缺血性二尖瓣反流伴射血分数降低患者二尖瓣修复与置换：早期和中期死亡率的危险因素†

Mitral valve repair versus replacement in patients with ischaemic mitral regurgitation and depressed ejection fraction: risk factors for early and mid-term mortality†.

作者信息

Lio Antonio, Miceli Antonio, Varone Egidio, Canarutto Daniele, Di Stefano Gioia, Della Pina Francesca, Gilmanov Daniyar, Murzi Michele, Solinas Marco, Glauber Mattia

机构信息

Department of Adult Cardiac Surgery, Fondazione Toscana G. Monasterio, Massa, Italy.

Department of Adult Cardiac Surgery, Fondazione Toscana G. Monasterio, Massa, Italy Bristol Heart Institute, University of Bristol, UK

出版信息

Interact Cardiovasc Thorac Surg. 2014 Jul;19(1):64-9. doi: 10.1093/icvts/ivu066. Epub 2014 Mar 27.

DOI:10.1093/icvts/ivu066

PMID:24676552

Abstract

OBJECTIVES

Mitral valve (MV) surgery for ischaemic mitral regurgitation (IMR) in patients with depressed left ventricular ejection fraction (LVEF) is associated with poor outcomes. The optimal surgical strategy for IMR in these patients remains controversial. The objective of this study was to compare the early mortality and mid-term survival of MV repair versus MV replacement in patients with IMR and depressed LVEF undergoing coronary artery bypass grafting (CABG).

METHODS

A retrospective, observational, cohort study was undertaken of prospectively collected data on 126 consecutive CABG patients with IMR and LVEF <40% undergoing either MV repair (n = 98, 78%) or MV replacement (n = 28, 22%) between July 2002 and February 2011.

RESULTS

The overall mortality rate was 7.9% (n = 10). MV replacement was associated with a 4-fold increase in the risk of death compared with MV repair [17.9%, n = 5 vs 5.1%, n = 5; odds ratio (OR) 4.04, 95% confidence interval (CI) 1.08-15.1, P = 0.04]. However, after adjusting for preoperative risk factors, the type of surgical procedure was not an independent risk factor for early mortality (OR 0.1, 95% CI 0.01-31, P = 0.7). Multivariable analysis showed that preoperative LVEF (OR 0.8, 95% CI 0.6-0.9, P = 0.018), preoperative B-type natriuretic peptide (BNP) levels (OR 1.01, 95% CI 1-1.02, P = 0.025), preoperative left ventricle end-systolic diameter (OR 0.8, 95% CI 0.7-1.0, P = 0.05) and preoperative left atrial diameter (OR 1.3, 95% CI 1.0-1.6, P = 0.015) were independent risk factors of early mortality. At the median follow-up of 45 months (interquartile range 20-68 months), the mid-term survival rate was 74% in the MV repair group and 70% in the MV replacement group (P = 0.08). At follow-up, predictors of worse survival were BNP levels [hazard ratio (HR) 1.0, 95% CI 1.0-1.01, P = 0.047], preoperative renal failure (HR 4.6, 95% CI 1.1-20.3, P = 0.039) and preoperative atrial fibrillation (HR 3.3, 95% CI 1.1-10, P = 0.032).

CONCLUSIONS

MV repair in CABG patients with IMR and depressed LVEF is not superior to MV replacement with regard to operative early mortality and mid-term survival.

摘要

目的

对于左心室射血分数（LVEF）降低的患者，缺血性二尖瓣反流（IMR）的二尖瓣（MV）手术预后较差。这些患者IMR的最佳手术策略仍存在争议。本研究的目的是比较接受冠状动脉旁路移植术（CABG）的IMR且LVEF降低患者中，MV修复与MV置换的早期死亡率和中期生存率。

方法

对2002年7月至2011年2月期间连续126例接受CABG的IMR且LVEF<40%患者的前瞻性收集数据进行回顾性观察队列研究，这些患者接受了MV修复（n = 98，78%）或MV置换（n = 28，22%）。

结果

总死亡率为7.9%（n = 10）。与MV修复相比，MV置换使死亡风险增加4倍[17.9%，n = 5 vs 5.1%，n = 5；比值比（OR）4.04，95%置信区间（CI）1.08 - 15.1，P = 0.04]。然而，在对术前危险因素进行校正后，手术方式并非早期死亡的独立危险因素（OR 0.1，95% CI 0.01 - 31，P = 0.7）。多变量分析显示，术前LVEF（OR 0.8，95% CI 0.6 - 0.9，P = 0.018）、术前B型利钠肽（BNP）水平（OR 1.01，95% CI 1 - 1.02，P = 0.025）、术前左心室收缩末期直径（OR 0.8，95% CI 0.7 - 1.0，P = 0.05）和术前左心房直径（OR 1.3，95% CI 1.0 - 1.6，P = 0.015）是早期死亡的独立危险因素。在中位随访45个月（四分位间距20 - 68个月）时，MV修复组的中期生存率为74%，MV置换组为70%（P = 0.08）。随访时，生存较差的预测因素为BNP水平[风险比（HR）1.0，95% CI 1.0 - 1.01，P = 0.047]、术前肾衰竭（HR 4.6，95% CI 1.1 - 20.3，P = 0.039）和术前心房颤动（HR 3.3，95% CI 1.1 - 10，P = 0.032）。