风湿性二尖瓣狭窄(RMS)合并肺高压(PH)经皮球囊二尖瓣成形术(PBMV)的短期疗效

复旦学报(医学版)

2019, Vol. 46

Issue (4): 499-503 DOI: 10.3969/j.issn.1672-8467.2019.04.011

Contents PDF Abstract Full text Fig/Tab

引用本文

黄晨旭, 林颖, 张蕾, 沈志云. 风湿性二尖瓣狭窄(RMS)合并肺高压(PH)经皮球囊二尖瓣成形术(PBMV)的短期疗效[J]. 复旦学报医学版, 2019, 46(4): 499-503.

HUANG Chen-xu, LIN Ying, ZHANG Lei, SHEN Zhi-yun. Short-term outcomes of percutaneous balloon mitral valvuloplasty complicated with pulmonary hypertension (PH)[J]. Fudan University Journal of Medical Sciences, 2019, 46(4): 499-503.

风湿性二尖瓣狭窄(RMS)合并肺高压(PH)经皮球囊二尖瓣成形术(PBMV)的短期疗效

黄晨旭¹ , 林颖¹ , 张蕾² , 沈志云¹

1. 复旦大学附属中山医院护理部上海 200032;
2. 复旦大学附属中山医院心内科上海 200032

收稿日期：2018-08-31

基金项目：复旦大学临床护理特色专科建设项目(FNSF201604)

摘要：目的评价经皮球囊二尖瓣成形术（percutaneous balloon mitral valvuloplasty，PBMV）对风湿性二尖瓣狭窄（rheumatic mitral stenosis，RMS）合并肺高压（pulmonary hypertension，PH）患者的短期疗效。方法回顾性连续纳入于2015年1月至2018年12月在复旦大学附属中山医院心内科住院接受PBMV治疗的患者，并根据PBMV术前所测得的肺动脉平均压（pulmonary artery mean pressure，PAMP）将患者分为两组：PH组（PAMP ≥ 25 mmHg）和非PH组（PAMP < 25 mmHg），采用右心导管经胸/经食道超声心动图测量的各项指标进行评价。结果共纳入157例患者。术后两组患者的二尖瓣瓣口面积（mitral valve area，MVA）、左心房内径（left atrial diameter，LAD）、PAMP、左房平均压（left atrial mean pressure，LAMP）、肺动脉收缩压（pulmonary artery systolic pressure，PASP）均有显著性改善（P < 0.05），其中PAMP降至正常或接近正常水平。PH组患者PAMP、LAMP、PASP的下降幅度显著大于非PH组患者（P < 0.05），但PH组患者术后MVA仍小于非PH组，LAD、PAMP、LAMP、PASP仍高于非PH组（P均 < 0.05）。结论无论术前肺动脉压是否正常，PBMV可有效降低RMS患者的肺动脉压，短期疗效较好；应在肺动脉压升高之前行PBMV，从而预防肺血管不可逆的改变。

关键词：风湿性二尖瓣狭窄(RMS) 肺高压(PH) 经皮球囊二尖瓣成形术(PBMV) 短期疗效

Short-term outcomes of percutaneous balloon mitral valvuloplasty complicated with pulmonary hypertension (PH)

HUANG Chen-xu¹ , LIN Ying¹ , ZHANG Lei² , SHEN Zhi-yun¹

1. Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai 200032, China;
2. Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai 200032, China

Foundation item: This work was supported by the Project of Characteristic Construction of Clinical Nursing Specialty, Fudan University (FNSF201604)

Corresponding author: LIN Ying, E-mail:lin.ying@zs-hospital.sh.cn.

Abstract: Objective To investigate the short-term outcomes of percutaneous balloon mitral valvuloplasty (PBMV) in patients with rheumatic mitral stenosis (RMS) complicated with pulmonary hypertension (PH). Methods Patients who received PBMV from Jan., 2015 to Dec., 2018 in the Department of Cardiology, Zhongshan Hospital, Fudan University were consecutively and retrospectively analyzed.Then they were divided into two groups with pre-operative pulmonary artery mean pressure (PAMP) ≥ 25 mmHg and PAMP < 25 mmHg, respectively.Pre-and post-operative cardiac catheterization, transthoracic and transesophageal echocardiography were used to evaluate the short-term outcomes of PBMV in the two groups. Results A total of 157 patients were enrolled mitral valve area (MVA), left atrial diameter (LAD), PAMP, left atrial mean pressure (LAMP) and pulmonary artery systolic pressure (PASP) of the two groups were all significantly improved after PBMV (P < 0.05), and PAMP could be reduced to normal or near normal level.The decrease of PAMP, LAMP and PASP in the group with PAMP ≥ 25 mmHg was significantly greater than those in the other group (P < 0.05).However, the MVA were still smaller (P < 0.05) and the LAD, PAMP, LAMP, PASP were still higher (P < 0.05) in the group with PAMP ≥ 25 mmHg than those in the other group. Conclusions PBMV can effectively reduce the pulmonary artery pressure in patients with RMS, and its short term outcomes is well whether the preoperative pulmonary artery pressure is normal or not.However, PBMV should be performed before the increase of pulmonary artery pressure to prevent the irreversible change of pulmonary vessels.

