左心室衰竭的手術(shù)治療西方的觀點(diǎn)-課件幻燈

IrvingL.Kron.M.D.充血性心力衰竭美國的患者人數(shù)>5百萬每年新增的患者數(shù)400,000~700,000發(fā)病率升高–人口老齡化每年耗資超過100億美元其中75%為住院費(fèi)用心臟移植和心力衰竭

30-天死亡率 37% 3-年存活率 15%HochbergMS,etal.JTCV86:519-27,1983Kron,etal.AnnSurg210:348-54,1989心室功能p<0.05結(jié)果院內(nèi)存活院內(nèi)死亡預(yù)測(cè)因子N=88N=8年齡(歲)62.6±0.968.8±2.0*心絞痛穩(wěn)定型80%(70)75%(6)不穩(wěn)定型11%(10)12.5%(1)無9%(8)12.5%(1)EF(%)20.3±0.3420.3±2.0*p<0.05comparedtoageofsurvivors結(jié)果院內(nèi)存活院內(nèi)死亡血管條件N=50N=7好90%(45)0%中等10%(5)0%差0%100%(7)**p<0.05comparedtovesselqualityinsurvivorsLangenbergSA,etal.AnnThorSurg.Nov60(5):1193-6,1995結(jié)論Yamaguchietal.AnnThoracSurg.1998;65:434-8存活率和LVESVI心力衰竭和LVESVIDor,etal.JThoracCardiovascSurg1998;116:50-9.Dor,etal.JTCVS116:50-9,1998MaxeyTS,KronIL,etalJThoracCardiovascSurg.2004Feb;127(2):428-34CABG(n=39)CABG+VR(n=56)年齡68.4±5.163.1±6.2性別31M,8F42M,14F手術(shù)前EF(%)25.75±0.7422.07±1.12左心室舒張末直徑(cm)6.4±0.36.5±0.3NYHA分級(jí)III-IV3755二尖瓣返流2230CABG(n=39)CABG+VR(n=56)單純不穩(wěn)定型心絞痛2220單純心力衰竭814心絞痛&心力衰竭916休克06*CABG(n=39)CABG+VR(n=56)#移植物3.4±0.82.6±1.0MV修補(bǔ)2214缺血時(shí)間(分鐘)81±2290±28CPB時(shí)間(分鐘)104135手術(shù)死亡率00預(yù)后數(shù)據(jù)CABG(n=39)CABG+VR(n=56)手術(shù)后EF(%)29.03±0.61(提高5%)33.43±1.22*(提高11%)手術(shù)死亡率00住院時(shí)間(天)6.9±1.97.9±2.0反復(fù)心力衰竭18%4%*遠(yuǎn)期死亡率5.1%1.8%**p<0.05結(jié)論那么哪些是最佳適應(yīng)癥?心室增大前壁無運(yùn)動(dòng)或運(yùn)動(dòng)減弱遠(yuǎn)端血管條件好存在心肌缺血的證據(jù)主動(dòng)脈無動(dòng)脈粥樣硬化心室-二尖瓣復(fù)合物一場(chǎng)拔河比賽二尖瓣修補(bǔ)

缺血性MR的治療方法恢復(fù)瓣的功能保存瓣下結(jié)構(gòu)從而保持正常的瓣環(huán)瓣膜結(jié)構(gòu)關(guān)系，以保存其正常功能參數(shù)修補(bǔ)術(shù)置換術(shù)p

值感染5/547/560.586休克2/542/561.00肺部合并癥20/5418/560.589腎功能不全8/5410/560.666合并癥/患者數(shù)1.5±0.21.7±0.20.450Reeceetal,AnnSurg.2004May;239(5):671-5;discussion675-7修補(bǔ)術(shù)置換術(shù)死亡率1/546/56p<0.05住院時(shí)間913p<0.05T.BrettReeceetal,AnnSurg.2004May;239(5):671-5;discussion675-7Tethered瓣葉Anterior

PapillaryMuscleMitralLeafletsAnt.PostNormal

PPMDisplacedPPMMRLALAMRLV復(fù)位縫合缺血性MR–結(jié)果

n=1050~

1+MR手術(shù)后TEE100%30-天死亡率3%5年總存活率87.3%手術(shù)后5-年未復(fù)發(fā)率100%復(fù)發(fā)性MR5%GazoniLM,etal.AnnThoracSurg2007Sep;84(3):750-7;discussion758心臟移植術(shù)(UNOS2須花費(fèi)$30,000)5.8%CABG4.0%二尖瓣修補(bǔ)聯(lián)合CABG6.7%左心室成形術(shù)4.0%Copeetal,AnnThoracSurg2001;(72)1298-305心臟移植術(shù)(UNOS2須花費(fèi)$30,000)$76,000CABG$25,000二尖瓣修補(bǔ)聯(lián)合CABG$32,000左心室成形術(shù)$27,000Copeetal,AnnThoracSurg2001;(72)1298-305“每一個(gè)問題都有一個(gè)解答：簡(jiǎn)單的，明了的，或錯(cuò)誤的”-H.L.MenckenSurgeryfortheFailing

LeftVentricle-

PerspectiveWestIrvingL.Kron.M.D.CongestiveHeartFailure>5millionAmericansaffected400,000to700,000newcases/yrIncreasingincidence-elderlypopulationAnnualcostexceeds$10billion75%ofthecostduetohospitalizationTransplantation&HeartFailure“Atanygivenday,thechanceofgettingaheartforamalebloodtypeOislessthangettinghitbylightning.”–C.VanMeter“Theideaoftreatingheartfailurewithtransplantationisliketreatingpovertywiththelottery.”–L.W.StevensonPriortothemid1980’s,CABGinpatientswithEF<20%associatedwithprohibitivemortality

