Gelsomino Sandro, Lorusso Roberto, De Cicco Giuseppe, Capecchi Irene, Rostagno Carlo, Caciolli Sabina, Romagnoli Stefano, Da Broi Ugo, Stefàno Pierluigi, Gensini Gian Franco
Department of Heart and Vessels, Careggi HospitalViale Morgagni 85, 50134 Florence, Italy.
Eur Heart J. 2008 Jan;29(2):231-40. doi: 10.1093/eurheartj/ehm468. Epub 2007 Nov 7.
We present 5-year echocardiographic results of combined undersizing mitral ring annuloplasty (UMRA) and coronary artery bypass grafting (CABG) in chronic ischaemic mitral regurgitation (CIMR).
Two hundred and fifty-one patients (aged 68.4 +/- 8.1, 62.5% male) undergoing combined CABG and UMRA in our Institution (Cardiac Surgery, Careggi Hospital, Florence, Italy) between September 2001 and March 2007 were prospectively enrolled in the study. Median follow up was 32.9 months [interquartile range (IQR) 17.5-51.6]. Fourteen patients with significant residual mitral regurgitation (MR) needing immediate intraoperative revision (n = 3) or at discharge (n = 11) were excluded from the study. Serial echocardiograms were performed in 220 survivors at baseline, discharge, and annually thereafter. Additionally, 17 patients died (2 early and 15 late deaths) and were also excluded from the study. MR remained stable at 1 year and re-increased at 3 years (P < 0.001) and 5 years (P < 0.001). Five-year actuarial survival was 83.2 +/- 4.4. Five-year freedom from re-operation for failed repair was 78.2 +/- 4.9%. Mean systolic and diastolic diameters decreased significantly at discharge (P = 0.001 and P = 0.01, respectively) and at early follow up (P = 0.004 and P = 0.02) but raised at 3 years (P < 0.001) and 5 years (P < 0.001). Systolic and diastolic sphericity indexes improved at discharge (P < 0.001) remained stable at 1 year but they re-increased at 3-year control (P = 0.006 and P = 0.03, respectively) with a late raise exceeding the pre-operative value (P < 0.001). Left ventricular reverse remodelling was observed in 44.2% of the study population with 10.3% of patients showing further left ventricular dilatation. At multivariable model, end-systolic volume > or =145 mL, systolic sphericity index > or =0.7, myocardial performance index > or =0.9, and wall motion score index > or =1.5 were predictors of recurrent MR.
Our findings emphasize the need for improved repair technique and better patient selection to identify patients with anticipated repair failure who could benefit more from valve replacement or other procedure directly addressing ventricular tethering.
我们展示了慢性缺血性二尖瓣反流（CIMR）患者行联合小尺寸二尖瓣环成形术（UMRA）及冠状动脉旁路移植术（CABG）的5年超声心动图结果。
2001年9月至2007年3月期间，在我们机构（意大利佛罗伦萨卡雷吉医院心脏外科）接受CABG和UMRA联合手术的251例患者（年龄68.4±8.1岁，62.5%为男性）被前瞻性纳入研究。中位随访时间为32.9个月[四分位间距（IQR）17.5 - 51.6]。14例有严重残余二尖瓣反流（MR）需要术中立即修正（n = 3）或出院时修正（n = 11）的患者被排除在研究之外。对220例幸存者在基线、出院时及此后每年进行系列超声心动图检查。另外，17例患者死亡（2例早期死亡和15例晚期死亡），也被排除在研究之外。MR在1年时保持稳定，在3年（P < 0.001）和5年（P < 0.001）时再次增加。5年精算生存率为83.2±4.4。5年免于因修复失败再次手术的比例为78.2±4.9%。平均收缩期和舒张期直径在出院时（分别为P = 0.001和P = 0.01）及早期随访时显著减小（P = 0.004和P = 0.02），但在3年（P < 0.001）和5年（P < 0.001）时增大。收缩期和舒张期球形指数在出院时改善（P < 0.001），在1年时保持稳定，但在3年复查时再次增加（分别为P = 0.006和P = 0.03），后期升高超过术前值（P < 0.001）。44.2%的研究人群观察到左心室逆向重构，10.3%的患者出现进一步的左心室扩张。在多变量模型中，收缩末期容积≥145 mL、收缩期球形指数≥0.7、心肌性能指数≥0.9和壁运动评分指数≥1.5是复发性MR的预测因素。
我们的研究结果强调需要改进修复技术并更好地选择患者，以识别那些预期修复失败且可能从瓣膜置换或其他直接解决心室束缚问题的手术中获益更多的患者。
