Russo Antonio, Grigioni Francesco, Avierinos Jean-François, Freeman William K, Suri Rakesh, Michelena Hector, Brown Robert, Sundt Thoralf M, Enriquez-Sarano Maurice
Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA.
J Am Coll Cardiol. 2008 Mar 25;51(12):1203-11. doi: 10.1016/j.jacc.2007.10.058.
We sought to define thromboembolic risk after surgery for mitral regurgitation (MR), particularly ischemic stroke (IS) compared with the general population.
Guidelines recommend surgery in asymptomatic patients with MR, but IS risks are unknown.
In 1,344 patients (age 65 +/- 12 years) consecutively operated for MR (procedures: 897 mitral valve repair [MRep] and 447 valve replacement: 231 mechanical mitral valve replacement [MVRm], 216 biological mitral valve replacement [MVRb]), thromboembolic complications, particularly IS (diagnosed by neurologists), during follow-up were assessed early (<30 days), midterm (30 to 180 days), and long-term (>or=180 days).
Ischemic stroke occurred in 130 patients: 1.9 +/- 0.4% and 2.7 +/- 0.5% at 30 days and 180 days, respectively, and 8.1 +/- 0.8% at 5 years. We found that IS rates were lowest after MRep versus MVRb and MVRm (6.1 +/- 0.9% vs. 8 +/- 2.1%, and 16.1 +/- 2.7% at 5 years, respectively, p < 0.001). Comparison with population-expected IS showed high risk at <30 days (risk ratio 41, 95% confidence interval 26 to 60, p < 0.001 but p > 0.10 between procedures) and moderate risk at >30 days (risk ratio 1.7 overall; 1.3 for MRep; 0.98 for MVRb; 4.8 for MVRm). Beyond 180 days, IS risk declined further and was similar to the population for MRep (relative risk 1.2) and for MVRb (relative risk 0.9). Bleeding risk >30 days was lowest in MRep versus MVRb and MVRm (10-year risk 7 +/- 1%, 14 +/- 4%, and 16 +/- 3%, respectively).
Thromboembolic complications after MR surgery are a reason for both concern and encouragement. The risk of IS is notable early, irrespective of procedure, but in the long term it is not greater than in the population after MRep and MVRb. Preference for MRep should be emphasized, and trials aiming at preventing IS should be conducted to reduce thromboembolic and hemorrhagic risk after surgery for MR.
我们试图明确二尖瓣反流（MR）手术后的血栓栓塞风险，特别是与普通人群相比的缺血性卒中（IS）风险。
指南推荐对无症状的MR患者进行手术，但IS风险尚不清楚。
对1344例连续接受MR手术的患者（年龄65±12岁）（手术方式：897例二尖瓣修复[MRep]和447例瓣膜置换：231例机械二尖瓣置换[MVRm]，216例生物二尖瓣置换[MVRb]），在随访期间评估早期（<30天）、中期（30至180天）和长期（≥180天）的血栓栓塞并发症，特别是IS（由神经科医生诊断）。
130例患者发生缺血性卒中：30天时为1.9±0.4%，180天时为2.7±0.5%，5年时为8.1±0.8%。我们发现MRep术后的IS发生率低于MVRb和MVRm（5年时分别为6.1±0.9%、8±2.1%和16.1±2.7%，p<0.001）。与人群预期的IS发生率相比，<30天时风险较高（风险比41，95%置信区间26至60，p<0.001，但各手术方式之间p>0.10），>30天时风险为中度（总体风险比1.7；MRep为1.3；MVRb为0.98；MVRm为4.8）。180天后，IS风险进一步下降，MRep（相对风险1.2）和MVRb（相对风险0.9）与人群相似。>30天的出血风险在MRep中低于MVRb和MVRm（10年风险分别为7±1%、14±4%和16±3%）。
MR手术后的血栓栓塞并发症既令人担忧又令人鼓舞。IS风险在早期显著，与手术方式无关，但从长期来看，MRep和MVRb术后并不高于普通人群。应强调优先选择MRep，并开展旨在预防IS的试验，以降低MR手术后的血栓栓塞和出血风险。
