Mickleborough L L, Carson S, Ivanov J
University of Toronto, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4 Canada.
J Thorac Cardiovasc Surg. 2001 Apr;121(4):675-82. doi: 10.1067/mtc.2001.112633.
In patients with a dyskinetic or akinetic area of the left ventricle, controversy exists over who will benefit from resection. This study evaluates results achieved with a modified linear closure in 193 of 196 consecutive cases. Preoperative cases (n = 160 [83%]) were in functional class III or IV with congestive heart failure (n = 115 [60%]), angina (n = 108 [56%]), and syncope (n = 67 [35%]). The ejection fraction was 25% +/- 8%, and echocardiography showed significant mitral regurgitation in 86 (45%) patients. In patients with detailed wall motion analysis, 50 (57%) were akinetic, and 37 (43%) were dyskinetic.
Repair was completed on the beating heart to minimize ischemia and allow assessment of wall function and viability to guide resection and repair. Additional procedures included coronary artery bypass grafting (n = 175 [91%]), septoplasty (n = 24 [12%]), and arrhythmia ablation (n = 77 [40%]). Ventricular and mitral valve function were assessed by means of preoperative and/or postoperative gated acquisition scans in 171 (90%) patients and Doppler echocardiograms in 170 (88%) patients.
Hospital mortality was low (5/193 [2.6%]), although 34 (18%) patients needed perioperative intra-aortic balloon pump support. Actuarial survival at 1 and 5 years was 91% and 84%. Most late deaths were due to congestive heart failure. Seven patients required transplantation (interval, 36 +/- 32 months). As determined by multivariable analysis, factors predicting poor outcome at 5 years were preoperative mitral regurgitation of 2+ or greater, congestive heart failure, and ventricular tachycardia. Among survivors, 126 (80%) of 157 were in functional class I or II, and the average increase in ejection fraction postoperatively was 9.1% +/- 10.0%. Postoperative echocardiograms in 70 patients with significant mitral regurgitation preoperatively showed improved valve function in 40 (57%) of 70 patients.
We conclude that repair of dyskinetic or akinetic aneurysms by means of a modified linear closure plus septoplasty in selected patients can be accomplished in the beating heart with low operative mortality, provides good symptomatic relief and long-term survival, and is associated with objective evidence of improved left ventricular and mitral valve function.
对于左心室存在运动障碍或无运动区域的患者，关于谁能从切除术获益存在争议。本研究评估了196例连续病例中的193例采用改良线性闭合术所取得的结果。术前病例（n = 160 [83%]）心功能分级为Ⅲ或Ⅳ级，伴有充血性心力衰竭（n = 115 [60%]）、心绞痛（n = 108 [56%]）和晕厥（n = 67 [35%]）。射血分数为25%±8%，超声心动图显示86例（45%）患者存在显著二尖瓣反流。在进行详细壁运动分析的患者中，50例（57%）无运动，37例（43%）运动障碍。
在跳动的心脏上完成修复，以尽量减少缺血，并评估壁功能和存活性，从而指导切除和修复。其他手术包括冠状动脉旁路移植术（n = 175 [91%]）、室间隔成形术（n = 24 [12%]）和心律失常消融术（n = 77 [40%]）。171例（90%）患者通过术前和/或术后门控采集扫描评估心室和二尖瓣功能，170例（88%）患者通过多普勒超声心动图评估。
医院死亡率较低（5/193 [2.6%]），尽管34例（18%）患者围手术期需要主动脉内球囊泵支持。1年和5年的精算生存率分别为91%和84%。大多数晚期死亡是由于充血性心力衰竭。7例患者需要进行移植（间隔时间为36±32个月）。多变量分析确定，预测5年预后不良的因素为术前二尖瓣反流2+或更严重、充血性心力衰竭和室性心动过速。在幸存者中，157例中有126例（80%）心功能分级为Ⅰ或Ⅱ级，术后射血分数平均增加9.1%±10.0%。术前存在显著二尖瓣反流的70例患者术后超声心动图显示，70例患者中有40例（57%）瓣膜功能改善。
我们得出结论，在选定患者中通过改良线性闭合术加室间隔成形术修复运动障碍或无运动的动脉瘤，可在跳动的心脏上完成，手术死亡率低，能提供良好的症状缓解和长期生存，且有左心室和二尖瓣功能改善的客观证据。
