Kim Yong-Hwan, Czer Lawrence S C, Soukiasian Harmik J, De Robertis Michele, Magliato Kathy E, Blanche Carlos, Raissi Sharo S, Mirocha James, Siegel Robert J, Kass Robert M, Trento Alfredo
Division of Cardiothoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California 90048-1865, USA.
Ann Thorac Surg. 2005 Jun;79(6):1895-901. doi: 10.1016/j.athoracsur.2004.11.005.
In this study we compared the surgical management of ischemic mitral regurgitation (IMR) by revascularization alone and by revascularization combined with mitral valve repair.
We studied 355 patients who underwent revascularization alone (n = 168) or revascularization combined with mitral valve repair (n = 187) for IMR from March 1994 to September 2003. Preoperative and operative characteristics, postoperative mitral regurgitation severity, operative mortality, and late survival were examined for each surgical group.
No differences were noted between the two groups in age, sex, history of diabetes or hypertension, and number of bypass grafts. The combined surgical group had a lower preoperative left ventricular ejection fraction (0.38 +/- 0.14 versus 0.44 +/- 0.15), greater severity of IMR, higher frequency of prior myocardial infarction, and longer cross-clamp and pump times (p < 0.01). The combined surgical group had a greater reduction in IMR grade (2.7 +/- 0.1 grades versus 0.2 +/- 0.1 grade), a lower postoperative IMR grade (0.9 +/- 0.1 versus 2.3 +/- 0.1), and a higher success with reduction of IMR by two or more grades (89% versus 11%) (p < 0.001). In patients with 3+ or 4+ IMR, both groups had similar operative mortality (11.0% in the combined group compared with 4.7% for revascularization alone, p = 0.11) and actuarial survival at 5 years (44% +/- 5% versus 41% +/- 7%, p = 0.53). Independently predictive of higher early mortality (< or = 30 days) by Cox analysis were longer pump time (p < 0.001) and older age (p < 0.02). Predictive of late mortality (> 30 days) were older age (p < 0.001), fewer bypass grafts (p < 0.01), and lower ejection fraction (p < 0.01). After adjustment for these variables, there was a trend (p = 0.08) toward a higher late survival with the combined surgical procedure.
In patients with IMR, combined mitral valve repair and revascularization resulted in less postoperative mitral regurgitation and similar 5-year survival when compared with revascularization alone. Attempts to reduce pump time by using off-pump techniques may reduce early mortality in these high-risk patients.
在本研究中，我们比较了单纯血运重建与血运重建联合二尖瓣修复治疗缺血性二尖瓣反流（IMR）的手术管理方法。
我们研究了1994年3月至2003年9月期间因IMR接受单纯血运重建（n = 168）或血运重建联合二尖瓣修复（n = 187）的355例患者。对每个手术组的术前和手术特征、术后二尖瓣反流严重程度、手术死亡率和晚期生存率进行了检查。
两组在年龄、性别、糖尿病或高血压病史以及旁路移植数量方面没有差异。联合手术组术前左心室射血分数较低（0.38±0.14对0.44±0.15），IMR严重程度更高，既往心肌梗死发生率更高，体外循环和泵血时间更长（p < 0.01）。联合手术组IMR分级降低幅度更大（2.7±0.1级对0.2±0.1级），术后IMR分级更低（0.9±0.1对2.3±0.1），IMR降低两级或更多级的成功率更高（89%对11%）（p < 0.001）。在IMR为3+或4+的患者中，两组的手术死亡率相似（联合组为11.0%，单纯血运重建组为4.7%，p = 0.11），5年精算生存率也相似（44%±5%对41%±7%，p = 0.53）。Cox分析独立预测早期死亡率较高（≤30天）的因素是泵血时间较长（p < 0.001）和年龄较大（p < 0.02）。预测晚期死亡率（> 30天）的因素是年龄较大（p < 0.001）、旁路移植数量较少（p < 0.01）和射血分数较低（p < 0.01）。在对这些变量进行调整后，联合手术方法的晚期生存率有升高趋势（p = 0.08）。
在IMR患者中，与单纯血运重建相比，二尖瓣修复联合血运重建术后二尖瓣反流更少，5年生存率相似。尝试使用非体外循环技术减少泵血时间可能会降低这些高危患者的早期死亡率。
