二尖瓣置换术几个问题的商榷

二尖瓣置换术几个问题的商榷张宝仁第二军医大学长海医院胸心外科上海市成人心血管临床医学中心中国人民解放军心胸外科研究所心脏瓣膜手术409524例主动脉瓣手术216245例，死亡率5.7％二尖瓣手术120641例，死亡率7.7％居第二位，死亡率高STS的资料〔1994－2003年〕心脏瓣膜手术主动脉瓣手术1026例，死亡率3.25％二尖瓣手术3416例，死亡率4.30％居第一位，死亡率高上海长海医院资料〔1978-2006年〕风湿性瓣膜病80％瓣膜置换术70～85％病理特点二尖瓣瓣膜与瓣下结构严重受损合并房颤发生率高〔70％〕合并三尖瓣的病变多〔67％〕上海长海医院二尖瓣病变病因人造瓣膜的选择与匹配保存瓣下结构的问题合并巨大右心房的处理重视合并房颤的处理合并三尖瓣病变的处理钙化瓣环的处理二尖瓣置换术应重视的问题Zam报告884例术后Ech，随访5.1±4.1年PPM定义〔有效开口面积指数〕<0.25cm²/m²EOA²=关于MVR人造瓣膜与病人不匹配〔PPM〕EOA〔cm²〕BSA〔m²〕心功能不全跨瓣压差高肺动脉高压右室压升高PPA对心功能的影响有效的维护左心功能保存二尖瓣后瓣下结构保存二尖瓣全瓣下结构人工腱索或瓣中瓣二、关于保存瓣下结构问题保存瓣环手术Ⅰ型：向下压迫左心室的基底部Ⅱ型：向上向左压迫总支气管Ⅲ型：向右压迫左肺中下叶，施行不同部位折叠术三、巨大左房〔>300ml〕的处理巨大左房风湿性二尖瓣病变合并房颤高达50～79％心功能不全进一步加重增加血栓栓塞的发生率影响术后近、远期效果射频消融法冷冻消融法四、重视合并房颤的处理有效率70～80％风湿性全心炎慢性二尖瓣置换术后，左室腔容积减少，室间隔左移，TV加重常规探查，瓣环直径>21mm/m，TV成形术力争不做三尖瓣置换术五、术中三尖瓣探查与处理

〔三尖瓣关闭不全的原因〕二尖瓣环扩张，瓣膜受损较重二尖瓣环扩张，瓣膜受损较轻钙化瓣环是老年病人少见的病理病变常位于房室的联合部邻近房室沟的冠状血管困难的外科技术问题钙化瓣环的处理钙化二尖瓣瓣环的处理钙化二尖瓣瓣环的处理谢谢ControversiesandThoughts

inMitralValveReplacementDepartmentofCardiothoracicSurgeryChanghaiHospitalSecondMilitaryMedicalUniversityZhangBao-renNO.mortalityTotal409524AVprocedure2162455.7%MVprocedure1326417.7%OverviewfromSTS/AHADatabase(1994-2003)NO.mortalityAVprocedure10263.25%MVprocedure34164.3%OverviewfromChanghaiHospitalChina(1986-2006)ProfileofMVdiseaseinChinaThemostcommoncauseischronicrheumatic

mitralvalvedisease(80%)Themostcommonprocedureismitralvalvereplacement(70%~80%)PathologiccharacteristicsofrheumaticfindingsFibrosisandcalcificationofmitralvalveapparatusCombiningchronicatrialfibrillation(70%)Combiningtricuspidvalveregurgitation(67%)FromShanghaiChanghaihospitaldatabaseSpecialproblemsaboutMVproceduretheimpactofpatient-prosthesismismatchpreservationofthesubvalvularapparatusthemanagementofchronicatrialfibrillationthemanagementofgiantleftatriumthemanagementofcombinedtricuspidregurgitationthemanagementofcalcifiedannuluspatient-prosthesismismatch(PPM)PPMinthemitralposition

anoldconceptandnewevidencesthethresholdvalueformitralPPMishighthanforaorticPPM

mitralPPMisconsideredmoderatewhenindexedEOAis1.2~1.3cm2/m2★22ImpactofPPMoncardiacfunction

cardiacinsufficiencypulmonaryarteryhypertensionPreservationofsubvalvularapparatuspreservationofposteriorleafletspreservationofChordaetobothleafletsartificialtendineae

METHODSPreservationofsubvalvularapparatusManagementofgiantleftatriumCriterion:LA>300mladverseeffect:compressingventriclesandlungoptimalplicationprocedurecouldimproveventricularandlungfunctionGiantLeftAtriumManagementofatrialfibrillationThemostcommoncomplicationofMS(50~70%)adverseeffect:impairingventricularfunctionmethods:modifiedmazeop.andmodifiedablationManagementoftricuspidregurgitationformorethan25yearstoawareofTRcomplicatedinlargenumberofRHDTRisprogressivediseaseafterMVRTricuspidannuloplastymustbedonewhenannulusdiameteris>21mm/m2

MakeeveryefforttoavoiddoingTVreplacementManagementofcalcifiedannulusprevalencemorethan1/3posteriomedialannulusinvolved

treatmentcompletel