实时三维经食管超声指导下全胸腔镜技术二尖瓣成形术的中短期随访效果评价

doi:10.3877/cma.j.issn.1672-6448.2020.05.007

中华医学超声杂志（电子版） ›› 2020, Vol. 17 ›› Issue (05) : 427 -433. doi: 10.3877/cma.j.issn.1672-6448.2020.05.007

所属专题：文献；

心血管超声影像学

实时三维经食管超声指导下全胸腔镜技术二尖瓣成形术的中短期随访效果评价

李昱茜¹, 徐学增², 白炜³, 王博³, 陈亚武², 周党侠⁴^,^†(

), 孟欣³^,^†(

), 刘丽文³

^1. 710032　西安，解放军空军军医大学第一附属医院（西京医院）超声医学科　解放军空军军医大学第一附属医院（西京医院）肥厚型心肌病国际合作中心　陕西省肥厚型心肌病多学科会诊中心　西京医院肥厚型心肌病多学科诊治与遗传咨询中心；710061　西安，西安交通大学医学部病理系
^2. 710032　西安，解放军空军军医大学第一附属医院（西京医院）心血管外科
^3. 710032　西安，解放军空军军医大学第一附属医院（西京医院）超声医学科　解放军空军军医大学第一附属医院（西京医院）肥厚型心肌病国际合作中心　陕西省肥厚型心肌病多学科会诊中心　西京医院肥厚型心肌病多学科诊治与遗传咨询中心
^4. 710061　西安，西安交通大学医学部病理系

收稿日期:2020-03-29 出版日期:2020-05-01
通信作者: 周党侠, 孟欣
基金资助:
陕西省重点研发计划(2019SF-134，2019JM-029); 国家自然科学基金(81673224，81901755)

Short- and medium-term follow-up outcomes of mitral valvuloplasty guided by real-time three-dimensional transesophageal echocardiography

Yuxi Li¹, Xuezeng Xu², Wei Bai³, Bo Wang³, Yawu Chen², Dangxia Zhou⁴^,^†(), Xin Meng³^,^†(), Liwen Liu³

^1. Department of Ultrasound Medicine, First Affiliated Hospital of Air Force Medical University (Xi'jing Hospital); Hypertrophic Cardiomyopathy International Cooperation Center, the First Affiliated Hospital of Air Force Medical University (Xi'jing Hospital); Multidisciplinary Consultation Center of Hypertrophic Cardiomyopathy, Shaanxi Province; Multidisciplinary Clinic and Genetic Counseling Center of Hypertrophic Cardiomyopathy, Xijing Hospital, Xi'an 710032, China; Department of Pathology, Medical Department of Xi'an Jiaotong University, Xi′an 710061, China
^2. Department of Cardiovascular Surgery, First Affiliated Hospital of Air Force Medical University (Xi'jing Hospital); Hypertrophic Cardiomyopathy International Cooperation Center, the First Affiliated Hospital of Air Force Medical University (Xi'jing Hospital); Multidisciplinary Consultation Center of Hypertrophic Cardiomyopathy, Shaanxi Province; Multidisciplinary Clinic and Genetic Counseling Center of Hypertrophic Cardiomyopathy, Xijing Hospital, Xi'an 710032, China
^3. Department of Ultrasound Medicine, First Affiliated Hospital of Air Force Medical University (Xi'jing Hospital); Hypertrophic Cardiomyopathy International Cooperation Center, the First Affiliated Hospital of Air Force Medical University (Xi'jing Hospital); Multidisciplinary Consultation Center of Hypertrophic Cardiomyopathy, Shaanxi Province; Multidisciplinary Clinic and Genetic Counseling Center of Hypertrophic Cardiomyopathy, Xijing Hospital, Xi'an 710032, China
^4. Department of Pathology, Medical Department of Xi'an Jiaotong University, Xi′an 710061, China

Received:2020-03-29 Published:2020-05-01
Corresponding author: Dangxia Zhou, Xin Meng
About author:
Corresponding author: Meng Xin, Email: 22987143@qq.com;
Zhou Dangxia, Email: zhoudx2010@163.com

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引用本文：

李昱茜, 徐学增, 白炜, 王博, 陈亚武, 周党侠, 孟欣, 刘丽文. 实时三维经食管超声指导下全胸腔镜技术二尖瓣成形术的中短期随访效果评价[J]. 中华医学超声杂志（电子版）, 2020, 17(05): 427-433.

Yuxi Li, Xuezeng Xu, Wei Bai, Bo Wang, Yawu Chen, Dangxia Zhou, Xin Meng, Liwen Liu. Short- and medium-term follow-up outcomes of mitral valvuloplasty guided by real-time three-dimensional transesophageal echocardiography[J]. Chinese Journal of Medical Ultrasound (Electronic Edition), 2020, 17(05): 427-433.

