采用提吊成形环带修复二尖瓣治疗急性期感染性心内膜炎的中期结果
Midterm results of mitral valve repair with lifting annuloplasty strip for acute phase infective endocarditis.
作者信息
Lee Sung Jun, Yang Hyun Suk, Kim Jun Seok, Shin Je Kyoun, Son Jae Sung, Song Meong Gun, Chee Hyun Keun
机构信息
Department of Thoracic and Cardiovascular Surgery, Konkuk University Medical Center, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, South Korea.
Department of Cardiovascular medicine, Konkuk University Medical Center, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, South Korea.
出版信息
J Cardiothorac Surg. 2015 Oct 31;10:139. doi: 10.1186/s13019-015-0368-9.
BACKGROUND
Mitral valve repair is favored over replacement due to superior outcomes. However, extensive infective endocarditis (IE) often has been considered unreconstructable. We retrospectively analyzed the mid-term outcomes of an individualized repair approach using a lifting annuloplasty strip.
METHODS
Between December 2007 and March 2014, 27 consecutive patients with acute single mitral valve IE (age 43 ± 16 years, 11 men) underwent lifting mitral annuloplasty (LMA) with a strip (Mitracon® strip, 28 mm in 4, 32 mm in 10, and 34 mm in 13). Blood culture was positive in 70 % (Streptococcus 10, Staphylococcus 4, HACEK 3, Enterococcus 1, Gram negative bacilli 1). One case (4 %) had a previously repaired mitral valve-the repair was redone. Via right thoracotomy (74 %) or median sternotomy (26 %), repair was performed by removal of vegetation and resection of infected tissue, the defect typically then being repaired using a bovine pericardial patch (81 %). Artificial chordae were formed in 5 patients. Nine (33 %) of them had posterior leaflet augmentation (PLA) to get sufficient coaptation height. Clinical and echocardiographic follow-up were performed.
RESULTS
Compared with preoperative ones, postoperative echocardiograms revealed decreases of left ventricular (LV) end-diastolic dimensions (57.2 ± 6.3 versus, 45.4 ± 6.2, or 44.8 ± 4.1 mm, all p < 0.01). The LV ejection fraction decreased immediately, but recovered (64.4 ± 9.6 % vs. 54.5 ± 9.8 %, or 65.2 ± 6.1 %, p = 0.002, p = 1.000, respectively). The latest follow-up echocardiograms (median 28 months) universally showed no or minimal regurgitation, with a preserved mitral valve opening area (2.27 ± 0.48 cm(2)). During the clinical follow-up (median, 54 months), one (3.7 %) death was observed (in-hospital, due to biliary sepsis and pneumonia). There was no reoperation or major cardiovascular event. The 5 year survival rate was 96.3 %.
CONCLUSIONS
The repair technique of LMA and/or PLA in patients with IE achieved good structural and functional outcomes as well as an excellent 5 year survival rate. An individualized repair approach should be recommended in patients with acute phase IE.
背景
由于二尖瓣修复术效果更佳，因此相较于置换术更受青睐。然而，广泛感染性心内膜炎（IE）通常被认为无法修复。我们回顾性分析了采用提吊成形环带进行个体化修复方法的中期结果。
方法
2007年12月至2014年3月期间，连续27例急性单纯二尖瓣IE患者（年龄43±16岁，男性11例）接受了带条提吊二尖瓣成形术（LMA）（Mitracon®条带，4例为28mm，10例为32mm，13例为34mm）。血培养70%呈阳性（链球菌10例，葡萄球菌4例，HACEK菌3例，肠球菌1例，革兰阴性杆菌1例）。1例（4%）患者曾接受过二尖瓣修复术，此次重新进行了修复。通过右胸切口（74%）或正中胸骨切开术（26%），手术通过清除赘生物和切除感染组织进行，缺损通常随后使用牛心包补片修复（81%）。5例患者形成了人工腱索。其中9例（33%）进行了后叶增强（PLA）以获得足够的瓣叶对合高度。进行了临床和超声心动图随访。
结果
与术前相比，术后超声心动图显示左心室（LV）舒张末期内径减小（分别为57.2±6.3对45.4±6.2，或44.8±4.1mm，均p<0.01）。左心室射血分数立即下降，但随后恢复（分别为64.4±9.6%对54.5±9.8%，或65.2±6.1%，p = 0.002，p = 1.000）。最新的随访超声心动图（中位时间28个月）普遍显示无反流或微量反流，二尖瓣开口面积得以保留（2.27±0.48cm²）。在临床随访期间（中位时间54个月），观察到1例（3.7%）死亡（院内死亡，因胆源性败血症和肺炎）。无再次手术或重大心血管事件发生。5年生存率为96.3%。
结论
IE患者的LMA和/或PLA修复技术取得了良好的结构和功能结果以及出色的5年生存率。对于急性期IE患者，应推荐个体化修复方法。
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