Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minn 55905, USA.
J Thorac Cardiovasc Surg. 2011 Nov;142(5):995-1001. doi: 10.1016/j.jtcvs.2011.07.044. Epub 2011 Aug 19.
The treatment of patients with ischemic cardiomyopathy and concomitant mitral regurgitation can be challenging and is associated with reduced long-term survival. It is unclear how mitral valve repair versus replacement affects subsequent outcome. Therefore, we conducted this study to understand the predictors of mortality and to delineate the role of mitral valve repair versus replacement in this high-risk population.
From 1993 to 2007, 431 patients (mean age, 70 ± 9 years) with ischemic cardiomyopathy (left ventricular ejection fraction ≤ 45%) and significant ischemic mitral regurgitation (>2) were identified. Patients (44) with concomitant mitral stenosis were excluded from the analysis. A homogeneous group of 387 patients underwent combined coronary artery bypass grafting and mitral valve surgery, mitral valve repair in 302 (78%) and mitral valve replacement in 85 (22%). Uni- and multivariate analyses were performed on the entire cohort, and the predictors of mortality were identified in 2 distinct risk phases. Furthermore, we specifically examined the impact of mitral valve repair versus replacement by comparing 2 propensity-matched subgroups.
Follow-up was 100% complete (median, 3.6 years; range, 0-15 years). Overall 1-, 5-, and 10-year survivals were 82.7%, 55.2%, and 24.3%, respectively, for the entire group. The risk factors for an increased mortality within the first year of surgery included previous coronary artery bypass grafting (hazard ratio = 3.39; P < .001), emergency/urgent status (hazard ratio = 2.08; P = .007), age (hazard ratio = 1.5; P = .03), and low left ventricular ejection fraction (hazard ratio = 1.31; P = .026). Thereafter, only age (hazard ratio = 1.58; P < .001), diabetes (hazard ratio = 2.5; P = .001), and preoperative renal insufficiency (hazard ratio = 1.72; P = .025) were predictive. The status of mitral valve repair versus replacement did not influence survival, and this was confirmed by comparable survival in propensity-matched analyses.
Survival after combined coronary artery bypass grafting and mitral valve surgery in patients with ischemic cardiomyopathy (left ventricular ejection fraction ≤ 45%) and mitral regurgitation is compromised and mostly influenced by factors related to the patient's condition at the time of surgery. The specifics of mitral valve repair versus replacement did not seem to affect survival.
治疗缺血性心肌病合并二尖瓣反流的患者具有挑战性，且与长期生存率降低有关。二尖瓣修复与置换对后续结果的影响尚不清楚。因此，我们进行了这项研究，以了解死亡率的预测因素，并阐明二尖瓣修复与置换在这一高危人群中的作用。
1993 年至 2007 年间，我们确定了 431 例缺血性心肌病（左心室射血分数≤45%）和显著缺血性二尖瓣反流（>2）患者（平均年龄 70±9 岁）。分析排除了合并二尖瓣狭窄的 44 例患者。387 例患者接受了冠状动脉旁路移植术和二尖瓣手术联合治疗，其中 302 例（78%）行二尖瓣修复，85 例（22%）行二尖瓣置换。对整个队列进行了单变量和多变量分析，并确定了 2 个不同风险阶段的死亡率预测因素。此外，我们通过比较 2 个倾向匹配亚组，专门研究了二尖瓣修复与置换的影响。
随访率为 100%（中位数为 3.6 年；范围为 0-15 年）。整个队列的 1 年、5 年和 10 年生存率分别为 82.7%、55.2%和 24.3%。手术第一年死亡率增加的危险因素包括既往冠状动脉旁路移植术（风险比=3.39；P<.001）、紧急/紧急状态（风险比=2.08；P=.007）、年龄（风险比=1.5；P=.03）和左心室射血分数低（风险比=1.31；P=.026）。此后，只有年龄（风险比=1.58；P<.001）、糖尿病（风险比=2.5；P=.001）和术前肾功能不全（风险比=1.72；P=.025）是预测因素。二尖瓣修复与置换的状态并不影响生存率，这在倾向匹配分析中得到了证实。
缺血性心肌病（左心室射血分数≤45%）和二尖瓣反流患者行冠状动脉旁路移植术和二尖瓣手术的生存率受损，主要受手术时患者病情相关因素的影响。二尖瓣修复与置换的具体细节似乎并不影响生存率。
