缺血性二尖瓣反流单纯冠状动脉旁路移植术后的远期结果。
Late outcomes after isolated coronary artery bypass grafting for ischemic mitral regurgitation.
作者信息
Fukushima Satsuki, Kobayashi Junjiro, Bando Ko, Niwaya Kazuo, Tagusari Osamu, Nakajima Hiroyuki, Kitamura Soichiro
机构信息
Department of Cardiovascular Surgery, National Cardiovascular Center, Suita, Osaka, Japan.
出版信息
Jpn J Thorac Cardiovasc Surg. 2005 Jul;53(7):354-60. doi: 10.1007/s11748-005-0049-z.
OBJECTIVES
Although ischemic mitral regurgitation (IMR) is one of the most important issues to determine therapeutic strategy for ischemic heart disease, long-term outcome after coronary artery bypass grafting (CABG) for IMR is still unclear. It is also controversial how patients who would benefit from mitral valve (MV) surgery in combination with CABG should be identified. The purpose of this study is to elucidate late outcomes after isolated CABG for moderate IMR and to assess the indication of combined MV surgery.
METHODS
Two hundred and seventy-nine patients who had grade 2 or 3 IMR preoperatively and underwent isolated CABG between 1980 and 2002 in our institute were enrolled. Mitral regurgitation was assessed by 2-dimensional Doppler echocardiography and left ventriculography. Among them, 84 patients (30.1%) had left ventricular ejection fraction (LVEF) less than 30% and 186 patients (66.7%) had prior inferior myocardial infarction (MI).
RESULTS
One hundred and twenty-nine patients (46.2%) remained grade 2 or greater MR early postoperatively. Actuarial survival and freedom from cardiac events, analyzed by the Kaplan-Meier method, were 90.9% and 87.7% at 1 year, 79.2% and 68.8% at 5 years, 54.9% and 49.1% at 10 years and 48.8% and 18.9% at 15 years. Independent predictive risk factors for cardiac events, analyzed by multivariate analysis using the Cox proportional hazard model, were grade 2 or greater MR which remained early postoperatively (p = 0.0002), LVEF < 30% preoperatively (p = 0.0006), no inferior MI preoperatively (p = 0.007) and no internal thoracic artery-left anterior descending artery graft (p = 0.049). More than a 15% decrease in LVEF at more than 3 years after the operation was seen despite patent bypass grafts in 17.2% of patients who received a late follow-up catheterization, although 41.4% of patients showed an increase or less than 5% decrease in LVEF during this period.
CONCLUSION
Combined MV surgery with CABG for IMR should be considered in patients with poor LVEF or without prior inferior MI.
目的
虽然缺血性二尖瓣反流（IMR）是确定缺血性心脏病治疗策略时最重要的问题之一，但冠状动脉旁路移植术（CABG）治疗IMR后的长期预后仍不明确。对于哪些患者能从二尖瓣（MV）手术联合CABG中获益也存在争议。本研究的目的是阐明单纯CABG治疗中度IMR后的晚期预后，并评估联合MV手术的指征。
方法
纳入279例术前有2级或3级IMR且于1980年至2002年在我院接受单纯CABG的患者。通过二维多普勒超声心动图和左心室造影评估二尖瓣反流。其中，84例患者（30.1%）左心室射血分数（LVEF）低于30%，186例患者（66.7%）有既往下壁心肌梗死（MI）。
结果
129例患者（46.2%）术后早期仍有2级或更严重的二尖瓣反流。采用Kaplan-Meier法分析，1年时的精算生存率和无心脏事件生存率分别为90.9%和87.7%，5年时为79.2%和68.8%，10年时为54.9%和49.1%，15年时为48.8%和18.9%。使用Cox比例风险模型进行多变量分析，心脏事件的独立预测风险因素为术后早期仍存在2级或更严重的二尖瓣反流（p = 0.0002）、术前LVEF < 30%（p = 0.0006）、术前无下壁MI（p = 0.007）以及无胸廓内动脉-左前降支动脉搭桥（p = 0.049）。在接受晚期随访导管检查的患者中，尽管旁路移植血管通畅，但17.2%的患者术后3年以上LVEF下降超过15%，不过在此期间41.4%的患者LVEF升高或下降少于5%。
结论
对于LVEF较差或无既往下壁MI的IMR患者，应考虑MV手术联合CABG。
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