Tolis George A, Korkolis Dimitris P, Kopf Gary S, Elefteriades John A
Section of Cardiothoracic Surgery, Yale University School of Medicine, New Haven, Connecticut 06510, USA.
Ann Thorac Surg. 2002 Nov;74(5):1476-80; discussion 1480-1. doi: 10.1016/s0003-4975(02)03927-9.
Whether or not to perform adjunctive mitral repair in patients undergoing coronary artery bypass grafting (CABG) for advanced ischemic cardiomyopathy with moderately severe mitral regurgitation (MR) remains controversial.
We examine the clinical and echocardiographic outcome after isolated CABG in 49 patients with ischemic cardiomyopathy and 1+ to 3+ MR undergoing surgical revascularization. The patients were identified for analysis of mitral valve-related issues from a larger series of 183 patients with ischemic cardiomyopathy (MUGA ejection fraction < or = 30%) undergoing CABG by a single surgeon from 1986 to 1996. Patient age was 66.3 years (mean, range 45 to 83 years). There were 5 women (10.2%) and 44 men (89.8%). Mean ejection fraction was 22.4% with a range of 10% to 30%. Thirty-four patients had preoperative congestive heart failure (70%) and 12 (25%) had pulmonary edema. Number of grafts was 2.8 (mean, range 1 to 5). The MR was 1+ in 18 patients (37.5%), 2+ in 26 (52%) and 3+ in 5 patients (10.5%).
Hospital mortality was 2.0% (1 of 49 patients). Ejection fraction improved from 22.0% to 31.5% (p < 0.05) after CABG. Mean degree of MR improved with CABG alone from 1.73 to 0.54 (p < 0.05) as measured at a mean interval of 36.9 months from CABG. New York Heart-Association congestive heart failure class improved from 3.3 to 1.8 (p < 0.05). Long-term survival was 88%, 65%, and 50% at 1, 3, and 5 years postoperatively. No patient required subsequent mitral valve operation or heart transplantation in long-term follow-up.
We conclude that, in patients with advanced ischemic cardiomyopathy and mild-to-moderate MR, isolated CABG (without mitral valve, repair) suffices, producing dramatic improvement in ejection fraction, in congestive heart failure, and in degree of MR, with excellent (relative) long-term survival. The improvement in MR likely results from improved left ventricular function and size consequent upon revascularization.
对于患有晚期缺血性心肌病且伴有中度严重二尖瓣反流（MR）的患者，在进行冠状动脉旁路移植术（CABG）时是否进行二尖瓣修复仍存在争议。
我们研究了49例患有缺血性心肌病且MR为1+至3+并接受手术血运重建的患者单纯行CABG后的临床和超声心动图结果。这些患者是从1986年至1996年由一名外科医生进行CABG的183例缺血性心肌病（门控心血池显像射血分数≤30%）患者的更大系列中挑选出来进行二尖瓣相关问题分析的。患者年龄为66.3岁（平均，范围45至83岁）。有5名女性（10.2%）和44名男性（89.8%）。平均射血分数为22.4%，范围为10%至30%。34例患者术前有充血性心力衰竭（70%），12例（25%）有肺水肿。移植血管数量为2.8（平均，范围1至5）。18例患者（37.5%）的MR为1+，26例（52%）为2+，5例（10.5%）为3+。
住院死亡率为2.0%（49例患者中的1例）。CABG后射血分数从22.0%提高到31.5%（p<0.05）。单纯CABG后，平均MR程度从1.73改善到0.54（p<0.05），这是在CABG后平均36.9个月时测量的。纽约心脏协会充血性心力衰竭分级从3.3改善到1.8（p<0.05）。术后1年、3年和5年的长期生存率分别为88%、65%和50%。在长期随访中，没有患者需要后续的二尖瓣手术或心脏移植。
我们得出结论，对于患有晚期缺血性心肌病和轻至中度MR的患者，单纯CABG（不进行二尖瓣修复）就足够了，可使射血分数、充血性心力衰竭和MR程度得到显著改善，并具有出色的（相对）长期生存率。MR的改善可能是由于血运重建后左心室功能和大小的改善。
