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1、左心室衰竭的手术治疗 西方的观点,Irving L. Kron. M.D.,充血性心力衰竭,美国的患者人数5 百万 每年新增的患者数400,000700,000 发病率升高 人口老龄化 每年耗资超过100亿美元 其中75% 为住院费用,心脏移植和心力衰竭,“ 在一天里,一位血型为O型的男性患者得到一个心脏的几率低于被闪电击中的几率.” C.Van Meter “ 通过心脏移植术治疗心力衰竭患者就好比利用彩票来救济穷人.” L.W. Stevenson,20世纪80年代中叶以前, EF 20% 的患者行CABG手术时死亡率非常之高,使其成为手术的禁忌症,30-天死亡率 37% 3-年存活率 15
2、%,Hochberg MS, et al. J TCV 86:519-27, 1983,低射血分数患者的CABG 术,手术死亡率 = 2.6% (1/39),Kron, et al. Ann Surg 210:348-54, 1989,心室功能,23例患者手术后后期评估左心室功能 手术前 EF 18.6 手术后 EF 26.0,p0.05,结果,*p0.05 compared to age of survivors,结果,*p0.05 compared to vessel quality in survivors,Langenberg SA, et al. Ann Thor Surg. Nov
3、 60(5): 1193-6, 1995,结论,最适合行CABG的低EF值患者: 存在心肌缺血的证据 远端血管条件良好(完全再血管化) 首次手术,左心室容积预测缺血性心肌病患者的手术后存活率,41例EF 100ml/m2,Yamaguchi et al. Ann Thorac Surg. 1998; 65:434-8,存活率和 LVESVI,心力衰竭和 LVESVI,Dor术式治疗无运动疤痕 Centre Cardiothoracique de Monaco (n=100),无运动的疤痕 (n=51) vs. 运动功能减弱的疤痕 (n=49) 同时行 CABG 98% 院内死亡率 12% 存在
4、大面积无运动或运动功能减弱疤痕及严重左心功能异常的患者,手术后早期及晚期纽约心功能分级和EF都得到了改善,Dor, et al. J Thorac Cardiovasc Surg 1998;116:50-9.,Dor, et al. JTCVS 116:50-9, 1998,“对于缺血性心肌病患者,冠状动脉搭桥术联合心室成形术优于单纯的冠状动脉搭桥术”,Maxey TS, Kron IL, et al J Thorac Cardiovasc Surg. 2004 Feb;127(2):428-34,手术前比较,手术指征,手术中的资料,预后数据,*p0.05,结论,CABG & 心室成形术能够改
5、善心肌缺血及心室增大患者的左心室的功能 心室成形与单纯CABG相比,能够显著的改善患者的EF值,而不增加死亡率,那么哪些是最佳适应症?,心室增大 前壁无运动或运动减弱 远端血管条件好 存在心肌缺血的证据 主动脉无动脉粥样硬化,缺血性二尖瓣返流的手术治疗,心室-二尖瓣复合物 一场拔河比赛,手术方法,置换术 瓣环成形术 瓣叶延长术 后乳头肌复位 Dor,二尖瓣修补 缺血性MR的治疗方法,恢复瓣的功能 保存瓣下结构 从而保持正常的瓣环瓣膜结构关系,以保存其正常功能,存在冠状动脉疾病时,二尖瓣修补手术优于置换手术,Reece et al, Ann Surg. 2004 May;239(5):671-5
6、; discussion 675-7,T. Brett Reece et al, Ann Surg. 2004 May;239(5):671-5; discussion 675-7,存在冠状动脉疾病时,二尖瓣修补手术优于置换手术,Tethered 瓣叶,Anterior Papillary Muscle,Mitral Leaflets Ant. Post,Normal PPM,Displaced PPM,MR,LA,LA,MR,LV,复位缝合,缺血性MR 结果 n=105,Gazoni LM, etal. Ann Thorac Surg 2007 Sep; 84(3): 750-7; disc
7、ussion 758,这些手术与心脏移植术的比较?,治疗心肌病的手术 手术死亡率,p=0.8 心脏移植术 vs. 其他术式,Cope et al, Ann Thorac Surg 2001; (72) 1298-305,治疗心肌病的手术 费用,心脏移植术的平均总费用比其他术式高3倍以上 (p 0.001),Cope et al, Ann Thorac Surg 2001; (72) 1298-305,“每一个问题都有一个解答:简单的,明了的,或错误的”,-H.L. Mencken,Surgery for the Failing Left Ventricle- Perspective West,
8、Irving L. Kron. M.D.,Congestive Heart Failure,5 million Americans affected 400,000 to 700,000 new cases/yr Increasing incidence - elderly population Annual cost exceeds $10 billion 75% of the cost due to hospitalization,Transplantation & Heart Failure,“ At any given day, the chance of getting a hear
9、t for a male blood type O is less than getting hit by lightning.” C.Van Meter “ The idea of treating heart failure with transplantation is like treating poverty with the lottery.” L.W. Stevenson,Prior to the mid 1980s, CABG in patients with EF 20% associated with prohibitive mortality,30-day mortali
10、ty 37% 3-year survival 15%,Hochberg MS, et al. J TCV 86:519-27, 1983,CABG for low EF,Operative Mortality = 2.6% (1/39),Kron, et al. Ann Surg 210:348-54, 1989,Ventricular Function,23 patients had late postoperative measurements of left ventricular function Pre-operative EF 18.6 Post-operative EF 26.0