Key words: rheumatic mitral stenosis (RMS) pulmonary hypertension (PH) percutaneous balloon mitral valvuloplasty (PBMV) short-term outcome

风湿性二尖瓣狭窄(rheumatic mitral stenosis, RMS)是发展中国家不容忽视的心脏疾病^[1], 也是导致心力衰竭和卒中的主要原因, 其特征为左心房排空受阻、左心房平均压(left atrial mean pressure, LAMP)进行性升高并导致肺高压(pulmonary hypertension, PH)^[2]。当RMS患者合并PH时, 又可致右心扩大、右心衰, 故RMS合并PH与患者预后密切相关, 虽然药物治疗可以减轻症状, 但是并不能解除狭窄瓣膜对血流的阻碍。自1984年日本学者Inoue等^[3]首次报道经皮球囊二尖瓣成形术(percutaneous balloon mitral valvuloplasty, PBMV)以来, PBMV已成为形态学适合的RMS患者的最佳治疗选择^[2]。术后肺动脉平均压(pulmonary artery mean pressure, PAMP)持续升高与远期预后不良相关^[4], 故在肺动脉压升高之前行PBMV可预防肺血管不可逆的改变。本研究主要探讨RMS合并PH患者PBMV术后的短期临床效果, 现报道如下。

资料和方法

临床资料 回顾性连续纳入于2015年1月至2018年12月在复旦大学附属中山医院心内科住院并成功接受PBMV治疗的患者。第五届肺高压国际会议将肺高压定义为经右心导管测量的平均肺动脉压(PAMP)≥25 mmHg (1 mmHg=0.133 kPa, 下同)^[5], 因此本研究根据PBMV前所测得的PAMP将患者分为两组:PH组(PAMP≥25 mmHg)和非PH组(PAMP＜25 mmHg)。

PBMV疗效的判定 完成全部操作过程, 术后二尖瓣瓣口面积＞1.5 cm², 无重度二尖瓣反流发生(mitral regurgitation, MR), 心尖区舒张期杂音显著减轻或消失^[2], 视为有效。

结局指标收集方法 纳入的患者分别于术前1~3天和术后1~3天进行经胸或经食道超声心动图测量二尖瓣瓣口面积(mitral valve area, MVA)、左心房内径(left atrial diameter, LAD)、左心室射血分数(left ventricular ejection fraction, LVEF)和MR。球囊扩张前后行右心导管即刻测量PAMP、LAMP、肺动脉收缩压(pulmonary artery systolic pressure, PASP)。判定PBMV后再狭窄的标准:PBMV术后随访中二尖瓣瓣口面积≤1.5 cm²或二尖瓣瓣口面积的增加值在随访中缩小50%以上^[2]。

统计学分析 采用SPSS 20.0对数据进行录入和分析, 计量资料以x±s; 计数资料采用百分比、率等进行统计描述。正态分布数据组间比较采用两独立样本t检验、非正态分布数据组间比较采用两独立样本秩和检验; 正态分布数据自身前后比较采用配对t检验、非正态分布数据组间比较采用配对秩和检验; 计数资料采用χ²检验或Fisher精确检验等进行统计推断。P＜0.05为差异有统计学意义。

结果

一般资料 本研究共纳入157例患者, 平均年龄(53.97±14.74)岁(26~85岁); 女性118例(75.2%), 男性39例(24.8%); 纽约心功能分级(NYHA)Ⅰ级28例(17.83%), Ⅱ级105例(66.88%), Ⅲ级24例(15.29%); 64例(40.76%)患者有心房颤动(atrial fibrillation, AF); 15例(9.55%)患者为PBMV术后再狭窄, PBMV术后再狭窄出现时间中位数为6.00, 四分位间距为(3.50, 15.00), 1例患者为外科二尖瓣置换术后1个月发生再狭窄。非PH组61例, PH组96例。两组患者基线情况比较, 术前MVA、LAD、PASP、PAMP、LAMP差异具有统计学意义(P＜0.05), 其他情况差异均无统计学意义(表 1)。

表 1 两组患者PBMV术前的一般情况、超声心动图及血流动力学参数分析 Tab 1 Analysis of demographic data, echocardiography and hemodynamic parameters between two groups before PBMV

