Faculty of Medicine, Cardiothoracic Surgery, University Hospital, Coimbra, Portugal.
Eur J Cardiothorac Surg. 2013 Jul;44(1):32-40. doi: 10.1093/ejcts/ezs676. Epub 2013 Jan 22.
To define the impact of surgical strategy [concomitant mitral valve surgery or isolated aortic valve replacement (AVR)] in patients with moderate secondary mitral regurgitation (MR) at the time of AVR.
From January 1999 to December 2009, 3339 patients underwent AVR of whom 255 had secondary MR >2+ and constituted the study population. Patients were stratified into two groups, with (Group A, n = 94, 36.8%) and without concomitant mitral valve surgery (Group B, n = 161, 63.2%). Follow-up up to 12 years (1076 patient-years) was analysed for survival, valve-related events and persistent MR. Predictors of late mortality and persistent MR were further analysed. A case-match analysis [age, gender, New York Heart Association (NYHA) and left ventricular ejection fraction] was performed, excluding patients with coronary artery disease (CAD).
The mean age of the population was 67.0 ± 11.7 years, 63.5% male and 64.7% in NYHA III-IV. Group B patients were significantly older and had higher incidence of coronary disease, hypertension and mitral calcification. They also had a higher ejection fraction and transaortic gradients, and lower MR grade (mean MR: 2.8 vs 3.2) and pulmonary artery pressure. Mitral surgery consisted mainly of annuloplasty procedures (96%). Only 2 patients from the entire cohort were reoperated on/for the mitral valve. Thirty-day mortality rate was 0.3%. There was no difference in long-term survival and valve-related complications, even after case-matched analysis. CAD, history of cerebrovascular accident, permanent atrial fibrillation, renal failure and persistence of MR emerged as independent predictors of late mortality (P < 0.05). MR improved in 67.4% of patients from Group B against 82.3% from Group A (P = 0.011). Atrial fibrillation (AF) and higher MR grade at discharge were the only independent predictors for persistent MR (P < 0.05). Patients with persistent MR early after AVR had decreased late survival (hazard ratio: 4.9, P = 0.001).
Secondary MR improves after AVR even without mitral surgery. Concomitant mitral surgery was significantly associated with greater improvement of postoperative MR, but had no significant impact on survival. However, patients who did not improve immediately after AVR had compromised survival. Patients in AF should have mitral valve repair at the time of surgery.
定义在主动脉瓣置换术（AVR）时合并二尖瓣手术或单纯主动脉瓣置换术（AVR）对中度继发性二尖瓣反流（MR）患者的手术策略的影响。
1999 年 1 月至 2009 年 12 月，3339 例患者接受 AVR，其中 255 例存在>2+的继发性 MR，构成研究人群。患者分为两组，一组为合并二尖瓣手术（A 组，n = 94，36.8%），另一组为未合并二尖瓣手术（B 组，n = 161，63.2%）。对 12 年（1076 人年）的生存、瓣膜相关事件和持续性 MR 进行分析。进一步分析晚期死亡率和持续性 MR 的预测因素。进行病例匹配分析（年龄、性别、纽约心脏协会（NYHA）和左心室射血分数），排除冠状动脉疾病（CAD）患者。
人群的平均年龄为 67.0±11.7 岁，63.5%为男性，64.7%为 NYHA III-IV 级。B 组患者年龄明显较大，CAD、高血压和二尖瓣钙化的发生率较高。他们的射血分数和跨主动脉梯度较高，MR 分级较低（平均 MR：2.8 对 3.2），肺动脉压较低。二尖瓣手术主要包括瓣环成形术（96%）。整个队列中只有 2 例患者再次接受/行二尖瓣手术。30 天死亡率为 0.3%。即使在病例匹配分析后，长期生存率和瓣膜相关并发症也没有差异。CAD、脑血管意外史、永久性房颤、肾衰竭和持续性 MR 是晚期死亡率的独立预测因素（P<0.05）。B 组中有 67.4%的患者的 MR 得到改善，而 A 组中有 82.3%的患者得到改善（P=0.011）。出院时房颤（AF）和较高的 MR 分级是持续性 MR 的唯一独立预测因素（P<0.05）。AVR 后早期存在持续性 MR 的患者晚期生存率降低（风险比：4.9，P=0.001）。
即使没有二尖瓣手术，AVR 后继发性 MR 也会得到改善。合并二尖瓣手术与术后 MR 改善显著相关，但对生存率无显著影响。然而，AVR 后即刻未改善的患者生存状况受损。AF 患者应在手术时进行二尖瓣修复。
