Coutinho Gonçalo F, Branco Carlos Filipe, Jorge Elisabete, Correia Pedro M, Antunes Manuel J
Centre of Cardiothoracic Surgery, University Hospital and Medical School, Coimbra, Portugal.
Centre of Cardiothoracic Surgery, University Hospital and Medical School, Coimbra, Portugal
Eur J Cardiothorac Surg. 2015 Jan;47(1):e1-6. doi: 10.1093/ejcts/ezu365.
Due to progression of rheumatic disease, percutaneous mitral commissurotomy (PMC) is a palliative procedure. We aimed at evaluating the outcomes of patients requiring surgery for failure of PMC, focusing on the fate of the mitral valve (MV) (repair versus replacement).
From January 1993 through December 2012, 61 patients with previous PMC were submitted to MV surgery. Detailed operative findings were collected from all patients and an intraoperative anatomical score was introduced to predict reparability. Time to surgery, overall survival and freedom from reoperation were analysed.
The mean time to surgery after PMC was 6.9±5.9 years and indications were restenosis in 25 patients (41%) and mitral regurgitation or mixed lesion in 36 (59%). Nine patients (14.8%) had more than one previous intervention. Intraoperative inspection of the valve revealed leaflet laceration outside the commissural area in 27 patients (44.3%). Valve repair was accomplished in 38 patients (62.3%). Pulmonary hypertension, calcification and intraoperative anatomical score were independently associated with the probability of valve replacement (OR 1.12, OR 7.03 and OR 4.49, respectively, P<0.05). There was no hospital mortality. MV area increased on average 1.6 cm2 after surgery to 2.7 cm2; 5-, 10- and 20-year survival rates were 98.1±1.9, 91±5.2 and 82.7±9.2%, respectively. The rate of freedom from mitral reoperation (for repaired cases) at 5, 10 and 15 years was 100, 95.8±4.1 and 87.8±8.5%, respectively. There was no difference in survival between repaired or replaced MVs, but the former had less valve-related events during follow-up.
The MV can be repaired after failed PMC, with very low complication rates and excellent long-term results. Hence, whenever possible, these patients should be sent to reference centres where repair can be successfully achieved.
由于风湿性疾病进展，经皮二尖瓣交界切开术（PMC）是一种姑息性手术。我们旨在评估因PMC失败而需要手术治疗的患者的结局，重点关注二尖瓣（MV）的转归（修复与置换）。
从1993年1月至2012年12月，61例曾接受PMC的患者接受了MV手术。收集所有患者的详细手术发现，并引入术中解剖评分来预测可修复性。分析手术时间、总生存率和再次手术的自由度。
PMC后平均手术时间为6.9±5.9年，25例（41%）的手术指征为再狭窄，36例（59%）为二尖瓣反流或混合病变。9例（14.8%）患者曾接受过不止一次干预。术中检查瓣膜发现27例（44.3%）患者在交界区以外有瓣叶撕裂。38例（62.3%）患者完成了瓣膜修复。肺动脉高压、钙化和术中解剖评分与瓣膜置换的可能性独立相关（分别为OR 1.12、OR 7.03和OR 4.49，P<0.05）。无医院死亡病例。术后MV面积平均增加1.6 cm²至2.7 cm²；5年、10年和20年生存率分别为98.1±1.9%、91±5.2%和82.7±9.2%。修复病例5年、10年和15年二尖瓣再次手术的自由度分别为100%、95.8±4.1%和87.8±8.5%。修复或置换的MV之间生存率无差异，但前者在随访期间瓣膜相关事件较少。
PMC失败后MV可以修复，并发症发生率极低，长期效果良好。因此，只要有可能，这些患者应被送往能够成功进行修复的参考中心。