目的

探讨实时三维经食管超声心动图（RT3D-TEE）指导下全胸腔镜技术行二尖瓣成形术的意义及术后近中期效果评价。

方法

选取2016年1月至2018年12月在空军军医大学第一附属西京医院采用全胸腔镜技术行二尖瓣成形术治疗二尖瓣关闭不全的147例患者临床资料，其中男性97例（66.0%）、女性50例（34.0%），年龄10~68岁，平均年龄（45.8±14.5）岁，术前均行RT3D-TEE检查，观察二尖瓣病变部位、分析反流机制、测量二尖瓣结构各项指标，帮助手术医师选择成形环型号及手术方式。术后即刻行RT3D-TEE评价二尖瓣成形效果，随诊时记录经胸超声心动图结果。采用单因素方差分析比较术前和术后LA左右径、LV前后径、LVEF、EDV、ESV以及二尖瓣反流或狭窄情况等指标的变化，有统计学意义的组间进行LSD-t检验。

结果

全组无围手术期死亡患者，有2例术中成形失败转而选择二尖瓣置换术，二尖瓣成形即刻成功率为98.6%。中期随访超声心动图显示，二尖瓣无或微量反流114例（78.6%），少量反流19例（13.1%），少-中量反流10例（6.9%），中量反流2例（1.4%）。术后出现二尖瓣前叶收缩期前向运动（SAM征）0例；二尖瓣前向血流速度加快8例。与术前比较，术后1个月、3个月、12个月LA左右径、LV前后径、EDV、ESV较术前均缩小[分别为LA左右径（50.9±8.2）mm vs（39.9±7.1） mm vs（39.3±5.4）mm vs（39.8±7.9）mm，F=87.032，P<0.05；LV前后径（56.9±6.8）mm vs（49.0±5.8）mm vs（48.2±4.3）mm vs（48.5±6.3）mm，F=71.042，P<0.05；EDV（135.4±38.6）ml vs（99.1±30.1）ml vs（93.1±21.6）ml vs（98.6±37.3）ml，F=52.639，P<0.05；ESV（58.3±20.9）ml vs（47.7±21.3）ml vs（41.8±13.4）ml vs（44.1±25.8）ml ，F=18.300，P<0.05]；与术前比较，术后1个月、3个月LVEF较术前略减低[分别为（57.5±5.1）% vs（53.1±6.5）% vs（55.8±5.6）%，F=14.885，P<0.05]；术后12个月与术前LVEF比较差异无统计学意义[术前（57.5±5.1）% vs（56.5±5.9）%，P>0.05]。平均随访时间为（23±10）个月，随访时所有患者均存活，无因反流复发再次行手术治疗的患者。

结论

采用RT3D-TEE指导二尖瓣成形术对提高手术成功率、降低并发症的发生率有重要意义。RT3D-TEE指导下胸腔镜技术治疗二尖瓣关闭不全近中期结果满意，值得推广。

关键词: 实时三维经食道超声, 二尖瓣成形, 二尖瓣关闭不全, 中期效果评价

Objective

To assess the clinical value of mitral valvuloplasty under the guidance of real-time three-dimensional transesophageal echocardiography (RT3D-TEE) and its short-and medium-term effects.

Methods

The clinical data of 147 patients with mitral insufficiency treated by VATS from January 2016 to December 2018 were collected, including 97 males (66%) and 50 females (34%) ranging in age from 10 to 68 (mean, 45.8±14.5) years. RT3D-TEE was performed before operation to help surgeons choose the model of ring and surgical procedure. RT3D-TEE was performed immediately after operation to evaluate the effect of mitral valvuloplasty. Echocardiographic results were recorded during follow-up. The changes in the diameters of the left atrium (LA) and left ventricle (LV), left ventricular ejection fraction (LVEF), and mitral regurgitation or stenosis before and after operation were compared.

