Menicanti L, Di Donato M, Frigiola A, Buckberg G, Santambrogio C, Ranucci M, Santo D
Department of Cardiac Surgery, Istituto Policlinico San Donato, San Donato Milanese, Milan, Italy.
J Thorac Cardiovasc Surg. 2002 Jun;123(6):1041-50. doi: 10.1067/mtc.2002.121677.
Functional mitral regurgitation in ischemic cardiomyopathy carries a poor prognosis, and its surgical management remains problematic and controversial. The aim of this study was to report the results of our surgical approach to patients who have had myocardial infarctions and have ventricular dilatation, mitral regurgitation, reduced pump function, pulmonary hypertension and coronary artery disease. This surgical approach consists of endoventricular mitral repair without prosthetic ring, ventricular reconstruction with or without patch, and coronary artery bypass grafting.
Forty-six patients (aged 64 +/- 10 years) with previous anterior transmural myocardial infarction and mitral regurgitation comprised the study group. Indication for surgery was heart failure in 93% of cases; 25 patients were in New York Heart Association functional class IV and 17 were in class III. Mitral regurgitation was moderate to severe in 32 cases (69%).
All patients underwent coronary artery bypass grafting, with a mean of 3.2 +/- 1.3 grafts. Associated aortic valve replacement was performed in 4 cases. Global operative mortality rate was 15.2%. End-diastolic and end-systolic volumes significantly decreased after surgery (from 140 +/- 40 to 98 +/- 36 mL/m(2) and from 98 +/- 32 to 63 +/- 22 mL/m(2), respectively, P =.001). Systolic pulmonary pressure decreased significantly (from 55 +/- 13 to 43 +/- 16 mm Hg, P =.001). Ejection fraction did not change significantly. Postoperative mitral regurgitation was absent or minimal in 84% of cases; 1 patient had severe mitral regurgitation necessitating valve replacement. New York Heart Association functional class significantly improved. The mean preoperative functional class was 3.4 +/- 0.6 (median 3, range 2-4); after the operation, this decreased to 1.9 +/- 0.7 (median 2, range 1-3, P <.001). Cumulative survival at a 30-month follow-up was 63%.
Our aggressive, combined surgical approach is aimed at correcting the three components of ischemic cardiomyopathy: relieving ischemia, reducing left ventricular wall tension by decreasing left ventricular volumes, and reducing volume overload and pulmonary hypertension by repairing the mitral valve. Despite a relatively high perioperative mortality rate, surviving patients benefitted from the operation, with improved clinical functional class and thus quality of life.
缺血性心肌病中的功能性二尖瓣反流预后较差，其手术治疗仍然存在问题且存在争议。本研究的目的是报告我们对心肌梗死、心室扩张、二尖瓣反流、泵功能降低、肺动脉高压和冠状动脉疾病患者的手术治疗结果。这种手术方法包括无人工瓣环的心室内二尖瓣修复、有或无补片的心室重建以及冠状动脉旁路移植术。
46例（年龄64±10岁）既往有前壁透壁性心肌梗死和二尖瓣反流的患者组成了研究组。93%的病例手术指征为心力衰竭；25例患者为纽约心脏协会心功能IV级，17例为III级。32例（69%）二尖瓣反流为中重度。
所有患者均接受了冠状动脉旁路移植术，平均移植3.2±1.3支血管。4例患者同时进行了主动脉瓣置换术。总体手术死亡率为15.2%。术后舒张末期和收缩末期容积显著降低（分别从140±40降至98±36 mL/m²和从98±32降至63±22 mL/m²，P = 0.001）。收缩期肺动脉压显著降低（从55±13降至43±16 mmHg，P = 0.001）。射血分数无显著变化。84%的病例术后二尖瓣反流消失或轻微；1例患者有严重二尖瓣反流，需要进行瓣膜置换。纽约心脏协会心功能分级显著改善。术前平均心功能分级为3.4±0.6（中位数3，范围2 - 4）；术后降至1.9±0.7（中位数2，范围1 - 3，P < 0.001）。30个月随访时的累积生存率为63%。
我们积极的联合手术方法旨在纠正缺血性心肌病的三个组成部分：缓解缺血、通过减少左心室容积降低左心室壁张力以及通过修复二尖瓣减少容量超负荷和肺动脉高压。尽管围手术期死亡率相对较高，但存活的患者从手术中获益，临床功能分级改善，生活质量提高。
