Rao V, Komeda M, Weisel R D, Ivanov J, Ikonomidis J S, Shirai T, David T E
Division of Cardiovascular Surgery, Toronto Hospital, University of Toronto, Ontario, Canada.
Ann Thorac Surg. 1996 Jul;62(1):179-83. doi: 10.1016/0003-4975(96)00264-0.
Previous studies have shown that preservation of the chordae tendineae improves early and late postoperative left ventricular function after mitral valve replacement. This report describes the results of represervation of the chordae tendineae during redo mitral valve replacement in patients who had their chordae tendineae preserved during their initial operation.
Fifty-four patients undergoing reoperative mitral valve replacement with preservation of their chordal annular attachments (chordae group) were compared with 187 patients who had redo mitral valve replacement without preservation of the chordae (nonchordae group). The interval between the initial operation and the reoperation was 8.7 +/- 4.4 years in the chordae group and 8.6 +/- 4.9 years in the nonchordae group (p = 0.315). Seventy-three patients underwent aortic valve replacement during their redo mitral valve replacement compared with 168 patients who had mitral valve replacement alone. There were 15 patients who had their chordal attachments represerved during redo double-valve replacement.
In the chordae group, intraoperative assessment revealed excellent chordal connection between the preserved papillary muscles and the mitral annulus in all patients. One patient had adhesions between the preserved chordae and the stent of the tissue valve. The chordal attachments were preserved during insertion of the second valve in all patients. The incidence of low output syndrome and operative mortality in the chordae group was 16.7% and 7.4%, respectively. In the nonchordae group, the incidence of low output syndrome was 27.3% (p = 0.112 compared with the chordae group) and the operative mortality was 13.4% (p = 0.236 compared with the chordae group). In patients with double-valve replacement, represervation of the chordae was associated with a reduction in low output syndrome (0% versus 24%; p = 0.034) and mortality (6.7% versus 15.5%; p = 0.374).
Preservation of the chordal attachments between the papillary muscles and the mitral annulus can be accomplished during reoperative mitral valve replacement. Represervation of the chordae tendineae may reduce postoperative low output syndrome, especially in high-risk patients undergoing redo double-valve replacement.
既往研究表明，保留腱索可改善二尖瓣置换术后早期和晚期左心室功能。本报告描述了在初次手术时保留腱索的患者再次进行二尖瓣置换时再次保留腱索的结果。
将54例行再次二尖瓣置换且保留腱索瓣环附着结构的患者（腱索组）与187例行再次二尖瓣置换但未保留腱索的患者（非腱索组）进行比较。腱索组初次手术与再次手术的间隔时间为8.7±4.4年，非腱索组为8.6±4.9年（p = 0.315）。73例患者在再次二尖瓣置换时同时进行了主动脉瓣置换，而168例患者仅进行了二尖瓣置换。15例患者在再次双瓣膜置换时保留了腱索附着结构。
在腱索组，术中评估显示所有患者保留的乳头肌与二尖瓣环之间的腱索连接良好。1例患者保留的腱索与组织瓣膜支架之间存在粘连。所有患者在植入第二个瓣膜时均保留了腱索附着结构。腱索组低心排综合征发生率和手术死亡率分别为16.7%和7.4%。在非腱索组，低心排综合征发生率为27.3%（与腱索组相比，p = 0.112），手术死亡率为13.4%（与腱索组相比，p = 0.236）。在双瓣膜置换患者中，再次保留腱索与低心排综合征（0%对24%；p = 0.034）和死亡率（6.7%对15.5%；p = 0.374）降低相关。
再次二尖瓣置换时可实现乳头肌与二尖瓣环之间腱索附着结构的保留。再次保留腱索可能降低术后低心排综合征的发生率，尤其是在进行再次双瓣膜置换的高危患者中。
