The short-term outcomes of mitral valvuloplasty for patients with rheumatic mitral stenosis and small left ventricle
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摘要: 目的 探讨二尖瓣成形术在风湿性二尖瓣狭窄合并小左室患者的围手术期及近期临床治疗效果。方法 回顾性分析2018年8月—2022年4月在郑州大学人民医院心脏中心心外科接受二尖瓣手术的67例风湿性二尖瓣狭窄合并小左室患者资料。其中30例行二尖瓣成形手术(MVP组)，37例行二尖瓣置换术(MVR组)。收集两组患者术前、术中及术后1、3、6个月临床资料，进行对比分析。结果 两组患者在呼吸机使用时间、术后监护室滞留时间、术后病死率及应用辅助设备等方面均差异无统计学意义。MVP组体外循环时间及主动脉阻断时间均长于MVR组(均P < 0.05)；MVP组术后血管活性药使用时间、住院时间更短，术后瓣膜峰值流速更低，随访期间再住院及出血、血栓栓塞等情况发生率均更低(均P < 0.05)。结论 二尖瓣成形术治疗风湿性二尖瓣狭窄合并小左室的临床疗效满意，相较于二尖瓣置换，虽然手术花费时间较长，但可以获得更好的血流动力学表现，并且有效地保护了左心功能，有利于患者术后早期心功能更快地恢复。Abstract: Objective To investigate the perioperative and short-term clinical effects of mitral valvuloplasty for patients with rheumatic mitral stenosis and small left ventricle.Methods This observational prospective study enrolled 67 patients with rheumatic mitral stenosis and small left ventricle who underwent mitral valve surgery from August 2018 to April 2022 at the Department of Cardiac Surgery, Fuwai Central China Hospital. Thirty patients underwent mitral valvuloplasty(MVP group) and 37 patients underwent mitral valve replacement(MVR group). The clinical data of the two groups before, during 1, 3 and 6 months after operation were collected for comparative analysis.Results In terms of ventilation time, ICU stay, mortality and application of auxiliary equipment after surgery, no significant difference was observed between the MVP and MVR groups. The cardiopulmonary bypass time and aortic cross-clamp duration was longer in the MVP group than those in the MVR group(both P < 0.05). Conversely, the duration of vasoactive drug treament and hospital stay after surgery were shorter, the postoperative peak mitral valve velocity was lower, and the incidence of rehospitalization and bleeding or thromboembolism during follow-up were lower in the MVP group compared to the MVR group(all P < 0.05).Conclusion Mitral valvuloplasty is effective in treating rheumatic mitral stenosis with a small left ventricle. Mitral valvuloplasty is more time-consuming but brings better hemodynamic results compared with mitral valve replacement, which is conducive to early postoperative cardiac function recovery.
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表 1 患者一般资料
Table 1. General data
例(%), X±S, M(IQR) 项目 总体 MVP组(30例) MVR组(37例) 统计值 P值 女性 53(79.1) 26(86.7) 27(73.0) 1.879 0.170 年龄/岁 57(13) 56.5(12) 58(15) -1.673 0.094 体重/kg 63.35±10.60 62.92±8.80 63.70±11.97 -0.300 0.765 BSA/m2 1.65±0.17 1.68±0.14 1.70±0.19 -0.385 0.721 LVEF/% 59.04±6.15 59.80±6.32 58.43±6.03 -0.899 0.372 LVEDD/mm 42.34±3.11 41.93±2.39 42.68±3.59 -0.971 0.335 LVEDVI/(mL/m2) 48.42±6.24 47.98±6.00 48.77±6.49 -0.514 0.609 NYHA分级 3.00±0.49 2.90±0.55 3.08±0.43 1.475 0.146 二尖瓣瓣口面积/cm2 1.00(0.40) 1.05(0.33) 1.00(0.40) -1.455 0.146 合并中度以上尖瓣关闭不全 28(41.8) 12(40.0) 16(43.2) 0.072 0.789 高血压 10(14.9) 2(6.7) 8(21.6) 1.859 0.173 糖尿病 8(11.9) 4(13.3) 4(10.8) < 0.001 >0.999 冠心病 6(9.0) 1(3.3) 5(13.5) 1.042 0.307 脑卒中 15(22.4) 6(20.0) 9(24.3) 0.187 0.673 房颤 50(74.6) 22(73.3) 28(83.8) 0.048 0.827 肝肾功能不全 3(4.5) 2(6.7) 1(2.7) 0.035 0.852 