11、,p0.05,Results,*p0.05 compared to age of survivors,Results,*p0.05 compared to vessel quality in survivors,Langenberg SA, et al. Ann Thor Surg. Nov 60(5): 1193-6, 1995,Conclusions,CABG for low EF has the best results When there is evidence of ischemia When distal vessels are of good quality (complete
12、 revascularization) As a primary operation,Left Ventricular Volume Predicts Postoperative Survival in Ischemic Cardiomyopathy,41 patients undergoing CABG with EF 100ml/m2,Yamaguchi et al. Ann Thorac Surg. 1998; 65:434-8,Survival and LVESVI,Heart Failure and LVESVI,Dor Procedure in Akinetic Scars Cen
13、tre Cardiothoracique de Monaco (n=100),Akinetic scar (n=51) vs. dyskinetic scar (n=49) Concomitant CABG 98% Hospital Mortality 12% Patients with either large akinetic or dyskinetic scar and severe LV dysfunction improved early and late NYHA class and EF,Dor, et al. J Thorac Cardiovasc Surg 1998;116:
14、50-9.,Dor, et al. JTCVS 116:50-9, 1998,“Coronary Artery Bypass with Ventricular Remodeling is Superior to Coronary Artery Bypass Alone in Patients with Ischemic Cardiomyopathy”,Maxey TS, Kron IL, et al J Thorac Cardiovasc Surg. 2004 Feb;127(2):428-34,Preoperative Comparisons,Indication for Operation
15、,Intraoperative Data,Outcome Data,*p0.05,Conclusions,CABG & ventricular remodeling improve left ventricular function in patients with ischemia and ventricular enlargement Ventricular remodeling affords significant improvement in EF compared to CABG alone, without added mortality,So who is the best c
16、andidate?,Large ventricle Anterior akinesis or dyskinesia Good distal vessels Evidence of ischemia Lack of aortic atherosclerosis,Surgical Therapy for Ischemic Mitral Regurgitation,Surgical Approaches,Replacement Annuloplasty Leaflet extension Posterior papillary repositioning Dor,Mitral Valve Repai
17、r Technique for Ischemic MR,Restore valvular competence Preservation of subvalvular apparatus Thus preservation of natural annulovalvular relationship for functional preservation,Mitral Repair is Superior to Replacement When Associated with Coronary Artery Disease,Reece et al, Ann Surg. 2004 May;239
18、(5):671-5; discussion 675-7,Mitral Repair is Superior to Replacement When Associated with Coronary Artery Disease,T. Brett Reece et al, Ann Surg. 2004 May;239(5):671-5; discussion 675-7,Tethered Leaflet,Anterior Papillary Muscle,Mitral Leaflets Ant. Post,Normal PPM,Displaced PPM,MR,LA,LA,MR,LV,Repos
19、itioning Stitch,Ischemic MR Results n=105,Gazoni LM, etal. Ann Thorac Surg 2007 Sep; 84(3): 750-7; discussion 758,How do these procedures compare to cardiac transplantation?,Cardiomyopathy Procedures Operative Mortality,p=0.8 for heart transplantation vs. other operations,Cope et al, Ann Thorac Surg 2001; (72) 1298-305,Cardiomyopathy Procedures Cost,Transplant mean total cost 3x higher (p 0.001),Cope et al, Ann Thorac Surg 2001; (72) 1298-305,“For every problem, there is one solution which is simple, neat, and wrong”,-H.L. Mencken,
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