Tribouilloy Christophe, Grigioni Francesco, Avierinos Jean François, Barbieri Andrea, Rusinaru Dan, Szymanski Catherine, Ferlito Marinella, Tafanelli Laurence, Bursi Francesca, Trojette Faouzi, Branzi Angelo, Habib Gilbert, Modena Maria G, Enriquez-Sarano Maurice
Department of Cardiology, INSERM, ERI 12, and University Hospital, Amiens, France.
J Am Coll Cardiol. 2009 Nov 17;54(21):1961-8. doi: 10.1016/j.jacc.2009.06.047.
This study analyzed the association of left ventricular end-systolic diameter (LVESD) with survival after diagnosis in organic mitral regurgitation (MR) due to flail leaflets.
LVESD is a marker of left ventricular function in patients with organic MR but its association to survival after diagnosis is unknown.
The MIDA (Mitral Regurgitation International Database) registry is a multicenter registry of echocardiographically diagnosed organic MR due to flail leaflets. We enrolled 739 patients with MR due to flail leaflets (age 65 +/- 12 years; ejection fraction: 65 +/- 10%) in whom LVESD was measured (36 +/- 7 mm).
Under conservative management, 10-year survival and survival free of cardiac death were higher with LVESD <40 mm versus > or =40 mm (64 +/- 5% vs. 48 +/- 10%; p < 0.001, and 73 +/- 5% vs. 63 +/- 10%; p = 0.001). LVESD > or =40 mm independently predicted overall mortality (hazard ratio [HR]: 1.95, 95% confidence interval [CI]: 1.01 to 3.83) and cardiac mortality (HR: 3.09, 95% CI: 1.35 to 7.09) under conservative management. Mortality risk increased linearly with LVESD >40 mm (HR: 1.15, 95% CI: 1.04 to 1.27 per 1-mm increment). During the entire follow-up (including post-surgical), LVESD > or =40 mm independently predicted overall mortality (HR: 1.86, 95% CI: 1.24 to 2.80) and cardiac mortality (HR: 2.14, 95% CI: 1.29 to 3.56), due to persistence of excess mortality in patients with LVESD > or =40 mm after surgery (HR: 1.86, 95% CI: 1.11 to 3.15 for overall death, and HR: 1.81, 95% CI: 1.05 to 3.54 for cardiac death).
In MR due to flail leaflets, LVESD > or =40 mm is independently associated with increased mortality under medical management but also after mitral surgery. These findings support prompt surgical rescue in patients with LVESD > or =40 mm but also suggest that best preservation of survival is achieved in patients operated before LVESD reaches 40 mm.
本研究分析了连枷样瓣叶所致器质性二尖瓣反流（MR）患者左心室收缩末期内径（LVESD）与诊断后生存率之间的关联。
LVESD是器质性MR患者左心室功能的一个指标，但其与诊断后生存率的关联尚不清楚。
二尖瓣反流国际数据库（MIDA）登记处是一个对经超声心动图诊断为连枷样瓣叶所致器质性MR的多中心登记处。我们纳入了739例连枷样瓣叶所致MR患者（年龄65±12岁；射血分数：65±10%），并测量了其LVESD（36±7mm）。
在保守治疗下，LVESD<40mm患者的10年生存率和无心脏死亡生存率高于LVESD≥40mm患者（64±5%对48±10%；p<0.001，以及73±5%对63±10%；p=0.001）。在保守治疗下，LVESD≥40mm独立预测总死亡率（风险比[HR]：1.95，95%置信区间[CI]：1.01至3.83）和心脏死亡率（HR：3.09，95%CI：1.35至7.09）。LVESD>40mm时，死亡风险随LVESD增加呈线性上升（HR：1.15，95%CI：1.04至1.27，每增加1mm）。在整个随访期间（包括手术后），LVESD≥40mm独立预测总死亡率（HR：1.86，95%CI：1.24至2.80）和心脏死亡率（HR：2.14，95%CI：1.29至3.56），这是由于LVESD≥40mm的患者术后仍存在过高死亡率（总死亡HR：1.86，95%CI：1.11至3.15；心脏死亡HR：1.81，95%CI：1.05至3.54）。
在连枷样瓣叶所致MR中，LVESD≥40mm在药物治疗和二尖瓣手术后均独立与死亡率增加相关。这些发现支持对LVESD≥40mm的患者尽早进行手术挽救，但也表明在LVESD达到40mm之前进行手术的患者生存率最佳。