[(x±s) or n (%)]
Contents	Group with PAMP＜25 mmHg (n=61)	Group with PAMP≥ 25 mmHg (n=96)	Statistical	P
Age (y)	55.39±14.23	53.07±15.07	0.961⁽¹⁾	0.338
Female	46 (75.40)	72 (75.00)	0.003⁽²⁾	0.954
AF	21 (34.40)	43 (44.80)	1.660⁽²⁾	0.198
History of PBMV	9 (14.75)	6 (6.25)	3.122⁽²⁾	0.077
LVEF (%)	65.28±6.58	64.77±4.29	0.586⁽¹⁾	0.559
NYHA
Ⅰ	10 (16.39)	18 (18.75)	2.763⁽²⁾	0.251
Ⅱ	45 (73.77)	60 (62.50)
Ⅲ	6 (9.84)	18 (18.75)
MR [n (%)]
Slight/light	58 (95.10)	88 (81.70)	0.919⁽³⁾	0.842
Moderate	3 (4.90)	7 (7.30)
Sever	0 (0)	1 (1.00)
MVA (cm²)	1.10±0.21	1.00±0.19	3.093⁽⁴⁾	0.002
LAD (mm)	47.52±6.41	52.95±10.01	4.137⁽¹⁾	＜0.001
PASP (mmHg)	34.51±7.32	52.70±13.74	9.127⁽⁴⁾	＜0.001
PAMP (mmHg)	18.34±4.27	32.31±7.92	10.557⁽⁴⁾	＜0.001
LAMP (mmHg)	11.83±4.24	20.63±6.24	10.515⁽¹⁾	＜0.001
⁽¹⁾Independent-samples t-test; ⁽²⁾Chi-square test; ⁽³⁾Fisher exact test; ⁽⁴⁾Mann-Whitney U test.1 mmHg=0.133 kPa.

表选项

PBMV前后的超声心动图及血流动力学参数 两组患者PBMV前后的MVA、LAD、PAMP、LAMP、PASP的自身比较差异均有统计学意义(P＜0.001), PH组LVEF的自身差异比较也有统计学意义(P＜0.05)。两组患者PBMV后MVA、LAD的两样本t检验差异有统计学意义(P＜0.05), PAMP、LAMP、PASP的差值t检验和两样本t检验差异均有统计学意义(P＜0.05), 两组PBMV后的MR发生率差异无统计学意义(P＞0.05), 详见表 2和图 1。

表 2 两组患者PBMV前后的超声心动图及血流动力学参数比较 Tab 2 Comparison of echocardiographic and hemodynamic parameters before and after PBMV between two groups

(x±s)
Contents	Group with PAMP＜25 mmHg (n=61)	Group with PAMP≥25 mmHg (n=96)	Statistical	P
MVA (cm²)
Preoperative	1.10±0.21	1.00±0.19	0.878⁽³⁾	0.382
Postoperative	1.87±0.32	1.73±0.29	2.769 ⁽⁴⁾	0.006
Statistical	19.296⁽¹⁾	25.541⁽¹⁾
P	0.000	0.000
LAD (mm)
Preoperative	47.52±6.41	52.95±10.01	0.490⁽³⁾	0.624
Postoperative	44.28±4.76	49.09±8.71	4.465 ⁽⁴⁾	＜0.001
Statistical	6.353⁽¹⁾	7.202⁽²⁾
P	0.000	0.000
PAMP (mmHg)
Preoperative	18.34±4.27	32.31±7.92	7.766⁽³⁾	＜0.001
Postoperative	14.43±3.72	20.56±5.75	7.466 ⁽⁴⁾	＜0.001
Statistical	7.296⁽¹⁾	8.454⁽²⁾
P	0.000	0.000
LAMP (mmHg)
Preoperative	11.83±4.24	20.03±6.24	3.736⁽³⁾	＜0.001
Postoperative	8.02±3.09	13.38±5.72	7.592 ⁽⁴⁾	＜0.001
Statistical	6.982⁽¹⁾	11.180⁽¹⁾
P	0.000	0.000
PASP (mmHg)
Preoperative	34.51±7.32	52.70±13.74	5.659⁽³⁾	＜0.001
Postoperative	29.54±5.84	39.34±9.72	7.309 ⁽⁴⁾	＜0.001
Statistical	4.949⁽²⁾	8.203⁽²⁾
P	0.000	0.000
LVEF (%)
Preoperative	65.28±6.58	64.77±4.29	1.878⁽³⁾	0.060
Postoperative	65.31±5.69	65.96±4.26	0.820⁽⁴⁾	0.413
Statistical	0.046⁽²⁾	2.328⁽²⁾
P	0.964	0.020
PBMV MR [n (%)]
Slight /light	56 (91.80)	77 (80.20)	4.278⁽⁵⁾	0.105
Moderate	5 (8.20)	15 (15.60)
Sever	0 (0.00)	4 (4.20)
⁽¹⁾Paired-samples t-test; ⁽²⁾Paired-samples wilcoxon rank sum test; ⁽³⁾Independent-samples Δt-test; ⁽⁴⁾Independent-samples t-test; ⁽⁵⁾Fisher exact test.

