非缺血性功能性二尖瓣反流的二尖瓣瓣环成形术的选择性治疗算法。

Section of Cardiac Surgery, Chang Gung Institute of Technology, Chia-Yi, Taoyuan, Taiwan.

J Card Fail. 2009 May;15(4):341-6. doi: 10.1016/j.cardfail.2008.11.004. Epub 2008 Dec 23.

BACKGROUND

The success rate of mitral annuloplasty (MA) for functional mitral regurgitation (FMR) varies. This study evaluated the effectiveness of this procedure in nonischemic dilated cardiomyopathy (DCM) patients after a selective treatment protocol was followed.

METHODS AND RESULTS

This study analyzed 42 patients with nonischemic DCM and FMR (mean regurgitation grade, 3.6 +/- 0.3), aged a mean 56.5 +/- 15 years (range, 25 to 78 years), who underwent MA from April 2003 to December 2007. The analysis excluded patients with coronary artery disease, or mitral leaflets or subvalvular pathologies. All patients had taken maximal medications for at least 3 months and were still in New York Heart Association (NYHA) functional class III to IV (mean, 3.2 +/- 0.4). Mean ejection fraction (EF) was 31.4% +/- 12.9% (range, 8% to 58%), and left ventricular end-diastolic diameter (LVEDD) was 66.0 +/- 8.3 mm (range, 55 to 85 mm). Downsized Carpentier Physio ring (Carpentier-Edwards, Irvine, California) annuloplasty, mean size 26.3 +/- 2.3 (range, 24 to 30), was the preferred procedure. Concomitant procedures included 23 tricuspid valve repairs and 10 Maze operations for atrial fibrillation. Echocardiography was performed at early (<or=3 months; mean 1.6 +/- 1.5), short-term (6 to 12 months; mean 6.9 +/- 3.4), and midterm (>12 months; mean 29.5 +/- 13.4 months) follow-up. All late deaths and readmissions were recorded. One (2.4%) in-hospital death occurred due to low cardiac output. Follow-up was completed in 40 of 41 (97.6%) patients (mean duration, 31.9 +/- 16.1; range, 3.9 to 59.2 months). Eight (19.5%) patients were readmitted for heart failure, including 2 late MRs due to ring dehiscence and infective endocarditis. Three of 5 deaths during the follow-up period were attributed to cardiac death. Actuarial survival after 1 and 3 years was 88.9% and 79.2%, respectively. The number of patients treated with beta-blockers increased after operation, from 52.4% to 75.6% (P = .028). NYHA class decreased from 3.2 +/- 0.4 to 1.3 +/- 0.6 (P < .0001). Echo examination revealed left heart reverse remodeling and improved performance in all follow-up time frames.

CONCLUSION

This study shows that MA in patients with non-ischemic DCM and FMR is feasible and associated with reasonable short and long term outcomes.

背景

二尖瓣环成形术（MA）治疗功能性二尖瓣反流（FMR）的成功率存在差异。本研究评估了在遵循选择性治疗方案后，该术式在非缺血性扩张型心肌病（DCM）患者中的疗效。

方法和结果

本研究分析了 2003 年 4 月至 2007 年 12 月期间接受 MA 的 42 例非缺血性 DCM 合并 FMR（平均反流分级 3.6+/-0.3）患者。患者平均年龄为 56.5+/-15 岁（年龄范围 25 至 78 岁）。排除了患有冠状动脉疾病、二尖瓣叶或瓣下病变的患者。所有患者均至少接受了 3 个月的最大剂量药物治疗，且仍处于纽约心脏协会（NYHA）心功能 III 至 IV 级（平均 3.2+/-0.4）。平均射血分数（EF）为 31.4%+/-12.9%（范围 8%至 58%），左心室舒张末期直径（LVEDD）为 66.0+/-8.3mm（范围 55 至 85mm）。首选的手术方式为 Carpentier-Edwards 公司的小号 Carpentier Physio 环（Carpentier-Edwards，加利福尼亚州欧文）成形术，平均大小为 26.3+/-2.3（范围 24 至 30）。同时进行了 23 例三尖瓣修复和 10 例房颤迷宫手术。早期（<或=3 个月；平均 1.6+/-1.5 个月）、短期（6 至 12 个月；平均 6.9+/-3.4 个月）和中期（>12 个月；平均 29.5+/-13.4 个月）随访时均进行了超声心动图检查。记录了所有晚期死亡和再入院的情况。1 例（2.4%）患者院内死亡归因于低心输出量。41 例患者中的 40 例（97.6%）完成了随访（平均随访时间 31.9+/-16.1；范围 3.9 至 59.2 个月）。8 例（19.5%）患者因心力衰竭再次入院，其中 2 例因环裂开和感染性心内膜炎导致晚期 MR。5 例死亡中有 3 例归因于心脏原因。术后 1 年和 3 年的存活率分别为 88.9%和 79.2%。术后β受体阻滞剂的使用比例从 52.4%增加到 75.6%（P=0.028）。NYHA 心功能分级从 3.2+/-0.4 降至 1.3+/-0.6（P<0.0001）。超声心动图显示左心逆重构，所有随访时间点的左心功能均得到改善。