Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY 10029, USA.
Eur Heart J. 2011 Mar;32(5):618-26. doi: 10.1093/eurheartj/ehq331. Epub 2010 Sep 16.
Feasibility and efficacy of mitral repair in the elderly remain controversial. This study aims to compare outcomes of mitral repair and replacement in octogenarians.
We compared the outcomes of 322 consecutive octogenarian patients (mean age 82.6 ± 2.2 years) who underwent mitral repair (n = 227, 70%) or replacement (n = 95, 30%) at Mount Sinai Medical Center and Leipzig Herzzentrum between 1998 and 2008 using propensity score adjustment and univariate and multivariate analyses. Patients undergoing aortic valve replacement were excluded. Coronary bypass was performed in 47.5% (n = 153), and 31.1% (n = 100) required tricuspid repair. Propensity score adjustment yielded comparable groups. Thirty-day mortality in patients undergoing primary elective mitral repair for degenerative disease was 5.1% (2/39). Overall 90-day mortality was 18.9% (43/227) for repair compared with 31.6% (30/95) for replacement (P = 0.014). Pre-discharge echocardiography revealed less than moderate residual regurgitation in 99% of patients (231/232). Adjusted 1-, 3-, and 5-year survival for patients undergoing mitral repair was 71 ± 3, 61 ± 4, and 59 ± 4%, respectively, compared with 56 ± 5, 50 ± 6, and 45 ± 6% for patients undergoing mitral replacement (P = 0.046). Multivariate analysis demonstrated emergency surgery, previous myocardial infarction, concomitant coronary artery bypass surgery, and mitral replacement to be strong independent predictors of early mortality; mitral valve replacement was an independent predictor of reduced survival in degenerative patients.
Elective mitral repair can be performed with low operative mortality and good long-term outcomes in selected octogenarians with degenerative mitral disease, and is associated with better long-term survival than mitral replacement. The survival benefit associated with surgery for non-degenerative disease is more questionable.
二尖瓣修复在老年人中的可行性和疗效仍存在争议。本研究旨在比较 80 岁以上患者行二尖瓣修复和置换的结果。
我们比较了 1998 年至 2008 年期间在西奈山医疗中心和莱比锡心脏中心接受二尖瓣修复（n = 227，70%）或置换（n = 95，30%）的 322 例连续 80 岁以上患者的结果，使用倾向评分调整和单变量及多变量分析。排除行主动脉瓣置换的患者。47.5%（n = 153）的患者接受了冠状动脉旁路移植术，31.1%（n = 100）的患者需要三尖瓣修复。倾向评分调整后得到了可比的两组。原发性择期退行性二尖瓣疾病患者行二尖瓣修复的 30 天死亡率为 5.1%（2/39）。总体而言，修复组 90 天死亡率为 18.9%（227 例中有 43 例），而置换组为 31.6%（95 例中有 30 例）（P = 0.014）。出院前超声心动图显示 99%（231/232）的患者残余反流小于中度。二尖瓣修复患者的调整后 1、3 和 5 年生存率分别为 71 ± 3%、61 ± 4%和 59 ± 4%，而二尖瓣置换患者分别为 56 ± 5%、50 ± 6%和 45 ± 6%（P = 0.046）。多变量分析显示，急诊手术、既往心肌梗死、同期冠状动脉旁路移植术和二尖瓣置换术是早期死亡率的强独立预测因素；二尖瓣置换术是退行性二尖瓣疾病患者生存率降低的独立预测因素。
在选择的退行性二尖瓣疾病 80 岁以上患者中，选择性二尖瓣修复术可获得低手术死亡率和良好的长期结果，与二尖瓣置换术相比，长期生存率更高。非退行性疾病手术的生存获益更具争议性。