表选项

图 1 两组患者PBMV前后的超声心动图及血流动力学参数的自身差异比较 Fig 1 Self-comparison of echocardiographic and hemodynamic parameters before and after PBMV between two groups

图选项

讨论

PH是二尖瓣狭窄的常见并发症, 其机制主要有:左心房压力升高所致的被动性升高、肺小血管收缩和肺血管的结构改变, 后两者往往在二尖瓣狭窄解除后仍可持续存在^[2]。本研究中PBMV前的一般资料分析结果显示, PH组患者的MVA小于非PH组患者(P＜0.05), 因而LAD、LAMP、PAMP、PASP也均大于非PH组患者(P＜0.05), 这说明MVA越小的患者发生PH的可能性越大^[6]。

本研究中患者经PBMV治疗后, MVA、LAD的测量结局均较术前有所改善(P＜0.05), 说明PBMV可以有效扩大RMS患者的MVA并降低LAD, 但同时也体现了两组患者MVA、LAD自身差异的组间比较无统计学意义(P＞0.05), 而PBMV后的MVA、LAD的组间差异仍存在(P＜0.05)。该结果一方面提示了PBMV对RMS患者MVA、LAD的改善程度与RMS患者术前是否合并PH无关, 无论术前是否合并PH, PBMV术后MVA、LAD的短期疗效均较好, 这点与舒茂琴等^[7]的研究结果一致; 另一方面提示合并PH的RMS患者接受PBMV治疗后, MVA仍小于非PH组患者且LAD仍大于非PH组患者。

二尖瓣狭窄合并重度PH者预后较差, PH是PBMV术后发生心脏事件和需要再介入的独立预测因子^{[6, 8]}。但也有研究显示^[9], 肺血管阻力增高与PBMV成功率及远期效果并不相关。Nair等^[10]的研究显示, PBMV术后持续肺动脉压力增高的患者在长期随访中发生不良事件的风险增高, 这部分人群的中风发病率也较高, 需要再次行介入治疗(二尖瓣置换术、再次PBMV术)。本研究结果显示, 无论患者术前PAMP是否正常, PBMV术后的PAMP、LAMP、PASP均显著下降(P＜0.05), 其中PAMP可降至正常或接近正常水平, 这点也得到了多项研究的支持^[11-14]。但两组患者PBMV术后PAMP、LAMP、PASP差异仍存在统计学意义(P＜0.05), 说明PBMV术后PH组患者肺动脉压仍高于非PH组患者, 故在肺动脉压升高之前行PBMV可预防肺血管不可逆的改变^[10]。

值得注意的是PBMV前后两组患者LVEF的组间比较差异无统计学意义, 非PH组患者LVEF自身前后比较差异也无统计学意义, 但是PH组患者LVEF自身前后比较差异有统计学意义(P＜0.05)。其合理的解释可能是, 两组患者PBMV术前、术后的心功能均良好(术前:65.28%±6.58% vs.64.77%±4.29%;术后:65.31%±5.69% vs.65.96%±4.25%), 因此组间差异并不明显, 但PH组患者在PBMV术后心功能有效改善。两组患者PBMV术后的MR发生率差异无统计学意义, 说明患者在接受PBMV术后, MR风险并未增加。

综上所述, 经PBMV可以有效改善RMS患者的MVA、LAD, 降低肺动脉压力, 无论术前肺动脉压是否正常, 其短期疗效均较好。但RMS合并PH患者的疗效仍明显不及非PH RMS患者, 因此在肺动脉压升高之前行PBMV可预防肺血管不可逆的改变。本研究仅对风湿性心脏病合并PH经PBMV的预后作了初步探讨, 由于病例选择的局限, 结果可能缺乏广泛性, 更确切的结论有待积累更多的病例和延长随访时间后进一步研究得出。

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文章信息

黄晨旭, 林颖, 张蕾, 沈志云

HUANG Chen-xu, LIN Ying, ZHANG Lei, SHEN Zhi-yun

风湿性二尖瓣狭窄(RMS)合并肺高压(PH)经皮球囊二尖瓣成形术(PBMV)的短期疗效

Short-term outcomes of percutaneous balloon mitral valvuloplasty complicated with pulmonary hypertension (PH)

复旦学报医学版, 2019, 46(4): 499-503.

Fudan University Journal of Medical Sciences, 2019, 46(4): 499-503.

Corresponding author
LIN Ying, E-mail:lin.ying@zs-hospital.sh.cn.

基金项目
复旦大学临床护理特色专科建设项目(FNSF201604)

Foundation item
This work was supported by the Project of Characteristic Construction of Clinical Nursing Specialty, Fudan University (FNSF201604)

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