30-daymortality 37% 3-yearsurvival 15%HochbergMS,etal.JTCV86:519-27,1983CABGforlowEF

OperativeMortality=2.6%(1/39)Kron,etal.AnnSurg210:348-54,1989VentricularFunction23patientshadlatepostoperativemeasurementsofleftventricularfunction Pre-operativeEF 18.6 Post-operativeEF 26.0p<0.05ResultsHospitalSurvivorsHospitalDeathsPredictorsN=88N=8Age(years)62.6±0.968.8±2.0*Angina

Stable80%(70)75%(6)

Unstable11%(10)12.5%(1)

None9%(8)12.5%(1)EF(%)20.3±0.3420.3±2.0*p<0.05comparedtoageofsurvivorsResultsHospitalSurvivorsHospitalDeathsVesselqualityN=50N=7Good90%(45)0%Fair10%(5)0%Poor0%100%(7)**p<0.05comparedtovesselqualityinsurvivorsLangenbergSA,etal.AnnThorSurg.Nov60(5):1193-6,1995ConclusionsCABGforlowEFhasthebestresultsWhenthereisevidenceofischemiaWhendistalvesselsareofgoodquality(completerevascularization)AsaprimaryoperationLeftVentricularVolumePredicts

PostoperativeSurvivalinIschemicCardiomyopathy41patientsundergoingCABGwithEF<30%TwooperativedeathsSixlatedeaths16patientsfoundtohaveLVend-systolicvolumeindices(LVESVI)>100ml/m2Yamaguchietal.AnnThoracSurg.1998;65:434-8SurvivalandLVESVIHeartFailureandLVESVIDorProcedureinAkineticScars

CentreCardiothoraciquedeMonaco(n=100)Akineticscar(n=51)vs.dyskineticscar(n=49)

ConcomitantCABG 98% HospitalMortality 12%PatientswitheitherlargeakineticordyskineticscarandsevereLVdysfunctionimprovedearlyandlateNYHAclassandEFDor,etal.JThoracCardiovascSurg1998;116:50-9.Dor,etal.JTCVS116:50-9,1998“CoronaryArteryBypasswithVentricularRemodelingisSuperiortoCoronaryArteryBypassAloneinPatientswithIschemicCardiomyopathy”MaxeyTS,KronIL,etalJThoracCardiovascSurg.2004Feb;127(2):428-34PreoperativeComparisonsCABG(n=39)CABG+VR(n=56)Age68.4±5.163.1±6.2Sex31M,8F42M,14FPreoperativeEF(%)25.75±0.7422.07±1.12LVEDdiameter(cm)6.4±0.36.5±0.3NYHAclassIII-IV3755Mitralregurgitation2230IndicationforOperationCABG(n=39)CABG+VR(n=56)Unstableanginaalone2220CHFalone814Angina&CHF916Shock06*IntraoperativeDataCABG(n=39)CABG+VR(n=56)#grafts3.4±0.82.6±1.0MVrepair2214Ischemictime(min)81±2290±28CPBtime(min)104135Operativemortality00OutcomeDataCABG(n=39)CABG+VR(n=56)PostoperativeEF(%)29.03±0.61(5%increase)33.43±1.22*(11%increase)Operativemortality00Hospitalstay(days)6.9±1.97.9±2.0Recurrentheartfailure18%4%*Long-termmortality5.1%1.8%**p<0.05ConclusionsCABG&ventricularremodelingimproveleftventricularfunctioninpatientswithischemiaandventricularenlargementVentricularremodelingaffordssignificantimprovementinEFcomparedtoCABGalone,withoutaddedmortalitySowhoisthebestcandidate?LargeventricleAnteriorakinesisordyskinesiaGooddistalvesselsEvidenceofischemiaLackofaorticatherosclerosisSurgicalTherapyforIschemicMitralRegurgitationSurgicalApproachesReplacementAnnuloplastyLeafletextensionPosteriorpapillaryrepositioningDorMitralValveRepair

TechniqueforIschemicMRRestorevalvularcompetencePreservationofsubvalvularapparatusThuspreservationofnaturalannulovalvularrelationshipforfunctionalpreservationMitralRepairisSuperiortoReplacementWhenAssociatedwithCoronaryArteryDiseaseVariableRepairReplacementpvalueInfection5/547/560.586Stroke2/542/561.00PulmonaryComplication20/5418/560.589RenalInsufficiency8/5410/560.666Complication/patient1.5±0.21.7±0.20.450Reeceetal,AnnSurg.2004May;239(5):671-5;discussion675-7

RepairReplacementMortality1/546/56p<0.05HospitalStay913p<0.05MitralRepairisSuperiortoReplacementWhenAssociatedwithCoronaryArteryDiseaseT.BrettReeceetal,AnnSurg.2004May;239(5):671-5;discussion675-7TetheredLeafletAnterior

PapillaryMuscleMitralLeafletsAnt.PostNormal

PPMDisplacedPPMMRLALAMRLVRepositioningStitchIschemicMR–Results

n=1050to1+MRpost-opTEE100%30-daymortality3%Overall5-yearsurvival87.3%5-year