University Heart Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
Eur J Cardiothorac Surg. 2013 Sep;44(3):490-6; discussion 496. doi: 10.1093/ejcts/ezt036. Epub 2013 Feb 10.
Corrective surgery for secondary mitral regurgitation (MR) by restrictive annuloplasty has proven beneficial in that it improves New York Heart Association (NYHA) functional class and induces reverse left ventricular remodelling. However, proof of a survival benefit for these patients is still pending. Percutaneous techniques of mitral valve repair (MVR) have become a viable treatment alternative for selected high-risk patients with severe secondary MR.
We retrospectively analysed our prospective hospital database of patients with severe secondary MR undergoing either surgical MVR or percutaneous treatment using the MitraClip device. Patient characteristics and 6-month clinical and effectiveness outcomes are reported.
From March 2002 through June 2010, 76 patients with secondary MR underwent isolated surgical MVR, while 95 were treated using the MitraClip device at our centre. Patients undergoing MitraClip treatment were significantly older (mean 72.8 ± 8.2 vs 64.5 ± 11.4 years, P < 0.001), had a lower left ventricular ejection fraction (mean 36.2 ± 12.5 vs 42.1 ± 16.2%, P = 0.014) and were generally more high risk, with a significantly higher mean logistic EuroSCORE I compared with surgical candidates (33.7 ± 18.7 vs 10.1 ± 8.7%, P < 0.001). Procedural success was 98.7 (75 of 76) for MVR and 95.8% (91 of 95) for MitraClip treatment (P = 0.383). Thirty-day mortality was 4.2 (4 of 95) and 2.6% (2 of 76; P = 0.557), and the mean grade of residual MR was 1.4 ± 0.8 and 0.2 ± 0.4 (P < 0.001) after MitraClip treatment and surgical MVR, respectively. Six-month survival rates after adjustment for baseline differences were not significantly different in the respective groups (P = 0.642).
In our experience, characteristics and risk factors of patients with severe secondary MR undergoing surgery differ significantly from those considered for percutaneous therapy. Surgery was more effective compared with MitraClip in reducing MR. However, a large proportion of patients benefits from percutaneous intervention with sustained MR Grade <2+ and improvement in NYHA functional class at 6 months. MitraClip therapy seems to be an adequate alternative to surgery, especially for elderly patients with reduced left ventricular function and relevant comorbidities. Assessment, treatment and postprocedural care of patients by an interdisciplinary team are of paramount importance for clinical success.
通过限制性瓣环成形术对继发性二尖瓣反流（MR）进行矫正手术已被证明是有益的，因为它可以改善纽约心脏协会（NYHA）功能分级并诱导左心室逆向重构。然而，这些患者的生存获益仍有待证明。二尖瓣修复（MVR）的经皮技术已成为治疗严重继发性 MR 的高危患者的一种可行治疗选择。
我们回顾性分析了我们前瞻性医院数据库中接受外科 MVR 或经皮 MitraClip 装置治疗的严重继发性 MR 患者。报告患者特征和 6 个月的临床和疗效结果。
从 2002 年 3 月至 2010 年 6 月，76 例继发性 MR 患者接受了单纯外科 MVR 治疗，而 95 例患者在我们中心接受了 MitraClip 治疗。接受 MitraClip 治疗的患者年龄明显较大（平均 72.8±8.2 岁比 64.5±11.4 岁，P<0.001），左心室射血分数较低（平均 36.2±12.5%比 42.1±16.2%，P=0.014），且风险普遍较高，平均逻辑 EuroSCORE I 明显高于手术候选者（33.7±18.7%比 10.1±8.7%，P<0.001）。MVR 的手术成功率为 98.7%（75/76），MitraClip 治疗的成功率为 95.8%（91/95）（P=0.383）。30 天死亡率分别为 4.2%（4/95）和 2.6%（2/76；P=0.557），MitraClip 治疗和外科 MVR 后残余 MR 的平均分级分别为 1.4±0.8 和 0.2±0.4（P<0.001）。调整基线差异后，两组 6 个月生存率无显著差异（P=0.642）。
根据我们的经验，接受手术治疗的严重继发性 MR 患者的特征和危险因素与接受经皮治疗的患者有明显不同。与 MitraClip 相比，手术在降低 MR 方面更有效。然而，很大一部分患者受益于经皮介入治疗，MR 分级持续<2+，6 个月时 NYHA 功能分级改善。MitraClip 治疗似乎是手术的一种合理替代方法，特别是对于左心室功能降低和相关合并症的老年患者。由多学科团队进行评估、治疗和术后护理对临床成功至关重要。
