风湿性心脏病并心肌致密化不全行二尖瓣置换术后发生左室破裂死亡临床报告  

A Clinical Report of Left Ventricular Rupture after Mitral Valve Replacement in One Mortality Case Diagnosed as Rheumatic Heart Disease with Noncompaction of Ventricular Myocardium

作　　者：齐胤尊 马云鹏[1] 

机构地区：[1]天水市第一人民医院心血管外科,甘肃天水741000

出　　处：《临床误诊误治》2016年第6期59-62,共4页Clinical Misdiagnosis & Mistherapy

摘　　要：目的探讨风湿性心脏病(rheumatic heart disease,RHD)并心肌致密化不全(noncompaction of Ventricular myocardium,NVM)的诊治策略。方法对RHD并NVM行二尖瓣置换术后发生左室破裂死亡1例的临床资料进行回顾性分析,并复习相关文献。结果本例因诊断RHD、二尖瓣狭窄并关闭不全、心房颤动(房颤)8年,病情加重15 d入院。入院后行3次心脏超声检查,均提示风湿性二尖瓣重度关闭不全并中度狭窄,三尖瓣中量反流,其中1次报告提示可疑左室后壁NVM。诊断:RHD,二尖瓣狭窄并关闭不全,三尖瓣关闭不全,肺动脉高压,房颤,心功能Ⅳ级。予改善心功能治疗2周,左室射血分数(LVEF)由入院时的31%增至42%,后在体外循环下行二尖瓣置换及三尖瓣环缩术,术后10 h见鲜红色血液自纵隔引流管涌出、血压下降,急诊床旁开胸探查证实发生Ⅲ型左室破裂,破裂部位的心室壁有NVM改变,经抢救无效死亡。最终诊断:RHD并NVM。结论临床对有左心功能受损的RHD要警惕合并NVM可能,慎重制定治疗方案,如决定行二尖瓣手术,保留瓣下结构的二尖瓣置换术对预防术后左室破裂和促进心功能恢复会有帮助。Objective To discuss therapeutic strategy of rheumatic heart disease（ RHD） combined with noncompaction of ventricular myocardium（ NVM）. Methods The clinical data of left ventricular rupture after mitral valve replacement in one mortality case diagnosed as RHD with NVM was respectively analyzed,and the related literatures were reviewed. Results The patient was admitted to hospital for RHD,mitral stenosis and insufficiency and atrial fibrillation for 8 years,and the patient was hospitalized 15 days after relapse. The case was confirmed as severe rheumatic mitral regurgitation and moderate stenosis by echocardiograph for 3 times,and one of the reports mentioned that the case was possibly combined with NVM of posterior left ventricle. So the patient was diagnosed as having RHD,mitral stenosis and insufficiency,tricuspid regurgitation,pulmonary arterial hypertension,atrial fibrillation,and NYHA Ⅳ. The left ventricular ejection fraction（ LVEF） was enhanced from 31% to 42%after 2 weeks of medical treatment,and then we performed mitral valve replacement and tricuspid annuloplasty under cardiopulmonary bypass. Red blood gushed from mediastinal drainage tube and blood pressure dropped rapidly 10 hours after operation. It was identified as the occurrence of type Ⅲ left ventricular rupture by emergency thoracotomy,and pathological changes of NVM was observed in the ruptured site. The patient died after all measures failed. The final diagnosis was RHD combined with NVM.Conclusion It is suggested that RHD with left ventricular dysfunction may probably be combined with NVM. We should make the treatment plan cautiously. Mitral valve replacement with preservation of subvalvular apparatus may help to reduce the risk of left ventricle rupture and to improve the left ventricular function,if a dicision has been made to perform such an operation.

关 键 词：心肌致密化不全 风湿性心脏病 二尖瓣置换术 左室破裂 

分 类 号：R654.2[医药卫生—外科学]