Asklepios Kliniken St. Georg/Eimsbüttel, Abteilung für Herzchirurgie, Hamburg, Germany.
Asklepios Kliniken St. Georg/Eimsbüttel, Abteilung für Herzchirurgie, Hamburg, Germany.
Ann Thorac Surg. 2014 Jan;97(1):56-63. doi: 10.1016/j.athoracsur.2013.07.038. Epub 2013 Sep 25.
This study analyzed the effect of failed percutaneous mitral intervention with the MitraClip device (Abbott Laboratories, Abbott Park, IL) on subsequent mitral valve (MV) operations.
Nineteen patients (74 ± 9 years) with treatment failure after implantation of 37 MitraClips (mean, 1.9 ± 0.8; range, 1 to 4) for functional or degenerative MV disease underwent operations a median of 12 days later (range, 0 to 546 days). All patients were studied before and after the operation by clinical investigation and echocardiographic analysis. Intraoperative findings and the effect on the operation were analyzed and are described in detail. Data before clipping and at the time of operation were compared, and the surgical outcome was recorded.
There was a significant increase in risk between that at the time of clipping and that at subsequent operations, noted as a rise of the European System for Cardiac Operative Risk Evaluation II from a median 12.74% to 26.87%, respectively (p < 0.0001, Wilcoxon signed rank test). Severe clip implantation-induced tissue damage was found in most patients. Surgical MV repair could be performed in 5 of 6 patients (83%) with a 1-clip implant and in only 3 of 13 patients (23%) when 2 or more clips had been inserted (p = 0.0188, Wilcoxon-Mann-Whitney test). All patients required other associated procedures: closure of an artificial atrial septal defect that was caused by the clipping procedure (100%), tricuspid valve repair (37%), atrial fibrillation ablation operations (37%), coronary artery bypass grafting (16%), and aortic valve replacement (11%). Two early cardiac deaths (< 30 days) occurred. Survival at 1 year was 68%.
There is a remarkable impact of failed clipping procedures on MV operations. We observed a severely aggravated cardiac pathology in parallel with a reduced preoperative clinical state compared with the original condition. Moreover, the likelihood of an optimal surgical solution with valve reconstruction was reduced thereafter. However, operations in the critical situation of an unsuccessful mitral clipping procedure should be discussed immediately, because it still seems to be an option compared with conservative therapy.
本研究分析了经皮二尖瓣介入治疗（MitralClip 装置，雅培实验室，雅培公园，IL）失败对随后二尖瓣（MV）手术的影响。
19 例患者（74±9 岁）在植入 37 个 MitraClip（平均 1.9±0.8；范围，1 至 4）治疗功能性或退行性 MV 疾病后治疗失败，中位数 12 天后（范围，0 至 546 天）进行手术。所有患者均在术前和术后进行临床检查和超声心动图分析。术中发现和对手术的影响进行了分析，并作了详细描述。比较了夹闭前和手术时的数据，并记录了手术结果。
夹闭时的风险明显高于随后手术时的风险，欧洲心脏手术风险评估系统 II 从中位数 12.74%分别上升至 26.87%（p<0.0001，Wilcoxon 符号秩检验）。大多数患者发现严重的夹闭诱导的组织损伤。在 6 例 1 夹植入患者中，5 例（83%）可进行 MV 修复手术，而在 13 例 2 或更多夹植入患者中，仅 3 例（23%）可进行 MV 修复手术（p=0.0188，Wilcoxon-Mann-Whitney 检验）。所有患者均需行其他辅助手术：夹闭操作引起的人工房间隔缺损的闭合（100%），三尖瓣修复（37%），房颤消融手术（37%），冠状动脉旁路移植术（16%）和主动脉瓣置换术（11%）。2 例早期心脏死亡（<30 天）。1 年生存率为 68%。
夹闭失败对 MV 手术有显著影响。与原始情况相比，我们观察到心脏病理严重恶化，同时术前临床状态恶化。此外，此后进行瓣膜重建的最佳手术解决方案的可能性降低。然而，在二尖瓣夹闭失败的危急情况下，应立即讨论手术，因为与保守治疗相比，手术仍然是一种选择。
