Micovic Slobodan, Milacic Petar, Otasevic Petar, Tasic Nebojsa, Boskovic Srdjan, Nezic D, Djukanovic B
Cardiac Surgery Department and Echocardiography Cabinet, Cardiology Department, Cardiovascular Institute Dedinje, Belgrade, Serbia.
Heart Surg Forum. 2008 Dec;11(6):E340-5. doi: 10.1532/HSF98.20081087.
Mitral incompetence is a chronic sequela of myocardial infarction. It is caused by apical displacement and tethering of the mitral valve leaflets after myocardial infarction, resulting in incomplete coaptation. The consensus is for mitral valve surgery in the presence of significant ischemic mitral regurgitation (IMR). Previously, the only option was mitral valve replacement (MVR) with a mechanical or tissue valve. The suboptimal results obtained prompted the development of several methods of mitral valve repair. Today, the most commonly used repair is undersized annuloplasty.
We conducted a retrospective nonrandomized study of all patients who underwent operation for coronary artery disease and IMR between 2000 and 2006. The surgeon chose the surgical method used for the mitral valve procedure. The most commonly used procedures were restrictive mitral valve annuloplasty (MVP) and MVR with a mechanical prosthesis. We collected all pertinent preoperative, intraoperative, and early-postoperative data. We followed up with phone interviews of the patients and their relatives and with complete clinical and echocardiography examinations.
We carried out operations on 138 patients during the study period (MVR, 52 patients; MVP, 86 patients). The 2 groups had comparable demographic data and risk factors. The 2 groups were significantly different with respect to mean (+/-SD) New York Heart Association (NYHA) class (MVP, 2.72 +/- 0.62; MVR, 2.48 +/- 0.70; P < .01) and ejection fraction (MVP, 29.01% +/- 11.00%; MVR, 35.87% +/- 11.00%; P </= .01). The 30-day mortality rates for the MVR and MVP groups were significantly different (9.61% and 5.81%, respectively; P < .01). Our follow-up included 83% of the patients and continued for up to 84 months. The 2 groups showed no significant difference in mortality by the end of follow-up; however, the MVR patients had a better ejection fraction (37.79% versus 29.86%) and NYHA functional class (1.88 +/- 0.498 versus 2.36 +/- 0.564; P < .01).
Correcting chronic IMR with either repair or replacement produces a good mid-term survival rate (approximately 75%) for survivors in NYHA classes I and II. In our study, mortality rates for the MVP and MVR groups were similar, even though the repair group had a lower mean ejection fraction and a higher NYHA class before and after the operation. We therefore conclude that repair is superior to replacement in treating ischemic mitral insufficiency. A prospective randomized study is needed to better compare these 2 approaches.
二尖瓣反流是心肌梗死的慢性后遗症。它是由心肌梗死后二尖瓣叶的心尖移位和牵拉引起的，导致瓣叶不能完全对合。对于存在严重缺血性二尖瓣反流（IMR）的患者，目前的共识是进行二尖瓣手术。以前，唯一的选择是使用机械瓣或组织瓣进行二尖瓣置换术（MVR）。所获得的不理想结果促使人们开发了几种二尖瓣修复方法。如今，最常用的修复方法是小环缩窄成形术。
我们对2000年至2006年间接受冠状动脉疾病和IMR手术的所有患者进行了一项回顾性非随机研究。外科医生选择用于二尖瓣手术的手术方法。最常用的手术方法是限制性二尖瓣环缩窄成形术（MVP）和使用机械假体的MVR。我们收集了所有相关的术前、术中和术后早期数据。我们通过电话采访患者及其亲属，并进行完整的临床和超声心动图检查进行随访。
在研究期间，我们对138例患者进行了手术（MVR组52例；MVP组86例）。两组的人口统计学数据和危险因素具有可比性。两组在平均（±标准差）纽约心脏协会（NYHA）分级（MVP组，2.72±0.62；MVR组，2.48±0.70；P<.01）和射血分数（MVP组，29.01%±11.00%；MVR组，35.87%±11.00%；P≤.01）方面存在显著差异。MVR组和MVP组的30天死亡率有显著差异（分别为9.61%和5.81%；P<.01）。我们的随访包括83%的患者，并持续了长达84个月。随访结束时，两组在死亡率方面无显著差异；然而，MVR组患者的射血分数更好（37.79%对29.86%），NYHA功能分级更好（1.88±0.498对2.36±0.564；P<.01）。
对于纽约心脏协会I级和II级的心衰患者，通过修复或置换纠正慢性IMR可使中期生存率良好（约75%）。在我们的研究中，如果不考虑手术前和手术后的平均射血分数较低和NYHA分级较高，MVP组和MVR组的死亡率相似。因此，我们得出结论，在治疗缺血性二尖瓣关闭不全方面，修复优于置换。需要进行一项前瞻性随机研究以更好地比较这两种方法。
