Smedira N G, Selman R, Cosgrove D M, McCarthy P M, Lytle B W, Taylor P C, Apperson-Hansen C, Stewart R W, Loop F D
Cleveland Clinic Foundation Department of Thoracic and Cardiovascular Surgery, Ohio 44195, USA.
J Thorac Cardiovasc Surg. 1996 Aug;112(2):287-91; discussion 291-2. doi: 10.1016/S0022-5223(96)70251-9.
Several techniques are currently used to repair anterior leaflets with elongated or ruptured chordae. To evaluate the efficacy of these techniques, we analyzed the case histories of 108 patients operated on from 1989 through 1992 with degenerative mitral valve disease and prolapse of the anterior leaflet. The mean age was 59 +/- 15 years (range 18 to 87 years) and 74 (69%) were male.
Chordal shortening was performed in 31 (29%) and chordal transfer in 77 (71%) of the repairs. Of the transfers, 58 (75%) were from the posterior to the anterior leaflet and 16 (21%) were from the secondary to the primary position of the anterior leaflet. Three patients had both types of transfers. Seventy-one (66%) patients had isolated repairs and the remainder had associated procedures. The degree of preoperative mitral regurgitation was 3+ or greater for 107 (99%) of the patients, mean 3.4 for shortening and 3.7 for transfer.
Four (4.0%) hospital deaths occurred, none after isolated repair. Follow-up of hospital survivors was 100% complete at a mean of 4.0 years. A total of 421 patient-years of follow-up were available for analysis. There were seven late deaths, for a 5-year actuarial survival of 93%. Eleven patients underwent reoperation for recurrent mitral regurgitation. Five-year actuarial freedom from reoperation was 90%-96% after chordal transfer and 74% after chordal shortening, p = 0.003. Independent predictors for reoperation include chordal shortening and preoperative New York Heart Association functional class III or IV. The mechanism of valve failure in six of seven patients undergoing reoperation after chordal shortening was rupture of the previously shortened chordae.
We conclude that chordal transfer is superior to chordal shortening, providing a more predictable correction of mitral regurgitation and a lower incidence of reoperation. Reoperations after chordal shortening are a result of rupture of the previously shortened chordae.
目前有几种技术用于修复腱索延长或断裂的前叶。为评估这些技术的疗效，我们分析了1989年至1992年接受手术治疗的108例退行性二尖瓣疾病伴前叶脱垂患者的病历。平均年龄为59±15岁（范围18至87岁），男性74例（69%）。
在31例（29%）修复手术中进行了腱索缩短，77例（71%）进行了腱索转移。在转移手术中，58例（75%）是从后叶转移至前叶，16例（21%）是从前叶的二级位置转移至一级位置。3例患者同时进行了两种转移。71例（66%）患者进行了单纯修复，其余患者进行了相关手术。107例（99%）患者术前二尖瓣反流程度为3+或更高，腱索缩短组平均为3.4，腱索转移组平均为3.7。
发生4例（4.0%）医院死亡，单纯修复后无死亡病例。医院幸存者的随访100%完成，平均随访时间为4.0年。共有421患者年的随访资料可供分析。有7例晚期死亡，5年实际生存率为93%。11例患者因复发性二尖瓣反流接受再次手术。腱索转移后5年再次手术的实际无复发生存率为90% - 96%，腱索缩短后为74%，p = 0.003。再次手术的独立预测因素包括腱索缩短和术前纽约心脏协会功能分级III或IV级。腱索缩短后接受再次手术的7例患者中有6例瓣膜功能衰竭的机制是先前缩短的腱索断裂。
我们得出结论，腱索转移优于腱索缩短，能更可预测地纠正二尖瓣反流且再次手术发生率更低。腱索缩短后再次手术是先前缩短的腱索断裂所致。
