Duke University Medical Center, Durham, North Carolina 27710, USA.
Ann Thorac Surg. 2009 Dec;88(6):1828-37. doi: 10.1016/j.athoracsur.2009.08.008.
Recent advances in surgical technique allow repair of most mitral valves with degenerative disease. However, few long-term data exist to support the superiority of repair versus prosthetic valve replacement, and repair could be limited by late durability or other problems. This study was designed to compare survival characteristics of mitral valve repair versus prosthetic replacement for degenerative disorders during a 20-year period.
From 1986 to 2006, 2,580 patients underwent isolated mitral valve procedures (with or without coronary artery bypass grafting), with 989 classified as having degenerative origin. Of these, 705 received valve repair, and 284 had prosthetic valve replacement. Differences in baseline characteristics between groups were assessed, and unadjusted survival estimates were generated using Kaplan-Meier methods. Survival curves were examined after adjustment for differences in baseline profiles using a Cox model, and average adjusted survival differences were quantified by area under the curve methodology. Survival differences during 15 years of follow-up also were assessed with propensity matching.
Baseline characteristics were similar, except for (variable: repair, replacement) age: 62 years, 68 years; concomitant coronary artery bypass grafting: 24%, 32%; ejection fraction: 0.51, 0.55; congestive heart failure: 68%, 43%; and preoperative arrhythmia: 11%, 7% (all p < 0.05). Long-term survival was significantly better in the repair group, both for unadjusted data (p < 0.001) and for risk-adjusted results (p = 0.040). Patient survival in the course of 15 years averaged 7.3% better with repair, and increased with time of follow-up: 0.7% better for 0 to 5 years, 4.9% better for 5 to 10 years, and 21.3% better for 10 to 15 years. Treatment interaction between repair or replacement and age was negative (p = 0.66). In the propensity analysis, survival advantages of repair versus replacement were similar in magnitude with a p value of 0.046.
As compared with prosthetic valve replacement, mitral repair is associated with better survival in patients with degenerative disease, especially after 10 to 15 years. This finding supports the current trend of increasing repair rates for degenerative disorders of the mitral valve.
最近外科技术的进步使得大多数退行性二尖瓣疾病可以通过修复来治疗。然而，支持修复优于人工瓣膜置换术的长期数据很少，而且修复可能会受到晚期耐久性或其他问题的限制。本研究旨在比较 20 年内退行性病变患者二尖瓣修复与人工瓣膜置换的生存特征。
1986 年至 2006 年，2580 例患者接受了单纯二尖瓣手术（伴或不伴冠状动脉旁路移植术），其中 989 例为退行性起源。其中，705 例接受了瓣膜修复，284 例接受了人工瓣膜置换。评估了两组间基线特征的差异，并使用 Kaplan-Meier 方法生成未经调整的生存估计值。使用 Cox 模型调整基线特征差异后，检查生存曲线，并通过曲线下面积方法量化平均调整后的生存差异。在 15 年的随访期间还使用倾向匹配评估了生存差异。
基线特征相似，但（变量：修复、置换）年龄不同：62 岁，68 岁；伴冠状动脉旁路移植术不同：24%，32%；射血分数不同：0.51，0.55；充血性心力衰竭不同：68%，43%；术前心律失常不同：11%，7%（均 p<0.05）。修复组的长期生存率明显更好，未经调整的数据（p<0.001）和风险调整结果（p=0.040）均如此。在 15 年的随访过程中，修复组的患者平均生存质量提高了 7.3%，并且随着随访时间的延长而增加：0 至 5 年提高 0.7%，5 至 10 年提高 4.9%，10 至 15 年提高 21.3%。修复或置换与年龄之间的治疗相互作用为负（p=0.66）。在倾向分析中，修复与置换相比，修复的生存优势在统计学上具有相似的意义（p=0.046）。
与人工瓣膜置换相比，退行性二尖瓣疾病患者的二尖瓣修复与更好的生存率相关，尤其是在 10 至 15 年后。这一发现支持目前退行性二尖瓣疾病修复率增加的趋势。
