Recent clinical efficacy of mitral valvuloplasty versus mitral valve replacement in rheumatic mitral valve lesions
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摘要: 目的 探讨二尖瓣成形术与二尖瓣置换术治疗风湿性二尖瓣病变的近期临床疗效，并进行对比分析。方法 选取我科单一治疗组于2018年7月—2021年10月行风湿性二尖瓣手术患者共计100例，按其接受术式分为成形组(49例)和置换组(51例)，比较两组围术期及随访的临床指标。结果 两组在主动脉阻断时间、术后气管插管时间、术后24 h胸腔引流量、术后ICU滞留天数、术后住院天数以及术后病死率方面差异无统计学意义。术后复查心脏彩超，成形组在出院前左房内径(前后径)及术后3个月左室舒张末期内径小于置换组(P < 0.05)，且其术后6个月左室射血分数高于置换组(P < 0.05)。随访期间，置换组中2例因术后心功能差、肺部感染及多器官功能衰竭自动出院，均于出院后48 h内死亡。2例行二尖瓣机械瓣置换患者于术后6个月分别出现脑出血和全身多发瘀斑；成形组无再次手术及死亡患者。结论 风湿性二尖瓣成形术可以获得与瓣膜置换同样满意的近期临床效果，在术后早期心功能恢复方面甚至优于二尖瓣置换。Abstract: Objective To investigate the short-term clinical efficacy of mitral valvuloplasty(MVP) and mitral valve replacement(MVR) in rheumatic mitral valve lesions.Methods The 100 patients with rheumatic mitral valve surgery were researched and divided into the MVP group(n=49) and the MVR group(n=51) according to the surgical procedures which were treated in the single treatment group of our department from July 2018 to October 2021. And some concerned results from perioperative and follow-ups of the two groups were compared.Results There were no significant differences in aortic occlusion time, postoperative endotracheal intubation time, thoracic drainage volume 24 hours after operation, postoperative ICU stay days, postoperative hospital stay days and postoperative mortality between the two groups(P>0.05). Postoperative echocardiography showed that the left atrial diameter(anterior-posterior diameter) before hospital discharge and left ventricular end-diastolic diameter at 3 months after surgery in the MVP group were smaller than those in the MVR group(P < 0.05), and the LVEF at 6 months after surgery was higher than that in the MVR group(P < 0.05). During the follow-up period, 2 patients in the MVR group left hospital despairingly on account of postoperative poor heart function, pulmonary infection and multiple organ failure, and both died within 48 hours after discharge. And cerebral hemorrhage and multiple ecchymosis severally occurred in 2 patients with mitral valve(mechanical) replacement 6 months after operation. There was no reoperation or death in the MVP group.Conclusion Rheumatic mitral valvuloplasty can achieve the same satisfactory short-term clinical results as mitral valve replacement, and even better than mitral valve replacement in early postoperative cardiac function recovery.
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表 1 两组患者基线资料比较
Table 1. General data
例(%), X±S 项目 成形组(49例) 置换组(51例) 统计值 P值 男性 10(20.4) 20(39.2) 4.209 0.04 年龄/岁 53.29±10.28 56.71±8.75 -1.788 0.77 身高/cm 161.41±6.43 161.51±7.73 -0.735 0.465 体重/kg 61.07±11.87 63.02±10.61 -0.845 0.401 吸烟史 5(10.2) 11(21.6) 2.401 0.121 冠心病史 6(12.2) 3(5.9) 0.581 0.446 高血压史 6(12.2) 9(17.6) 0.572 0.449 糖尿病史 7(14.3) 4(7.8) 0.504 0.478 脑卒中史 12(24.5) 9(17.5) 0.705 0.401 PBMV史 4(8.2) 4(8.2) ＜0.001 ＞0.999 二尖瓣病变类型 - - 5.525 0.063 单纯狭窄 15(40.5) 22(59.5) - - 单纯关闭不全 15(71.4) 6(28.6) - - 混合病变 19(45.2) 23(54.8) - - 
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表 2 两组患者术中及术后资料比较
Table 2. Data before and after operation
例(%), X±S 项目 成形组(49例) 置换组(51例) 统计值 P值 同期行主动脉瓣手术 15(30.6) 19(37.3) 0.491 0.483 同期行三尖瓣手术 34(69.4) 41(80.4) 1.614 0.204 同期行改良迷宫Ⅳ型手术 30(61.2) 37(72.5) 1.449 0.229 体外循环时间/min 166.43±42.3 157.8±31.9 1.147 0.254 主动脉阻断时间/min 114.14±26.8 105.0±23.1 1.828 0.071 呼吸机使用时间/h 26.02±13.17 30.55±20.96 -1.281 0.204 术后24 h胸腔引流/mL 267.04±149.57 306.80±179.82 -1.197 0.234 ICU滞留时间/d 2.92±1.48 2.82±1.67 0.320 0.750 术后住院天数/d 12.3±4.4 13.9±6.9 -1.410 0.162 住院二次气管插管 0(0) 3(5.9) - 0.243 应用临时起搏器 44(89.8) 48(94.1) 0.183 0.669 应用IABP 0(0) 2(3.9) - 0.495 房颤消除 26(86.7) 32(86.5) < 0.001 > 0.999 并发症发生率 1(2.0) 4(7.8) 0.760 0.383 术后死亡 0(0) 2(3.9) - 0.495
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表 3 围术期及随访3个月、6个月心功能、胸片及超声心动图指标比较
Table 3. Data of cardiac function, chest radiography and echocardiography during perioperative period and follow-up of 3 months and 6 months
X±S 指标 成形组(49例) 置换组(51例) 统计值 P值 术前 NYHA心功能分级 2.84±0.69 2.73±0.57 0.880 0.381 心胸比 0.56±0.08 0.57±0.05 -0.913 0.364 LVEF 0.59±0.07 0.57±0.06 1.142 0.256 LVEDD/mm 48.73±6.74 47.56±7.64 0.811 0.419 LVESD/mm 35.16±13.49 34.52±10.08 0.268 0.789 LAD/mm 51.33±10.00 54.02±6.50 -1.586 0.117 出院前 NYHA心功能分级 1.23±0.56 1.43±0.81 -1.445 0.152 心胸比 0.55±0.06 0.56±0.06 -1.383 0.170 LVEF 0.59±0.07 0.59±0.07 -0.164 0.870 LVEDD/mm 43.77±4.70 44.47±5.42 -0.687 0.494 LVESD/mm 30.85±6.80 31.92±8.50 -0.682 0.491 LAD/mm 38.10±6.17 43.41±5.94 -4.355 < 0.001 随访3个月 NYHA心功能分级 1.15±0.47 1.22±0.60 -0.620 0.537 心胸比 0.52±0.04 0.53±0.04 -0.668 0.506 LVEF 0.60±0.06 0.59±0.07 0.909 0.366 LVEDD/mm 45.17±4.06 47.07±4.85 -2.016 0.047 LVESD/mm 30.76±3.98 32.47±4.73 -1.859 0.066 LAD/mm 42.85±6.87 45.38±8.62 -1.546 0.126 随访6个月 NYHA心功能分级 1.10±0.38 1.23±0.58 -1.147 0.255 心胸比 0.47±0.15 0.45±0.19 0.325 0.746 LVEF 0.61±0.05 0.58±0.06 2.388 0.020 LVEDD/mm 45.92±3.56 46.80±6.09 -0.779 0.438 LVESD/mm 30.62±3.18 32.15±5.41 -1.532 0.131 LAD/mm 44.23±7.93 46.15±6.67 -1.160 0.250
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