Gangemi J J, Tribble C G, Ross S D, McPherson J A, Kern J A, Kron I L
Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia Health Sciences Center, Charlottesville, Virginia 22903, USA.
Ann Surg. 2000 May;231(5):710-4. doi: 10.1097/00000658-200005000-00011.
To assess the surgical risk of additional mitral valve repairs in patients with ischemic cardiomyopathy.
Severe mitral regurgitation in patients with ischemic cardiomyopathy increases the death rate and symptomatic status. The 1-year survival rate for medical therapy in this subset of patients is less than 20%. Transplantation is usually not feasible because of donor shortage and death while on the waiting list.
To assess additive risk, a retrospective chart review from 1993 to 1998 was performed comparing patients with ischemic cardiomyopathy (ejection fraction [EF] <25%) and severe mitral regurgitation undergoing mitral valve repair and coronary artery bypass graft operations with patients with an EF of <25% undergoing coronary artery bypass graft alone. These groups were also compared with 140 patients receiving heart transplants since 1993 (group 3).
The overall hospital death rate for group 1 was 6.3%. The one death occurred 2 weeks after surgery secondary to sepsis. This was not significantly different from the death rate of 4.1% in group 2. In group 1, there were two deaths at 1 year (87% survival rate), one related to heart failure. One patient was New York Heart Association (NYHA) class IV at 1 year; the remainder of patients were NYHA class I-II. These results were not significantly different than the 8% death rate noted with transplantation. There was no change in EF and minimal residual mitral regurgitation in group 1 based on postoperative transesophageal echocardiography, whereas group 2 had an average 11.7% improvement in EF.
Previously, severe mitral regurgitation in the setting of ischemic cardiomyopathy has been associated with poor survival. In these authors' experience, repairing the mitral valve along with coronary artery bypass grafting does not increase the surgical risk, yields improvement in symptomatic status, and compares favorably to coronary artery bypass grafting alone and cardiac transplantation. However, the lack of change in EF in these patients probably represents an overestimation of the EF before surgery secondary to severe mitral regurgitation.
评估缺血性心肌病患者进行二尖瓣额外修复手术的风险。
缺血性心肌病患者的严重二尖瓣反流会增加死亡率和症状状态。该类患者药物治疗的1年生存率低于20%。由于供体短缺以及在等待名单上死亡，移植通常不可行。
为评估附加风险，对1993年至1998年的病历进行回顾性分析，比较缺血性心肌病（射血分数[EF]<25%）且有严重二尖瓣反流并接受二尖瓣修复和冠状动脉旁路移植手术的患者与仅接受冠状动脉旁路移植手术且EF<25%的患者。这些组还与自1993年以来接受心脏移植的140名患者（第3组）进行比较。
第1组的总体医院死亡率为6.3%。1例死亡发生在术后2周，死于败血症。这与第2组4.1%的死亡率无显著差异。在第1组中，1年时有2例死亡（生存率87%），1例与心力衰竭有关。1例患者在1年时为纽约心脏协会（NYHA）IV级；其余患者为NYHA I-II级。这些结果与移植时8%的死亡率无显著差异。根据术后经食管超声心动图检查，第1组的EF无变化，二尖瓣反流残留极少，而第2组的EF平均改善了11.7%。
此前，缺血性心肌病背景下的严重二尖瓣反流与生存率低相关。根据这些作者的经验，在冠状动脉旁路移植术的同时修复二尖瓣不会增加手术风险，可改善症状状态，与单纯冠状动脉旁路移植术和心脏移植相比具有优势。然而，这些患者EF无变化可能是由于严重二尖瓣反流导致术前EF被高估。
