Johnson Joyce T, Eckhauser Aaron W, Pinto Nelangi M, Weng Hsin-Yi, Minich L LuAnn, Tani Lloyd Y
The Division of Cardiology, Primary Children's Hospital and the University of Utah, 100 N. Mario Capecchi Dr., Salt Lake City, UT, 84113, USA,
Pediatr Cardiol. 2015 Feb;36(2):417-22. doi: 10.1007/s00246-014-1026-z. Epub 2014 Oct 11.
Based on outcome data, surgery is recommended for asymptomatic adults with chronic mitral regurgitation (MR) and systolic dysfunction, marked left ventricular (LV) dilation, pulmonary hypertension, atrial fibrillation, or high likelihood of successful repair; but indications for children are poorly defined. We sought to determine predictors of postoperative LV dysfunction in asymptomatic children with chronic MR. The surgical database was searched for all children who underwent mitral valve surgery for chronic MR (2000-2012). Exclusion criteria were preoperative symptoms, acute MR, cardiomyopathy, or other defects affecting LV size. Preoperative and latest follow-up clinical and echocardiographic data were obtained. LV dysfunction was defined as ejection fraction (EF) ≤55% or shortening fraction (SF) ≤28%. Associations between preoperative factors and late LV dysfunction were determined using univariate Poisson regression. For the 25 children who met criteria, preoperative median LV end systolic Z score (LVESZ) was 5.3, EF was 65%, and SF was 34%. At follow-up (median 3.9 years), nine patients (36%) had LV dysfunction. Lower preoperative SF (OR 0.6, p < 0.001) and higher LVESZ (OR 1.7, p < 0.01) were associated with late LV dysfunction. LVESZ ≥ 5 combined with SF ≤ 33% had a sensitivity of 89%, specificity of 88%, and negative predictive value of 93% for late LV dysfunction. Only 1/14 patients with preoperative SF > 33% had late LV dysfunction. For asymptomatic children with chronic MR, surgery should be considered before LVESZ exceeds five and SF falls below 33%. Patients with SF > 33% may be followed with serial echocardiographic measurements.
根据结果数据，对于患有慢性二尖瓣反流（MR）且有收缩功能障碍、明显左心室（LV）扩张、肺动脉高压、心房颤动或修复成功率高的无症状成年人，建议进行手术；但儿童的手术指征尚不明确。我们试图确定无症状慢性MR儿童术后左心室功能障碍的预测因素。在手术数据库中搜索所有因慢性MR接受二尖瓣手术的儿童（2000 - 2012年）。排除标准为术前有症状、急性MR、心肌病或其他影响左心室大小的缺陷。获取术前及最新随访的临床和超声心动图数据。左心室功能障碍定义为射血分数（EF）≤55%或缩短分数（SF）≤28%。使用单变量泊松回归确定术前因素与晚期左心室功能障碍之间的关联。对于符合标准的25名儿童，术前左心室收缩末期Z评分（LVESZ）中位数为5.3，EF为65%，SF为34%。在随访（中位数3.9年）时，9名患者（36%）出现左心室功能障碍。术前较低的SF（比值比0.6，p < 0.001）和较高的LVESZ（比值比1.7，p < 0.01）与晚期左心室功能障碍相关。LVESZ≥5且SF≤33%对晚期左心室功能障碍的敏感性为89%，特异性为88%，阴性预测值为93%。术前SF>33%的患者中只有1/14出现晚期左心室功能障碍。对于无症状慢性MR儿童，应在LVESZ超过5且SF降至33%以下之前考虑手术。SF>33%的患者可通过系列超声心动图测量进行随访。
