缺血性心肌病与扩张型心肌病患者的二尖瓣环成形术

Mitral annuloplasty in patients with ischemic versus dilated cardiomyopathy.

作者信息

Szalay Zoltan A, Civelek Ali, Hohe Stephen, Brunner-LaRocca Hans-Peter, Klövekorn Wolf-Peter, Knez Igor, Vogt Paul R, Bauer Erwin P

机构信息

Kerckhoff-Clinic Foundation, Benekestrasse 2-8, 61231 Bad Nauheim, Germany.

出版信息

Eur J Cardiothorac Surg. 2003 Apr;23(4):567-72. doi: 10.1016/s1010-7940(02)00864-3.

DOI:10.1016/s1010-7940(02)00864-3

PMID:12694777

Abstract

OBJECTIVE

Mitral regurgitation is a frequent finding in patients with end-stage cardiomyopathy predicting poor survival. Conventional treatment consists medical treatment or cardiac transplantation. However, despite severely decreased left ventricular function, mitral annuloplasty may improve survival and reduce the need for allografts.

METHODS

From January 1996 to July 2002, 121 patients with severe end-stage dilated (DCM) or ischemic cardiomyopathy (ICM), mitral regurgitation > or =2, and left ventricular ejection fraction < or =30% underwent mitral valve annuloplasty using a flexible posterior ring. DCM was diagnosed in 30 patients (25%), whereas ICM was found in 91 patients (75%). Concomitant tricuspid valve repair was performed in 14 (46.6%) patients in the DCM, and in 11 (12%) in the ICM group (P=0.0001), coronary artery bypass grafting in three (10%) in the DCM, and in 78 patients (86%) in the ICM group (P<0.00001). The mean follow-up time was 567+/-74 days in the DCM and 793+/-63 days in the ICM group (ns).

RESULTS

Early mortality was 6.6% (8/121), and was equal for both groups. Improvement in NYHA class (DCM 3.3+0.1-1.8+/-0.16; ICM from 3.2+0.04 to 1.7+/-0.07) were equal between groups after 1 year. Seventeen (15%) late deaths occurred during the follow-up period. There was no difference in the 2-year actuarial survival between groups (DCM/ICM 0.93/0.85). Risk factors for mitral reconstruction failure, defined as regurgitation > or =2 after 1 year, were preoperative NYHA IV in the DCM group (P=0.03), a preoperative posterior infarction (P=0.025), decreased left ventricular function (P=0.043), larger ring size (P=0.026) and preoperative renal failure (P=0.05) in the ICM group. Risk factors for death were larger ring size (P=0.02) and an increased LVEDD (P=0.027) in the DCM group and the postoperative use of IABP (P=0.002), renal failure (P=0.001), and a larger preoperative LVESD (P=0.035) in the ICM group.

CONCLUSION

Mitral reconstruction with a posterior annuloplasty using a flexible ring is effective in patients with severely depressed left ventricle function and has an acceptable operative mortality. Mid-term results are superior to medical treatment alone and comparable to cardiac transplantation.

摘要

目的

二尖瓣反流在终末期心肌病患者中很常见，预示着生存率较低。传统治疗方法包括药物治疗或心脏移植。然而，尽管左心室功能严重下降，但二尖瓣环成形术可能会提高生存率并减少同种异体移植的需求。

方法

从1996年1月至2002年7月，121例患有严重终末期扩张型心肌病（DCM）或缺血性心肌病（ICM）、二尖瓣反流≥2级且左心室射血分数≤30%的患者接受了使用柔性后环的二尖瓣环成形术。30例（25%）患者被诊断为DCM，而91例（75%）患者为ICM。DCM组14例（46.6%）患者同时进行了三尖瓣修复，ICM组11例（12%）患者进行了三尖瓣修复（P = 0.0001）；DCM组3例（10%）患者进行了冠状动脉旁路移植术，ICM组78例（86%）患者进行了冠状动脉旁路移植术（P < 0.00001）。DCM组的平均随访时间为567±74天，ICM组为793±63天（无显著性差异）。

结果

早期死亡率为6.6%（8/121），两组相同。1年后两组纽约心脏协会（NYHA）心功能分级的改善情况相同（DCM组从3.3±0.1降至1.8±0.16；ICM组从3.2±0.04降至1.7±0.07）。随访期间发生了17例（15%）晚期死亡。两组的2年预期生存率无差异（DCM/ICM为0.93/0.85）。二尖瓣重建失败的危险因素定义为术后1年反流≥2级，DCM组为术前NYHA IV级（P = 0.03），ICM组为术前后壁梗死（P = 0.025）、左心室功能下降（P = 0.043）、环尺寸较大（P = 0.026）和术前肾衰竭（P = 0.05）。死亡的危险因素在DCM组为环尺寸较大（P = 0.02）和左心室舒张末期内径增加（P = 0.027），在ICM组为术后使用主动脉内球囊反搏（IABP）（P = 0.002）、肾衰竭（P = 0.001）和术前左心室收缩末期内径较大（P = 0.035）。