左心室功能低下合并中度缺血性二尖瓣反流的外科治疗  

Surgical treatment of left ventricular dysfunction combined with moderate ischemic mitral regurgitation

作　　者：李维 陈聪 付威 吴立松[1] 张魁[1] 郑居兵[1] 刘韬帅[1] 宋跃[1] 董然[1] LI Wei;CHEN Cong;FU Wei;WU Lison;ZHANG Kui;ZHENG Jubing;LIU Taoshuai;SONG Yue;DONG Ran(Department of Cardiac Surgery,Beijing Anzhen Hospital,Capital Medical University,Beijing Institute of Heart,Lung and Blood Vessel Diseases,Beijing 100029,China)

机构地区：[1]首都医科大学附属北京安贞医院-北京市心肺血管疾病研究所心外科,100029

出　　处：《心肺血管病杂志》2023年第5期437-443,共7页Journal of Cardiovascular and Pulmonary Diseases

基　　金：北京市属医院科研培育计划项目(PX2018027)。

摘　　要：目的:评价冠状动脉旁路移植术(coronary artery bypass grafting,CABG)联合二尖瓣手术治疗左心室功能低下合并中度缺血性二尖瓣反流(ischemic mitral regurgitation,IMR)患者的围术期风险及临床预后。方法:回顾性分析北京安贞医院冠心病外科中心二区2017年1月至2020年12月,收治的LVEF≤40%合并中度IMR的冠心病患者65例,其中39例行单独CABG(单独组),26例行CABG联合二尖瓣成形或置换(联合组)。比较两组患者的术前一般资料,围术期资料,术后6个月超声心动图资料,二尖瓣反流和NYHA心功能改善情况,并随访比较两组患者发生主要不良心脑血管事件(major adverse cardiovascular and cerebrovascular events,MACCE)的情况。结果:两组患者术前资料差异无统计学意义(P>0.05),联合组有7例(26.9%)行二尖瓣置换。单独组术后死亡2例(5.1%),联合组3例(11.5%),两组围术期死亡率的差异无统计学意义(P>0.05)。联合组手术时间较长[(271.7±79.5)vs.(329.4±61.)min,P<0.01],术后呼吸机使用时间较长[23(22,25)vs.27(25,28)h,(P<0.01)]。两组患者术后6个月超声心动图结果LVEDD[单独组:(52.1±5.4)vs.(58.21±7.7)mm,P<0.001;联合组:(53.8±4.0)vs.(61.9±7.8)mm,P<0.001]、LVESD[单独组:(41.1±7.0)vs.(43.9±8.1)mm,P=0.002;联合组:(38.7±7.4)vs.(47.3±8.8)mm,P<0.001]、和LVEF[单独组:(40.9±7.4)vs.(37.9±7.2)mm,P=0.018;联合组:(41.3±6.9)%vs.(36.2±8.3)%,P=0.012],均较术前改善,且联合组二尖瓣反流面积更小[(1.6±0.4)vs.(3.7±0.8)cm^(2),P<0.01],二尖瓣反流改善的比例更高(P=0.025)。术后平均随访(31±11)个月,联合组NYHA心功能改善比例优于单独组(81.8%vs.55.6%,P=0.041),两组死亡率和MACCE发生率差异无统计学意义(P>0.05)。Kaplan-Meier生存分析两组患者累计无MACCE生存率,差异无统计学意义(联合组HR=1.42,95%CI:0.49~4.11,P=0.514)。结论:左心室功能低下合并中度IMR的患者,行CABG联合二尖瓣手术可更好改善反流和心功能分级。Objective:To evaluate the perioperative risk and clinical prognosis of coronary artery bypass grafting(CABG)combined with mitral valve surgery for patients with left ventricular dysfunction combined with moderate ischemic mitral regurgitation(IMR).Methods:A retrospective analysis of 65 patients with coronary artery disease with LVEF≤40%combined with moderate IMR admitted to the Coronary Surgery Center Ⅱ of Beijing Anzhen Hospital from January 2017 to December 2020,of whom 39 had CABG alone(alone group)and 26 had CABG combined with mitral valve repair or replacement(combined group).The two groups were compared for general preoperative data,perioperative data,echocardiographic data at six months postoperatively,improvement in mitral regurgitation and NYHA cardiac function,and follow-up to compare the occurrence of major adverse cardiovascular and cerebrovascular events(MACCE)in the two groups.Results:There was no statistically significant difference in the preoperative data between the two groups(P>0.05),and mitral valve replacement was performed in 7 cases(26.9%)in the combined group.There were two postoperative deaths in the alone group(5.1%)and three in the combined group(11.5%),with no statistically significant difference in perioperative mortality between the two groups(P>0.05).The combined group had longer operative time[(271.7±79.5)vs.(329.4±61.5)min,P<0.01]and postoperative ventilator use time[23(22,25)vs.27(25,28)h,P<0.01].Echocardiographic findings like LVEDD[a lone group:(52.1±5.4)vs.(58.21±7.7)mm,P<0.001;combined group:(53.8±4.0)vs.(61.9±7.8)mm,P<0.001]LVESD[a lone group:(41.1±7.0)vs.(43.9±8.1)mm,P=0.002;combined group:(38.7±7.4)vs.(47.3±8.8)mm,P<0.001]and LVEF[a lone group:(40.9±7.4)vs.(37.9±7.2)mm,P=0.018;combined group:(41.3±6.9)%vs.(36.2±8.3)%,P=0.012],improved in both groups at six months postoperatively compared to preoperative(P<0.05),and the combined group had a smaller mitral regurgitation area[(1.6±0.4)vs.(3.7±0.8)cm^(2),P<0.01]and a higher proportion of improved mitral reg

关 键 词：缺血性二尖瓣反流 左心室功能低下 冠状动脉旁路移植 二尖瓣手术 

分 类 号：R54[医药卫生—心血管疾病]