Cardiovascular Department, Ospedale Papa Giovanni XXIII, Bergamo, Italy; Bristol Heart Institute, University of Bristol, Bristol, United Kingdom.
Cardiovascular Department, Ospedale Papa Giovanni XXIII, Bergamo, Italy.
J Thorac Cardiovasc Surg. 2014 Aug;148(2):447-53.e2. doi: 10.1016/j.jtcvs.2013.05.053. Epub 2013 Nov 4.
Mitral valve annuloplasty and mitral valve replacement are common strategies for the management of functional ischemic mitral regurgitation with ischemic cardiomyopathy. However, mitral valve annuloplasty may create some degree of functional mitral stenosis. The purpose of this study was to compare the mitral valve hemodynamics in patients with functional ischemic mitral regurgitation undergoing mitral valve annuloplasty or mitral valve replacement, using exercise echocardiography.
We performed resting and exercise echocardiography in 70 patients matched for indexed effective orifice area, systolic pulmonary arterial pressure, and left ventricular ejection fraction after mitral valve annuloplasty or mitral valve replacement with coronary artery bypass grafting.
There was no significant difference between the 2 groups regarding baseline demographic and clinical data. Exercise systolic pulmonary arterial pressure was higher in the mitral valve annuloplasty group compared with the mitral valve replacement group (from 36.3 ± 8.1 mm Hg to 55 ± 12 mm Hg, vs mitral valve replacement: 33 ± 6 mm Hg to 42 ± 6.2 mm Hg, P = .0001). Exercise-induced improvement in effective orifice area and indexed effective orifice area was better in the mitral valve replacement group (mitral valve replacement: +0.23 ± 0.04 vs mitral valve annuloplasty: -0.1 ± 0.09 cm², P = .001, for effective orifice area; mitral valve replacement: +0.14 ± 0.03 vs mitral valve annuloplasty: -0.04 ± 0.07 cm²/m², P = .03, for indexed effective orifice area). Exercise indexed effective orifice area was correlated with exercise systolic pulmonary arterial pressure (r = -0.45; P = .01). In a multivariable analysis mitral valve annuloplasty, postoperative indexed effective orifice area and resting mitral peak gradients were independent predictors of elevated systolic pulmonary arterial pressure during exercise.
In patients with functional ischemic mitral regurgitation, mitral valve annuloplasty may cause functional mitral stenosis, especially during exercise. Mitral valve annuloplasty was associated with poor exercise mitral hemodynamic performance, lack of mitral valve opening reserve, and markedly elevated postoperative exercise systolic pulmonary arterial pressure compared with mitral valve replacement.
二尖瓣环成形术和二尖瓣置换术是治疗缺血性心肌病伴功能性缺血性二尖瓣反流的常用策略。然而，二尖瓣环成形术可能会导致一定程度的功能性二尖瓣狭窄。本研究旨在通过运动超声心动图比较功能性缺血性二尖瓣反流患者行二尖瓣环成形术或二尖瓣置换术后的二尖瓣血流动力学。
我们对 70 例患者进行了静息和运动超声心动图检查，这些患者在接受冠状动脉旁路移植术后，二尖瓣环成形术或二尖瓣置换术后的指数有效瓣口面积、收缩期肺动脉压和左心室射血分数相匹配。
两组患者的基线人口统计学和临床数据无显著差异。二尖瓣环成形术组的运动收缩期肺动脉压高于二尖瓣置换术组（从 36.3 ± 8.1 mmHg 增加至 55 ± 12 mmHg，而二尖瓣置换术组从 33 ± 6 mmHg 增加至 42 ± 6.2 mmHg，P =.0001）。二尖瓣置换术组的有效瓣口面积和指数有效瓣口面积在运动时的改善更明显（二尖瓣置换术组：+0.23 ± 0.04 比二尖瓣环成形术组：-0.1 ± 0.09 cm²，P =.001；二尖瓣置换术组：+0.14 ± 0.03 比二尖瓣环成形术组：-0.04 ± 0.07 cm²/m²，P =.03）。运动时的指数有效瓣口面积与运动时的收缩期肺动脉压呈负相关（r = -0.45；P =.01）。多变量分析表明，二尖瓣环成形术、术后指数有效瓣口面积和静息二尖瓣峰值梯度是运动时升高的收缩期肺动脉压的独立预测因素。
在功能性缺血性二尖瓣反流患者中，二尖瓣环成形术可能导致功能性二尖瓣狭窄，尤其是在运动时。与二尖瓣置换术相比，二尖瓣环成形术与较差的运动二尖瓣血流动力学性能、缺乏二尖瓣瓣口开放储备以及术后运动时显著升高的收缩期肺动脉压相关。
