重度肺动脉高压患者二尖瓣球囊成形术的近期及远期疗效

Immediate and long-term results of mitral balloon valvuloplasty in patients with severe pulmonary hypertension.

作者信息

Fawzy Mohamed Eid, Osman Adil, Nambiar Vijayaraghavan, Nowayhed Omar, El Dali Abdulmoniem, Badr Amr, Canver Charles C

机构信息

King Faisal Heart Institute, Riyadh, Saudi Arabia.

出版信息

J Heart Valve Dis. 2008 Sep;17(5):485-91.

PMID:18980082

Abstract

BACKGROUND AND AIM OF THE STUDY

Mitral stenosis (MS) with severe pulmonary hypertension (PHT) constitutes a high-risk subset for surgical commissurotomy or valve replacement. Mitral balloon valvuloplasty (MBV) has emerged as the treatment of choice for patients with severe pliable MS. The efficacy of this procedure in patients with severe PHT has not been fully elucidated, notably with regards to the long-term outcome.

METHODS

MBV was successfully performed in 531 consecutive patients. Of these patients, 82 (15%) had severe PHT at baseline (group A), defined as pulmonary artery systolic pressure (PASP) at rest > 60 mmHg, compared to the remaining 449 patients, who served as controls (group B).

RESULTS

Patients with PHT had a higher echo score and were more symptomatic, the majority (52.4%) having moderate to severe tricuspid regurgitation (TR). When comparing PHT with controls, the left atrial pressure was higher (28 +/- 4.9 versus 25.6 +/- 4.6 mmHg; p < 0.0001), the mean mitral gradient was similar (14.6 +/- 3.8 versus 14.4 +/- 2.1 mmHg; p = 0.30), the baseline mitral valve area (MVA) was smaller (0.72 +/- 0.17 versus 0.86 +/- 0.19 cm2; p < 0.0001), pulmonary vascular resistance was higher (612 +/- 343 versus 211 +/- 183 dyne/s/cm(-5); p < 0.0001), and post-procedure MVA was smaller (1.7 +/- 0.44 versus 1.85 +/- 0.54 cm2; p = 0.007). The PASP decreased significantly over 12 months after MBV, from 79 +/- 14 to 36.7 +/- 7.53 mmHg (p < 0.0001). Freedom from restenosis in PHT patients at 10 and 15 years, respectively, was 66 +/- 6% and 45 +/- 8% versus 78 +/- 2% and 47 +/- 3% in controls (p = 0.0066). Event-free survival at 10 and 15 years, respectively, was 77 +/- 6% and 41 +/- 11% in PHT patients versus 89 +/- 1% and 54 +/- 4% for controls (p = 0.0169). In total, 33 patients (40%) had moderate TR and 10 (12%) had severe TR at baseline. At follow up, only 12 patients had moderate TR and none had severe TR.

CONCLUSION

MBV is a safe and effective technique for treating patients with MS and severe PHT. Although the immediate results were comparable with those in controls, the long-term results proved to be slightly inferior, with a regression of PHT and concomitant severe TR.

摘要

研究背景与目的

二尖瓣狭窄（MS）合并严重肺动脉高压（PHT）是外科二尖瓣交界切开术或瓣膜置换术的高风险亚组。二尖瓣球囊瓣膜成形术（MBV）已成为重度柔韧性MS患者的首选治疗方法。该手术在重度PHT患者中的疗效尚未完全阐明，尤其是长期疗效。

方法

连续531例患者成功接受了MBV手术。其中82例（15%）患者基线时存在严重PHT（A组），定义为静息时肺动脉收缩压（PASP）>60 mmHg，其余449例患者作为对照组（B组）。

结果

PHT患者的超声心动图评分更高，症状更明显，大多数（52.4%）有中度至重度三尖瓣反流（TR）。与对照组相比，PHT患者的左心房压力更高（28±4.9 mmHg对25.6±4.6 mmHg；p<0.0001），平均二尖瓣压差相似（14.6±3.8 mmHg对14.4±2.1 mmHg；p = 0.30），基线二尖瓣瓣口面积（MVA）更小（0.72±0.17 cm²对0.86±0.19 cm²；p<0.0001），肺血管阻力更高（612±343对211±183达因/秒/厘米⁻⁵；p<0.0001），术后MVA更小（1.7±0.44 cm²对1.85±0.54 cm²；p = 0.007）。MBV术后12个月内PASP显著下降，从79±14 mmHg降至36.7±7.53 mmHg（p<0.0001）。PHT患者10年和15年无再狭窄生存率分别为66±6%和45±8%，而对照组分别为78±2%和47±3%（p = 0.0066）。PHT患者10年和15年无事件生存率分别为77±6%和41±11%，对照组分别为89±1%和54±4%（p = 0.0169）。共有33例患者（40%）基线时有中度TR，10例（12%）有重度TR。随访时，只有12例患者有中度TR，无重度TR患者。