Bando Ko, Kobayashi Junjiro, Hirata Mitsuhiro, Satoh Toshihiko, Niwaya Kazuo, Tagusari Osamu, Nakatani Satoshi, Yagihara Toshikatsu, Kitamura Soichiro
Department of Cardiovascular Surgery, National Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka, Japan.
J Thorac Cardiovasc Surg. 2003 Aug;126(2):358-64. doi: 10.1016/s0022-5223(03)00550-6.
We evaluated risk factors for mortality and stroke after mechanical mitral valve replacement between May 1977 and December 2001.
Early and late mortality and stroke were assessed. Potential predictors of mortality and stroke were entered into a Cox proportional hazards model. Actuarial survival and freedom from stroke were determined by a log-rank test.
Mitral valve replacement was performed in 812 patients. Concomitant procedures included left atrial appendage closure in 493 (61%) patients, tricuspid annuloplasty-replacement in 348 (43%) patients, maze procedure in 185 (23%) patients, plication of the left atrium in 148 (18%) patients, and other procedures in 151 (19%) patients. Five-year actuarial survival was 91.1% +/- 2.3%. Freedom from stroke at 8 years was significantly better in patients with sinus rhythm versus atrial fibrillation (P <.001). Ninety-nine percent of patients with mitral valve replacement combined with a maze procedure were free from stroke, whereas only 89% of patients with mitral valve replacement alone were free from stroke at 8 years after surgical intervention. Seventy-two patients had late stroke; sixty-five patients (90%) were in atrial fibrillation, and 47 (65%) patients had the left atrial appendage closed. Multivariate analysis showed that late atrial fibrillation (odds ratio, 3.39; 95% confidence interval, 1.72-6.67; P =.0001) and omission of the maze procedure (odds ratio, 3.40; 95% confidence interval, 1.14-10.14; P =.003) were the significant risk factors for late stroke.
Persistent atrial fibrillation was the most significant risk factor for late stroke after mechanical mitral valve replacement. Restoration of sinus rhythm with a maze procedure nearly eliminated the risk of late stroke, whereas neither closure of the left atrial appendage nor therapeutic anticoagulation prevented this complication.
我们评估了1977年5月至2001年12月期间机械二尖瓣置换术后的死亡和中风风险因素。
评估早期和晚期死亡率及中风情况。将死亡和中风的潜在预测因素纳入Cox比例风险模型。通过对数秩检验确定精算生存率和无中风生存率。
对812例患者进行了二尖瓣置换术。同期手术包括493例（61%）患者行左心耳封闭术、348例（43%）患者行三尖瓣环成形术 - 置换术、185例（23%）患者行迷宫手术、148例（18%）患者行左心房折叠术以及151例（19%）患者行其他手术。5年精算生存率为91.1%±2.3%。窦性心律患者8年无中风生存率显著优于房颤患者（P<.001）。二尖瓣置换术联合迷宫手术的患者中99%在术后8年无中风，而单纯二尖瓣置换术的患者在术后8年只有89%无中风。72例患者发生晚期中风；65例（90%）为房颤患者，47例（65%）患者的左心耳已封闭。多因素分析显示，晚期房颤（比值比，3.39；95%置信区间，1.72 - 6.67；P =.0001）和未行迷宫手术（比值比，3.40；95%置信区间，1.14 - 10.14；P =.003）是晚期中风的显著风险因素。
持续性房颤是机械二尖瓣置换术后晚期中风的最显著风险因素。通过迷宫手术恢复窦性心律几乎消除了晚期中风的风险，而左心耳封闭术和治疗性抗凝均不能预防这一并发症。