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表 2 MVR组和MVP组患者围术期资料比较
Table 2. Comparison of perioperative data between MVP and MVR groups
例(%), X±S, M(IQR) 项目 MVR组(37组) MVP组(30组) 统计值 P值 胸骨正中切口 36(97.3) 29(96.7) - >0.999 体外循环时间/min 119.43±23.37 143.83±22.00 4.390 < 0.001 主动脉阻断时间/min 85.00±18.53 100.07±19.75 3.192 0.002 术中出血量/mL 593.24±259.58 655.33±236.18 1.056 0.295 三尖瓣成形术 35(94.6) 25(83.3) 1.203 0.273 房颤射频消融术 27(73.0) 22(73.3) 0.001 0.974 左房血栓清除术 6(16.2) 3(10.0) 0.146 0.703 左房减容术 1(2.7) 0 - >0.999 呼吸机使用时间/h 36(40) 24(20) -1.817 0.069 术后24 h引流量/mL 260(175) 260(143) -0.764 0.445 监护室滞留时间/h 46(68) 45.5(26) -0.965 0.334 血管活性药使用时间/h 142(158) 111.5(56) -2.213 0.027 二次气管插管 3(8.3) 0 1.004 0.316 CRRT应用 1(2.7) 1(3.3) - >0.999 IABP应用 1(2.7) 0(0) - >0.999 低心排血量综合征 8(21.6) 2(6.7) 1.859 0.173 手术切口愈合不良 2(5.4) 0 - 0.498 严重不良并发症 3(10.8) 2(6.7) < 0.001 >0.999 院内死亡 1(2.7) 0 - >0.999 术后住院天数/d 10.5(3) 8(6) -2.383 0.017 注：血管活性药指多巴胺、肾上腺素、去甲肾上腺素、多巴酚丁胺、米力农、左西孟旦针剂药品；严重不良并发症包括心脏填塞、新发脑卒中、恶性心律失常、肢体缺血坏死、多器官功能衰竭。
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表 3 MVR组和MVP组患者术前、术后及随访心胸比、心功能、心脏超声指标比较
Table 3. Comparison of preoperative, postoperative, and follow-up cardiothoracic ratio, cardiac function, and cardiac ultrasound indicators between MVR and MVP groups
例(%), X±S, M(IQR) 项目 MVR组(37例) MVP组(30例) 统计值 P值 术前 心胸比 0.55(0.06) 0.55(0.08) -0.392 0.695 NYHA分级 3.08±0.43 2.90±0.55 -1.497 0.134 LVEF/% 59(6) 61(6) -1.310 0.190 LVFS/% 31(5) 32(4) -1.203 0.229 LVEDD/mm 42.68±3.59 41.93±2.39 -0.971 0.335 LVEDV/mL 83.65±15.99 80.40±1.17 -0.965 0.338 LAD/mm 54(10) 48.5(8) -1.763 0.078 二尖瓣舒张期峰值流速/(m/s) 2.01±0.34 1.89±0.28 -1.680 0.098 随访1个月 心胸比 0.55±0.07 0.53±0.05 -1.114 0.269 NYHA分级 1.44±0.56 1.20±0.41 -1.909 0.056 LVEF/% 59.72±4.74 61.13±2.21 1.500 0.139 LVFS/% 31.5(4) 32(3) -1.202 0.229 LVEDD/mm 44.33±4.40 42.47±3.63 -1.897 0.062 LVEDV/mL 91.50±21.79 83.57±16.81 -1.346 0.178 LAD/mm 44.03±8.72 41.13±5.55 -1.573 0.121 二尖瓣舒张期峰值流速/(m/s) 1.73±0.37 1.33±0.30 -4.833 < 0.001 随访3个月 心胸比 0.515(0.07) 0.50(0.05) -0.762 0.446 NYHA分级 1.31±0.47 1.20±0.41 -0.969 0.333 LVEF/% 59.22±5.17 62.60±3.76 3.068 0.003 LVFS/% 32.08±3.28 33.70±2.63 2.222 0.030 LVEDD/mm 15.17±4.08 44.20±3.15 -1.086 0.282 LVEDV/mL 95.89±20.38 90.73±14.23 -1.206 0.233 LAD/mm 46.56±7.60 44.07±5.93 -1.494 0.140 二尖瓣舒张期峰值流速/(m/s) 1.70±0.25 1.49±0.29 -3.174 0.002 随访6个月 心胸比 0.52±0.06 0.51±0.05 -0.883 0.380 NYHA分级 1.36±0.54 1.17±0.38 -1.569 0.117 LVEF/% 58.47±4.43 62.17±3.10 3.972 < 0.001 LVFS/% 32(4) 33(4) 2.660 0.010 LVEDD/mm 46.56±4.62 44.70±2.97 -1.818 0.069 LVEDV/mL 102.36±25.03 92.77±13.87 -1.778 0.075 LAD/mm 47.33±8.01 43.40±5.10 -2.418 0.019 二尖瓣舒张期峰值流速/(m/s) 1.77±0.28 1.51±0.26 -3.873 < 0.001
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表 4 MVR组和MVP组术后随访情况比较
Table 4. Comparison of postoperative follow-up data between MVR and MVP groups
例(%) 项目 MVR组(36例) MVP组(30例) 统计值 P值 瓣膜功能障碍 0 2(3.3) 4.429 0.109 中度及以上反流/狭窄 0 2(3.3) - 术后再住院 8(22.2) 0 - 0.006 心功能不全 3(8.3) 0 - 房颤转复治疗 3(8.3) 0 - 脑出血 1(2.8) 0 - 外科手术 1(2.8) 0 - 出血、血栓栓塞 7(19.4) 0 - 0.013 全身多处瘀斑 4(11.1) 0 - 咯血 1(2.8) 0 - 脑出血 2(5.6) 0 - 死亡 1(2.8) 0 - >0.999
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