二尖瓣置换术后左室破裂的外科处理  

Surgical treatment of left ventricular rupture after mitrul valve replacement

作　　者：祝岩[1] 王辉山[1] 汪曾炜[1] 李新民[1] 金岩[1] 

机构地区：[1]沈阳军区总医院心血管外科解放军心脏血管外科研究所,110016

出　　处：《中华胸心血管外科杂志》2012年第8期449-452,共4页Chinese Journal of Thoracic and Cardiovascular Surgery

摘　　要：目的探讨二尖瓣置换术后左心室破裂的原因、治疗及预防措施。方法1981年5月至2010年11月，2638例患者行二尖瓣置换术，其中11例发生左心室破裂，男4例，女7例；年龄28—71岁。术前心功能Ⅱ级2例，Ⅲ级9例。超声心动图提示左心室舒张期末直径32—62mm。结果根据左心室破裂时间分类，延迟破裂4例，早期破裂7例；无晚期左心室破裂。破裂类型经手术或尸检证实Ⅰ型5例，Ⅱ型4例，Ⅲ型2例。手术抢救成功4例，死亡7例。结论女性、高龄、病理改变以二尖瓣狭窄为主、小左心室（舒张期末直径〈35mm）和体重过低等是左心室破裂的危险因素。过多去除二尖瓣环上的钙化斑块；置换瓣膜型号过大，尤其是生物瓣瓣脚过高；瓣环处缝合进针过深；对乳头肌牵拉过度或者切除过多；心肌血肿以及粗暴搬动心脏等因素增加了左心室破裂的危险性。一旦发现左心室破裂，应尽快恢复体外循环，根据实际情况可以直接缝合或在心腔内、外同时修补较为确实、可靠，有可能挽救患者的生命。Objective To evaluate the causes, treatment, and prevention of left ventricular rupture after mitral valvereplacement. Methods From May 1981 to November 2010, 11 cases occurred in 4 male and 7 female patients aged 28 -71 years old. There were 2 cases of New York Heart Association （NYHA） functional class Ⅱ and 9 cases of class Ⅲ. Echocardiography showed that the left ventricular end diastolic internal diameter （LVEDI） was 32 -62 mm. Results Rupture probably occurs after endocardial damage to a thin myocardium that has lost the internal buttress of the subvalvar apparatus. With the rise in intraventricular pressure at the end of bypass blood dissects into the myocardium, resulting in a large haematoma and eventu- al rupture. According to the onset of ruptures, there were 4 cases of delayed rupture which occured at several hours till days post operation after the patients had been back in the ICU, and 7 cases of early ruptur, which occured at the early stage of sur- gery, while the patient was still in the operation room. There were no cases of ruptures. The types of the ruptures were identi- ＂fled by operation or necropsy as 5 cases of type Ⅰ , 4 cases of type Ⅱ, and 2 cases of type Ⅲ. Four patients were saved after emergency treatment, and 7 died. Conclusion It is difficult to repair left ventricle rupture, but effective prevention for onset can decrease its occurrence. The risk factors for left ventricular ruptures are female, advanced age, pathological changes char- acterized by mitral stenosis, small left ventricle （LVEDD 〈 35 mm）, and low weight（ 〈 50 kg ） . The following actions raise the risk of let ventricular rupture. Isolated replacement of the mitral valve than after double valve replacement or mitral valve re- placement and coronary artery bypass graft; aggressive removal of calcification at the mitral valve ; undue selection and replace- ment of mitral valve prostheses; large size of prosthetic valve with a high bioprosthetic angle in particular; deep sutures at the valv

关 键 词：二尖瓣 心脏瓣膜假体植入 心室 心脏破裂 

分 类 号：R654.2[医药卫生—外科学]