Results

There were two cases of surgical failure, in which mitral valve replacement was subsequently performed. The immediate success rate of mitral valvuloplasty was 98.6%. Echocardiography showed that there were 114 cases (78.6%) with no or minimal mitral regurgitation, 19 (13.1%) with mild mitral regurgitation, 10 (6.9%) with mild-to-moderate regurgitation, and 2 (1.4%) with moderate regurgitation. There were no cases with SAM sign (anterior leaflet systolic forward motion), and eight cases had faster mitral flow velocity. Compared with the values before operation, the diameters of LA and LV, end-diastolic volume (EDV) and end-systolic volume (ESV) decreased at 1, 3, and 12 months after operation [LA: (50.9±8.2) mm vs (39.9±7.1) mm, (39.3±5.4) mm, and (39.8±7.9) mm, F=87.032, P<0.05; LV: (56.9±6.8) mm vs (49.0±5.8) mm, (48.2±4.3) mm, and (48.5±6.3) mm, F=71.042, P<0.05; EDV: (135.4±38.6) ml vs (99.1±30.1) ml, (93.1±21.6) ml, and (98.6±37.3) ml, F=52.639, P<0.05; ESV: (58.3±20.9) ml vs (47.7±21.3) ml, (41.8±13.4) ml, and (44.1±25.8) ml, F=18.300, P<0.05]. Compared with preoperative LVEF, the LVEF at 1 and 3 months after operation was slightly lower [(57.5±5.1)% vs (53.1±6.5)% and (55.8±5.6)%, F=14.885, P<0.05). There was no statistical difference between preoperative LVEF and LVEF at 12 months after operation [(57.5±5.1)% vs (56.5±5.9)%, P>0.05]. The mean follow-up time was (23±10) months. All the patients survived during the follow-up, and there was no recurrence of reflux.

Conclusion

RT3D-TEE plays an important role in improving the success rate of operation and reducing the incidence of complications. The success rate is still very high after more than one year of follow-up. The short- and medium-term effects of RT3D-TEE guided thoracoscopic technique in the treatment of mitral regurgitation are satisfactory.

Key words: Real-time three-dimensional transesophageal ultrasound, Mitral valvoplasty, Mitral insufficiency, Mid-term effect evaluation

图1 二尖瓣成形术前TEE评估病变与术中实物对比。图a为2D-TEE二尖瓣脱垂超声图；图b为2D-TEE二尖瓣脱垂处反流彩色多普勒超声图；图c为在机3D软件切割图；图d为二尖瓣脱垂3D鸟瞰图；图e为胸腔镜二尖瓣修复术中图（白色箭头所示为瓣叶脱垂区域）

图2 二尖瓣成形术后经食管超声心动图评估手术效果。图a为术后二尖瓣3D鸟瞰图可见成形环且瓣叶脱垂问题已纠正；图b为二尖瓣成形术后彩色血流示瓣上仅微量反流

图3 二尖瓣成形环不同型号的使用频数情况

表1 二尖瓣成形术前、术后各项指标比较（±s）

分组	LA左右径（mm）	LV前后径（mm）	LV长径（mm）	EDV（ml）	ESV（ml）	LVEF（%）	MV-Vmax（cm/s）
术前	50.9±8.2	56.9±6.8	78.9±6.4	135.4±38.6	58.3±20.9	57.5±5.1	120.3±32.5
术后1个月	39.9±7.1^a	49.0±5.8^a	76.9±6.2^a	99.1±30.1^a	47.7±21.3^a	53.1±6.5^a	109.2±26.4^a
术后3个月	39.3±5.4^a	48.2±4.3^a	75.8±6.4^a	93.1±21.6^a	41.8±13.4^ab	55.8±5.6^ab	128.6±31.8^ab
术后12个月	39.8±7.9^a	48.5±6.3^a	76.8±6.4^a	98.6±37.3^a	44.1±25.8^a	56.5±5.9^b	132.1±26.3^ab
F值	87.032	71.042	6.175	52.639	18.300	14.885	13.210
P值	<0.001	<0.001	<0.001	<0.001	<0.001	<0.001	<0.001

表1 二尖瓣成形术前、术后各项指标比较（±s）

分组	LA左右径（mm）	LV前后径（mm）	LV长径（mm）	EDV（ml）	ESV（ml）	LVEF（%）	MV-Vmax（cm/s）
术前	50.9±8.2	56.9±6.8	78.9±6.4	135.4±38.6	58.3±20.9	57.5±5.1	120.3±32.5
术后1个月	39.9±7.1^a	49.0±5.8^a	76.9±6.2^a	99.1±30.1^a	47.7±21.3^a	53.1±6.5^a	109.2±26.4^a
术后3个月	39.3±5.4^a	48.2±4.3^a	75.8±6.4^a	93.1±21.6^a	41.8±13.4^ab	55.8±5.6^ab	128.6±31.8^ab
术后12个月	39.8±7.9^a	48.5±6.3^a	76.8±6.4^a	98.6±37.3^a	44.1±25.8^a	56.5±5.9^b	132.1±26.3^ab
F值	87.032	71.042	6.175	52.639	18.300	14.885	13.210
P值	<0.001	<0.001	<0.001	<0.001	<0.001	<0.001	<0.001

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