Enriquez-Sarano Maurice, Avierinos Jean-François, Messika-Zeitoun David, Detaint Delphine, Capps Maryann, Nkomo Vuyisile, Scott Christopher, Schaff Hartzell V, Tajik A Jamil
Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minn 55905, USA.
N Engl J Med. 2005 Mar 3;352(9):875-83. doi: 10.1056/NEJMoa041451.
The clinical outcome of asymptomatic mitral regurgitation is poorly defined, and the treatment is uncertain. We studied the effect on the outcome of quantifying mitral regurgitation according to recent guidelines.
We prospectively enrolled 456 patients (mean [+/-SD] age, 63+/-14 years; 63 percent men; ejection fraction, 70+/-8 percent) with asymptomatic organic mitral regurgitation, quantified according to current recommendations (regurgitant volume, 66+/-40 ml per beat; effective regurgitant orifice, 40+/-27 mm2).
The estimated five-year rates (+/-SE) of death from any cause, death from cardiac causes, and cardiac events (death from cardiac causes, heart failure, or new atrial fibrillation) with medical management were 22+/-3 percent, 14+/-3 percent, and 33+/-3 percent, respectively. Independent determinants of survival were increasing age, the presence of diabetes, and increasing effective regurgitant orifice (adjusted risk ratio per 10-mm2 increment, 1.18; 95 percent confidence interval, 1.06 to 1.30; P<0.01), the predictive power of which superseded all other qualitative and quantitative measures of regurgitation. Patients with an effective regurgitant orifice of at least 40 mm2 had a five-year survival rate that was lower than expected on the basis of U.S. Census data (58+/-9 percent vs. 78 percent, P=0.03). As compared with patients with a regurgitant orifice of less than 20 mm2, those with an orifice of at least 40 mm2 had an increased risk of death from any cause (adjusted risk ratio, 2.90; 95 percent confidence interval, 1.33 to 6.32; P<0.01), death from cardiac causes (adjusted risk ratio, 5.21; 95 percent confidence interval, 1.98 to 14.40; P<0.01), and cardiac events (adjusted risk ratio, 5.66; 95 percent confidence interval, 3.07 to 10.56; P<0.01). Cardiac surgery was ultimately performed in 232 patients and was independently associated with improved survival (adjusted risk ratio, 0.28; 95 percent confidence interval, 0.14 to 0.55; P<0.01).
Quantitative grading of mitral regurgitation is a powerful predictor of the clinical outcome of asymptomatic mitral regurgitation. Patients with an effective regurgitant orifice of at least 40 mm2 should promptly be considered for cardiac surgery.
无症状性二尖瓣反流的临床结局尚不明确，治疗方法也不确定。我们根据最新指南研究了二尖瓣反流定量对结局的影响。
我们前瞻性纳入了456例无症状性器质性二尖瓣反流患者（平均年龄[±标准差]为63±14岁；63%为男性；射血分数为70±8%），根据当前推荐方法进行定量评估（每搏反流容积为66±40 ml；有效反流口面积为40±27 mm²）。
药物治疗的患者中，估计的全因死亡、心源性死亡和心脏事件（心源性死亡、心力衰竭或新发心房颤动）的五年发生率（±标准误）分别为22±3%、14±3%和33±3%。生存的独立决定因素包括年龄增长、糖尿病的存在以及有效反流口面积增加（每增加10 mm²的调整风险比为1.18；95%置信区间为1.06至1.30；P<0.01），其预测能力超过了所有其他反流的定性和定量指标。有效反流口面积至少为40 mm²的患者的五年生存率低于根据美国人口普查数据预期的生存率（58±9%对78%，P=0.03）。与反流口面积小于20 mm²的患者相比，反流口面积至少为40 mm²的患者全因死亡风险增加（调整风险比为2.90；95%置信区间为1.33至6.32；P<0.01），心源性死亡风险增加（调整风险比为5.21；95%置信区间为1.98至14.40；P<0.01），心脏事件风险增加（调整风险比为5.66；95%置信区间为3.07至约10.56；P<0.01）。最终有232例患者接受了心脏手术，这与生存率提高独立相关（调整风险比为0.28；95%置信区间为0.14至0.55；P<0.01）。
二尖瓣反流的定量分级是无症状性二尖瓣反流临床结局的有力预测指标。有效反流口面积至少为40 mm²的患者应及时考虑接受心脏手术。
