Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, PA, USA.
J Thorac Cardiovasc Surg. 2013 Feb;145(2):341-7; discussion 347-8. doi: 10.1016/j.jtcvs.2012.10.043. Epub 2012 Dec 11.
Management of intermediate degrees of mitral regurgitation during aortic valve replacement for aortic stenosis remains controversial. We sought to evaluate the degree of reduction of mitral regurgitation in patients undergoing aortic valve replacement, as well as a mathematical relationship between aortic valve gradient reduction and the degree of mitral regurgitation decrement.
We retrospectively analyzed demographic, intraoperative, and echocardiographic data on 802 patients who underwent aortic valve replacement or aortic root replacement between January 2010 and March 2011. A total of 578 patients underwent aortic valve replacement or aortic root replacement without intervention on the mitral valve. We excluded 88 patients with severe aortic insufficiency, 3 patients who underwent ventricular assist device placement, 4 patients who underwent prior mitral valve replacement, and 21 patients with incomplete data, yielding 462 patients for analysis. For each patient, the degree of pre- and postoperative mitral regurgitation was graded on a standard 0 to 4+ scale.
Of the 462 patients, 289 patients had at least mild mitral regurgitation. On average, mitral regurgitation decreased 0.24 degrees per patient for this cohort of 289 patients. Of the 56 patients with at least moderate mitral regurgitation, mitral regurgitation decreased 0.54 degrees per patient. Of 62 patients who underwent isolated aortic valve replacements, who had at least mild mitral regurgitation, and who had no evidence of structural mitral valve disease, mitral regurgitation decreased 0.24 degrees per patient. Linear regression analysis revealed no relationship between reduction in mitral regurgitation and gradient reduction across the aortic valve.
Reduction in mitral regurgitation after relief of aortic outflow tract obstruction is modest at best. Further, the magnitude of gradient change across the aortic valve has little influence on the degree of reduction in mitral regurgitation. These observations argue at minimum for performing a prospective evaluation of the clinical benefits of addressing moderate mitral regurgitation at the time of aortic valve intervention and may support a more aggressive approach to concomitant mitral surgery.
主动脉瓣狭窄患者行主动脉瓣置换术时，对于中重度二尖瓣反流的处理仍存在争议。本研究旨在评估主动脉瓣置换术患者的二尖瓣反流程度，并探讨主动脉瓣跨瓣压差降低与二尖瓣反流程度变化之间的数学关系。
回顾性分析 2010 年 1 月至 2011 年 3 月期间 802 例行主动脉瓣置换术或主动脉根部置换术患者的临床资料，其中 578 例患者未行二尖瓣干预。排除重度主动脉瓣关闭不全 88 例、行心室辅助装置治疗 3 例、既往行二尖瓣置换术 4 例及临床资料不完整 21 例，共 462 例患者进入本研究。根据二尖瓣反流程度，每位患者术前和术后均被分为 0-4+个等级。
462 例患者中，289 例患者至少存在轻度二尖瓣反流。对于这 289 例患者，二尖瓣反流平均减轻 0.24 个等级。56 例至少存在中度二尖瓣反流的患者，二尖瓣反流平均减轻 0.54 个等级。62 例孤立性主动脉瓣置换术患者中，至少存在轻度二尖瓣反流且无结构性二尖瓣疾病，二尖瓣反流平均减轻 0.24 个等级。线性回归分析显示，二尖瓣反流程度的降低与主动脉瓣跨瓣压差的降低之间无相关性。
解除主动脉瓣流出道梗阻后，二尖瓣反流的减轻程度是有限的。另外，主动脉瓣跨瓣压差的变化幅度对二尖瓣反流程度的降低影响较小。这些观察结果至少表明，在主动脉瓣干预时，有必要前瞻性评估处理中度二尖瓣反流的临床获益，并可能支持对同期二尖瓣手术采取更为积极的策略。
