Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland, OH 44195, USA.
Ann Thorac Surg. 2010 Aug;90(2):481-8. doi: 10.1016/j.athoracsur.2010.03.101.
The American College of Cardiology/American Heart Association practice guidelines recommending surgery for asymptomatic patients with severe mitral regurgitation caused by degenerative disease remain controversial. This study examined whether delaying surgery until symptoms occur causes adverse cardiac changes and jeopardizes outcome.
From January 1985 to January 2008, 4,586 patients had primary isolated mitral valve surgery for degenerative mitral regurgitation; 4,253 (93%) underwent repair. Preoperatively, 30% were in New York Heart Association (NYHA) class I (asymptomatic), 56% in class II, 13% in class III, and 2% in class IV. Multivariable analysis and propensity matching were used to assess association of symptoms (NYHA class) with cardiac structure and function and postoperative outcomes.
Increasing NYHA class was associated with progressive reduction in left ventricular function, left atrial enlargement, and development of atrial fibrillation and tricuspid regurgitation. These findings were evident even in class II patients (mild symptoms). Repair was accomplished in 96% of asymptomatic patients, and in progressively fewer as NYHA class increased (93%, 86%, and 85% in classes II to IV, respectively; p < 0.0001). Hospital mortality was 0.37%, but was particularly high in class IV (0.29%, 0.20%, 0.67%, and 5.1% for classes I to IV, respectively; p = 0.004). Although long-term survival progressively diminished with increasing NHYA class, these differences were largely related to differences in left ventricular function and increased comorbidity.
In patients with severe degenerative mitral regurgitation, the development of even mild symptoms by the time of surgical referral is associated with deleterious changes in cardiac structure and function. Therefore, particularly because successful repair is highly likely, early surgery is justified in asymptomatic patients with degenerative disease and severe mitral regurgitation.
美国心脏病学会/美国心脏协会的实践指南建议对退行性疾病引起的无症状严重二尖瓣反流患者进行手术，但这一建议仍存在争议。本研究旨在探讨无症状患者延迟手术时机直至出现症状是否会导致心脏不良变化并危及预后。
1985 年 1 月至 2008 年 1 月，共有 4586 例患者因退行性二尖瓣反流行单纯二尖瓣手术，其中 4253 例（93%）接受了修复术。术前，30%的患者为纽约心脏协会（NYHA）心功能分级 I 级（无症状），56%为 II 级，13%为 III 级，2%为 IV 级。采用多变量分析和倾向匹配评估症状（NYHA 心功能分级）与心脏结构和功能及术后结局的相关性。
随着 NYHA 心功能分级的增加，左心室功能逐渐下降，左心房扩大，房颤和三尖瓣反流的发生率也逐渐增加。即使在 II 级患者（轻度症状）中也能观察到这些发现。无症状患者的修复率达到 96%，而随着 NYHA 心功能分级的增加，修复率逐渐降低（分别为 II 级、III 级和 IV 级 93%、86%和 85%；p<0.0001）。院内死亡率为 0.37%，但在 IV 级患者中较高（分别为 I 级至 IV 级 0.29%、0.20%、0.67%和 5.1%；p=0.004）。尽管随着 NYHA 心功能分级的增加，长期生存率逐渐降低，但这些差异主要与左心室功能的差异和合并症的增加有关。
在严重退行性二尖瓣反流患者中，即使在手术转诊时出现轻度症状，也与心脏结构和功能的有害变化相关。因此，对于退行性疾病和严重二尖瓣反流的无症状患者，尤其是由于成功修复的可能性较高，早期手术是合理的。
