二尖瓣关闭不全患者围术期左心功能改变的临床研究

The Clinical Research of Left Ventricular Function Changes in Perioperative for Patients with Mitral Insufficiency

作者: 专业:外科学 导师:冯德广 年度:2010  院校: 郑州大学

Keywords

Mitral insufficiency, Mitral Valve Replacement, Huge left ventricular, Left ventricular function, Perioperative
        研究背景和目的二尖瓣关闭不全(Mitral insufficiency, MI)是由于二尖瓣瓣环、瓣叶、腱索、乳头肌等二尖瓣装置发生病变所致。随着病情的发展,病人逐渐出现心力衰竭的表现。目前治疗二尖瓣关闭不全的主要方式还是外科手术治疗,包括二尖瓣成形术和二尖瓣置换术。对于二尖瓣病变严重,成形效果欠佳者往往选择二尖瓣置换术。目前在我们国家,瓣膜性疾病中风湿性原因仍占主要地位,选择二尖瓣置换术的患者较多。然而,部分患者就医时往往病情较重,心功能差,心脏扩大严重。目前对于LVEDD>70mm或LVESD>50mm者称为巨大左心室瓣膜病或重症瓣膜病。此类患者围术期风险高,术后死亡率高,远期心功能的恢复差。本文旨在研究二尖瓣关闭不全患者围术期左心功能改变情况,分析围术期并发症发生率、死亡率高的原因;探讨巨大左室二尖瓣关闭不全患者手术时机的选择及术后监护治疗的重点。研究对象和方法本组共51例患者,术前均经超声心动图诊断为二尖瓣关闭不全。依据术前超声心动图所测左室舒张末期内径大小将其分成两组;A组35例,LVEDD<70mm;B组16例,LVEDD>70mm。详细记录手术前两组患者年龄、心功能(NYHA)、术中主动脉阻断时间、体外循环时间、术后并发症及治疗、术后死亡率;对比两组术前、术后1周、2周、1个月、3个月时左室舒张末期内径(LVEDD)、左室收缩末期内径(LVESD)、左房大小(LAD)、左室射血分数(LVEF)、左室短轴缩短率(LVFS)的变化情况,分析其变化原因;所有数据均采用SPSS13.0统计软件进行统计学处理。P<0.05为差异有显著性意义。结果A组患者术中主动脉阻断时间61.29±19.84min;CPB时间93.11±32.82min;术后严重心律失常5例;再次开胸2例;低心排出量综合征3例;并发症发生率28.5%,死亡3例(8.57%);B组患者术中主动脉阻断时间52.65±11.25min;CPB时间104.23±24.14min;术后严重心律失常4例,肾功能不全血液透析1例,肺部感染1例。并发症发生率37.5%,死亡3例(18.75%)。两组患者LVEDD.LVESD.LAD术后各时间点均较术前减小(P<0.05);术后各时间点较前一时间点相比逐渐减小(P<0.05)。两组LVEF,LVFS术后1周,2周都呈减少趋势(P<0.05),而术后1月的时间开始回升(P<0.05);两组患者术后3月和术后1月相比LVEF变化不明显(P>0.05)。结论1. LVEDD>70mm的二尖瓣关闭不全患者围术期并发症发生率、死亡率明显高于LVEDD<70mm的二尖瓣关闭不全患者。2.二尖瓣关闭不全患者行MVR术后LVEDD、LVESD、LAD呈减小趋势。3.部分MVR患者术后1-2周时间内LVEF、LVFS降低,以LVEDD>70mm者表现明显。
    Background and ObjectivesMitral insufficiency (MI) is due to mitral valve ring, leaflets, chordate, papillary muscle disease, which lead to mitral regurgition. As the disease progresses, patients show the gradual heart failure. At present, the main form of the treatment for mitral regurgitation is surgical treatment, including mitral valvuloplasty and mitral valve replacement. For the patients with severe mitral valve disease and Mitral valve repair is ineffective often choose mitral valve replacement. Currently in our country, the main reason for the valve disease is still rheumatic and many patients choose mitral valve replacement. However, some patients have serious condition, heart dysfunction, seriously enlarged left ventricular when they seek medical treatment. At present, LVEDD>70mm or LVESD>50mm are referred to as a huge left ventricular valvular disease or severe valvular disease. Such patients have high risk of perioperative postoperative, mortality rates and poorly long-term recovery of ventricular function. This article aims to study perioperative changes in left ventricular function and to analyze the incidence of perioperative complications and the reasons for high mortality. Investigate the timing of operation for mitral regurgitation with large left ventricular. Subject and MethodsThere are 51 patients in this group. Preoperative, all patients were diagnosed mitral regurgitation by echocardiography. According to preoperative left ventricular end diastolic diameter, the patients were divided into two groups.,35 patients for A group, LVEDD<70mm; 16 patients for B group, LVEDD>70mm. Detailed record of the two groups patients age before surgery, cardiac function (NYHA), intraoperative aortic clamping time, CPB time, postoperative complications and treatment, postoperative mortality. Compare the changes of left ventricular end diastolic diameter, left ventricular end systolic diameter (LVESD), left atrial size (LAD), left ventricular shooting blood fraction (LVEF), left ventricular fractional shortening (LVFS) for two groups before surgery and 1 week,2 weeks,1 month,3 months after surgery, then analyze the causes of change. Use SPSS13.0 statistical software to analyze all data. P<0.05 for significant difference.ResultsGroup A patients undergoing myocardial clamp time 61.29±19.84min; CPB time of 93.11±32.82min;); 3 patients died after operation (8.57%);5 cases of serious arrhythmia; re-thoracotomy in 2 cases; low cardiac output syndrome in 3 cases; complication rate was 28.5%; Group B patients undergoing myocardial clamp time 52.65±11.25min; CPB time of 104.23±24.14min); 3 patients died after operation (18.75%); 4 cases of serious arrhythmia, renal insufficiency hemodialysis in 1 case and pulmonary infection in 1 case. Complication rate of 37.5%.Compared with the preoperative, The LVEDD, LVESD and LAD have a reduced tendency after operation for two groups (P<0.05) Each time point after operation compared with the previous point in time have a gradual decrease(P<0.05).The LVEF, LVFS declined in 1 week and 2 weeks after operation (P<0.05) and began to rise after 1 month’s time (P<0.05). For two groups of patients after 3 months and after one month, the LVEF did not change significantly when compared (P>0.05).Conclusions1. Mitral regurgitation with LVEDD>70mm peri operative complications, mortality was significantly higher than mitral regurgitation with LVEDD<70mm.2. Patients with mitral regurgitation showed a trend of decrease of LVEDD, LVESD and LAD after MVR. 3. Part of the patients, The LVEF, LVFS reduced within 1-2 weeks after MVR, the patients with LVEDD>70mm were obvious.
        

二尖瓣关闭不全患者围术期左心功能改变的临床研究

摘要4-6
Abstract6-8
论文部分 二尖瓣关闭不全患者围术期左心功能改变的临床研究10-31
    引言10-12
    对象与方法12-14
    结果14-19
    讨论19-30
    结论30-31
参考文献31-34
综述部分 二尖瓣病变患者手术治疗的研究进展34-46
    参考文献44-46
后记部分46-49
    缩略词索引46-47
    个人简历47-48
    在学期间发表的学术论文48-49
    致谢49
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