乳头肌靠拢的程度影响缺血性二尖瓣反流二尖瓣修复术的死亡率和持久性。
The extent of papillary muscle approximation affects mortality and durability of mitral valve repair for ischemic mitral regurgitation.
作者信息
Wakasa Satoru, Kubota Suguru, Shingu Yasushige, Ooka Tomonori, Tachibana Tsuyoshi, Matsui Yoshiro
机构信息
Department of Cardiovascular and Thoracic Surgery, Hokkaido University Graduate School of Medicine, Kita-15, Nishi-7, Kita-ku, Sapporo 060-8638, Japan.
出版信息
J Cardiothorac Surg. 2014 Jun 3;9:98. doi: 10.1186/1749-8090-9-98.
BACKGROUND
Since reduction annuloplasty alone for ischemic mitral regurgitation (MR) cannot prevent late recurrence of MR or improve survival for those with left ventricular (LV) dysfunction, and the surgical approach to this etiology is still controversial, we conducted a study to assess the efficacy of the additional papillary muscle approximation (PMA) procedure for ischemic MR by comparing the different subtypes of PMA.
METHODS
We studied 45 patients who underwent mitral annuloplasty and papillary muscle approximation (PMA) for ischemic MR between 2003 and 2012. Papillary muscles were approximated entirely (cPMA: complete PMA, n = 32) through an LV incision or partially from the tips to mid-parts (iPMA: incomplete PMA, n = 13) through the mitral and aortic valves. Twenty-three patients with cPMA also underwent LV plasty (LVP). We assessed the outcomes after PMA by comparing cPMA and iPMA.
RESULTS
The baseline MR grade, NYHA class, LV end-diastolic diameter, and LV ejection fraction (LVEF) were 2.8 ± 1.0, 3.2 ± 0.6, 67 ± 6 mm, and 30 ± 10%, respectively. There were no significant differences in these parameters among those with iPMA, cPMA/LVP-, and cPMA/LVP+, though iPMA patients had better LVEF than others. Three patients died before discharge and 12 died during the follow-up. Recurrence of grade 2+ and 3+ MR occurred in 8 and 2 patients, respectively. Reoperation for recurrent MR was performed only for the 2 patients with recurrence of grade 3+ MR. The cPMA was associated with lower mortality (log-rank P = 0.020) and a lower rate of recurrence of MR ≥2+ (log-rank P = 0.005) than iPMA. In contrast, there were no significant differences in the mortality (log-rank P = 0.45) and rate of recurrence (log-rank P = 0.98) between those with cPMA/LVP- and cPMA/LVP+. The 4-year survival rate and rate of freedom from recurrence of MR ≥2+ were 83% and 85% for those with cPMA, repectively. In contrast, the rates were 48% and 48% for those with iPMA, respectively.
CONCLUSIONS
Complete PMA could be associated with lower postoperative mortality and higher durability of mitral valve repair for ischemic MR.
背景
由于单独的二尖瓣环缩术治疗缺血性二尖瓣反流（MR）无法预防MR的晚期复发，也无法改善左心室（LV）功能不全患者的生存率，且针对该病因的手术方法仍存在争议，我们开展了一项研究，通过比较不同亚型的乳头肌靠拢术（PMA）来评估其对缺血性MR的疗效。
方法
我们研究了2003年至2012年间接受二尖瓣环缩术和乳头肌靠拢术（PMA）治疗缺血性MR的45例患者。乳头肌通过左心室切口完全靠拢（cPMA：完全PMA，n = 32）或通过二尖瓣和主动脉瓣从尖端至中部部分靠拢（iPMA：不完全PMA，n = 13）。23例接受cPMA的患者还接受了左心室成形术（LVP）。我们通过比较cPMA和iPMA评估PMA后的结果。
结果
基线MR分级、纽约心脏协会（NYHA）心功能分级、左心室舒张末期直径和左心室射血分数（LVEF）分别为2.8±1.0、3.2±0.6、67±6 mm和30±10%。iPMA患者、cPMA/LVP-患者和cPMA/LVP+患者在这些参数上无显著差异，尽管iPMA患者的LVEF优于其他患者。3例患者在出院前死亡，12例在随访期间死亡。2+级和3+级MR复发分别发生在8例和2例患者中。仅对2例3+级MR复发患者进行了复发性MR的再次手术。与iPMA相比，cPMA的死亡率较低（对数秩检验P = 0.020），MR≥2+的复发率较低（对数秩检验P = 0.005）。相比之下，cPMA/LVP-患者和cPMA/LVP+患者在死亡率（对数秩检验P = 0.45）和复发率（对数秩检验P = 0.98）上无显著差异。cPMA患者的4年生存率和MR≥2+无复发率分别为83%和85%。相比之下，iPMA患者的这两个率分别为48%和48%。
结论
完全PMA可能与缺血性MR术后较低的死亡率和较高的二尖瓣修复耐久性相关。
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