Magne Julien, Mathieu Patrick, Dumesnil Jean G, Tanné David, Dagenais François, Doyle Daniel, Pibarot Philippe
Laval Hospital Research Center/Québec Heart Institute, Faculty of Medicine, Laval University, Québec, Canada.
Circulation. 2007 Mar 20;115(11):1417-25. doi: 10.1161/CIRCULATIONAHA.106.631549. Epub 2007 Mar 5.
We recently reported that valve prosthesis-patient mismatch (PPM) is associated with persisting pulmonary hypertension after mitral valve replacement. Thus, the objective of this study was to evaluate the impact of PPM on mortality in patients undergoing mitral valve replacement.
The indexed valve effective orifice area was estimated for each type and size of prosthesis being implanted in 929 consecutive patients and used to define PPM as not clinically significant if > 1.2 cm2/m2, as moderate if > 0.9 and < or = 1.2 cm2/m2, and as severe if < or = 0.9 cm2/m2. Moderate PPM was present in 69% of patients; severe PPM was seen in 9%. For patients with severe PPM, 6-year survival (74+/-5%) and 12-year survival (63+/-7%) were significantly less than for patients with moderate PPM (84+/-1% and 76+/-2%; P=0.027) or nonsignificant PPM (90+/-2% and 82+/-4%; P=0.002). On multivariate analysis, severe PPM was associated with higher mortality (hazard ratio, 3.2; 95% confidence interval, 1.5 to 6.8; P=0.003).
Severe PPM is an independent predictor of mortality after mitral valve replacement. As opposed to other independent risk factors, PPM may be avoided or its severity may be reduced with the use of a prospective strategy at the time of operation. For patients identified as being at risk for severe PPM, every effort should be made to implant a prosthesis with a larger effective orifice area.
我们最近报道，瓣膜假体-患者不匹配（PPM）与二尖瓣置换术后持续存在的肺动脉高压有关。因此，本研究的目的是评估PPM对二尖瓣置换患者死亡率的影响。
对929例连续患者植入的每种类型和尺寸的假体估计其指数化瓣膜有效开口面积，若>1.2 cm²/m²则定义PPM为无临床意义，若>0.9且≤1.2 cm²/m²则为中度，若≤0.9 cm²/m²则为重度。69%的患者存在中度PPM；9%的患者存在重度PPM。重度PPM患者的6年生存率（74±5%）和12年生存率（63±7%）显著低于中度PPM患者（84±1%和76±2%；P=0.027）或无显著PPM患者（90±2%和82±4%；P=0.002）。多因素分析显示，重度PPM与较高的死亡率相关（风险比，3.2；95%置信区间，1.5至6.8；P=0.003）。
重度PPM是二尖瓣置换术后死亡率的独立预测因素。与其他独立危险因素不同，PPM可通过手术时采用前瞻性策略避免或降低其严重程度。对于被确定有重度PPM风险的患者，应尽一切努力植入有效开口面积更大的假体。
