慢性缺血性二尖瓣反流手术治疗的长期结果：修复与人工瓣膜置换的比较。

Long-term results of the surgical treatment of chronic ischemic mitral regurgitation: comparison of repair and prosthetic replacement.

作者信息

Mantovani Vittorio, Mariscalco Giovanni, Leva Cristian, Blanzola Claudio, Cattaneo Paolo, Sala Andrea

机构信息

Department of Cardiac Surgery, University of Insubria, Ospedale di Circolo e Fondazioni Macchi, Viale Borri 57, 21100 Varese, Italy.

出版信息

J Heart Valve Dis. 2004 May;13(3):421-8; discussion 428-9.

PMID:15222289

Abstract

BACKGROUND AND AIM OF THE STUDY

The optimal management of chronic ischemic mitral regurgitation (CIMR) remains controversial. Herein, the authors reviewed the past 10 years of their experience to compare the long-term results of mitral valve repair with prosthetic replacement.

METHODS

Between January 1993 and January 2003, 102 patients (mean age 67.8 years; range: 51-80 years) with a preoperative diagnosis of CIMR, underwent mitral valve repair (n = 61; 59.8%) or prosthetic replacement (n = 41; 40.2%), along with myocardial revascularization (2.5 +/- 1.0 distal anastomoses per patients, internal thoracic artery used in 78.5%). A Carpentier Classic ring was always used in the repair procedures. The two groups were homogeneous for preoperative characteristics and comorbidities.

RESULTS

Total operative mortality was 7.8% (repair 8.2%; prosthesis 7.3%; p = NS). The five-year actuarial survival (operative mortality included) was 66.6 +/- 7.4% for repair and 73.4 +/- 8.7% for prosthesis (p = NS). Cox multivariate analysis showed as independent risk factor for late survival a preoperative left ventricular ejection fraction (LVEF) < or = 30% (RR 3.91; 95% CI = 1.47-10.38) and a preoperative pulmonary artery pressure (PAP) > or = 35 mumHg (RR 2.74; 95% CI = 1.07-7.02), while the type of mitral procedure was not significant. Patients with annular dilation as a mechanism of regurgitation were significant more likely to undergo repair rather than receive a prosthesis. Their preoperative LVEF and PAP were significantly worse than patients who had altered leaflet motion as a regurgitation mechanism.

CONCLUSION

Prosthetic mitral replacement and valve repair offer very similar results for CIMR. When a perfect repair is not easily feasible, cardiac surgeons should not hesitate to perform mitral valve replacement, as it is an excellent alternative therapy, though long-term outcome is mainly dependent on preoperative condition.

摘要

研究背景与目的

慢性缺血性二尖瓣反流（CIMR）的最佳治疗方案仍存在争议。在此，作者回顾了过去10年的经验，以比较二尖瓣修复术与人工瓣膜置换术的长期效果。

方法

1993年1月至2003年1月期间，102例术前诊断为CIMR的患者（平均年龄67.8岁；范围：51 - 80岁）接受了二尖瓣修复术（n = 61；59.8%）或人工瓣膜置换术（n = 41；40.2%），同时进行了心肌血运重建（每位患者平均2.5 ± 1.0个远端吻合口，78.5%使用胸廓内动脉）。修复手术中均使用Carpentier经典环。两组患者术前特征和合并症情况相似。

结果

总手术死亡率为7.8%（修复术8.2%；人工瓣膜置换术7.3%；p = 无显著差异）。包括手术死亡率在内，修复术的五年精算生存率为66.6 ± 7.4%，人工瓣膜置换术为73.4 ± 8.7%（p = 无显著差异）。Cox多因素分析显示，术前左心室射血分数（LVEF）≤30%（风险比3.91；95%置信区间 = 1.47 - 10.38）和术前肺动脉压（PAP）≥35 mmHg（风险比2.74；95%置信区间 = 1.07 - 7.02）是晚期生存的独立危险因素，而二尖瓣手术类型并无显著影响。以瓣环扩张为反流机制的患者接受修复术而非人工瓣膜置换术的可能性显著更高。他们术前的LVEF和PAP明显比以瓣叶运动改变为反流机制的患者更差。