflet coaptation is a simple, reproducible and highly effective technique to restore valve competence in IMI.
背景
我们介绍了一种缩短后瓣环的技术，以增加瓣叶对合面积，解决缺血性二尖瓣关闭不全（IMI）中二尖瓣活动受限的问题，并报告其长期结果。
方法
1992 年至 2012 年间，75 例患者（平均年龄 64.6±10.4 岁；中位数 66.0 岁；范围 35.0-86.1 岁）接受了通过缩短后瓣环来增加瓣叶对合面积的修复手术，以治疗 IMI。该技术将瓣环直径缩小至 23-25mm，并将瓣口面积缩小至 3.5-4.5cm²，足以确保足够的瓣叶对合面积。使用未处理的心包膜条带加固缩短的瓣环，以避免瓣环再次扩张。这增加了后瓣叶的面积，增加了瓣叶面积/瓣口面积的比值，而瓣叶对合的最大间隙就在这个比值中。组织条带增加并提高了后瓣叶为前瓣叶提供的对合面积，使得在晚期瓣叶限制时也能实现瓣叶的关闭。
结果
在平均 7.62±0.66（中位数 8.53，范围 3.6-20.9）年的随访中，纽约心脏协会（NYHA）功能分级显著改善，左心室射血分数（LVEF）增加，MI 显著减轻（P<0.01）。瓣环面积从 9.2cm²缩小到 5.8cm²。修复后，对合面积从完全缺失增加到 6.6mm²。CT 显示后瓣环大小从 70.4mm 缩小到 54mm，后瓣叶长度从 15.9mm 增加到 19.6mm。CT 的一个显著发现是对合长度从 5.2mm 增加到 8.2mm。18 年无中度 MI 的生存率、无再次手术的生存率和总生存率分别为 80.7%±9%、84.9%±4.2%和 65.1%±6.3%。
结论
用心包条带加强缩短的后瓣环技术解决瓣叶对合不良的问题，是一种简单、可重复且非常有效的技术，可以恢复 IMI 中瓣膜的功能。
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