Goldstone Andrew B, Cohen Jeffrey E, Howard Jessica L, Edwards Bryan B, Acker Alexandra L, Hiesinger William, MacArthur John W, Atluri Pavan, Woo Y Joseph
Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California; Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
Ann Thorac Surg. 2015 Jun;99(6):1983-90; discussion 1990-1. doi: 10.1016/j.athoracsur.2014.12.076. Epub 2015 Apr 9.
We examined the feasibility and efficacy of a "repair-all" strategy applied in all patients with degenerative mitral regurgitation, regardless of valve complexity, risk profile, and surgical approach.
Between 2002 and 2011, 4,241 patients underwent mitral operations at our institution. Analysis was limited to 525 consecutive patients with mitral regurgitation due to leaflet prolapse (posterior, 75%; anterior, 5%; bileaflet, 20%) who underwent isolated mitral operations. A right minithoracotomy was used in 46% of procedures. Propensity scores identified 153 well-matched patient pairs for evaluation of the effect of surgical approach on valve reparability.
Mitral repair was successful in 99% (520 of 525) of patients. The location of the leaflet prolapse did not significantly influence the repair rate or the need for intraoperative revision of the initial repair. The repair rate and the need for intraoperative repair revision also did not significantly differ by surgical approach. Intraoperative revision did not confer a greater risk of perioperative morbidity or longer length of stay. At 8 years, freedom from severe mitral regurgitation was 97% ± 2%. Development of residual mitral regurgitation did not differ by location of the leaflet prolapse, need for repair revision, or surgical approach. After discharge, the survival trend did not differ between patients who did and did not require intraoperative repair revision.
In experienced centers, a "repair-all" strategy for degenerative mitral regurgitation can be used with nearly 100% repair rates and excellent outcomes, regardless of valve complexity. When necessary, intraoperative revision of the initial repair may be performed in most patients without a significant incremental risk, thereby further enhancing repair rates.
我们研究了“全面修复”策略应用于所有退行性二尖瓣反流患者的可行性和有效性，无论瓣膜复杂程度、风险状况和手术方式如何。
2002年至2011年期间，我院有4241例患者接受了二尖瓣手术。分析仅限于525例因瓣叶脱垂导致二尖瓣反流的连续患者（后叶脱垂占75%；前叶脱垂占5%；双叶脱垂占20%），这些患者接受了单纯二尖瓣手术。46%的手术采用右胸小切口。倾向评分法确定了153对匹配良好的患者对，以评估手术方式对瓣膜可修复性的影响。
二尖瓣修复在99%（525例中的520例）的患者中成功。瓣叶脱垂部位对修复率或初始修复术中进行再次修复的需求没有显著影响。修复率和术中修复再次手术的需求在手术方式上也没有显著差异。术中再次手术并未带来更高的围手术期发病率风险或更长的住院时间。在8年时，无严重二尖瓣反流的比例为97%±2%。残余二尖瓣反流的发生在瓣叶脱垂部位、修复再次手术需求或手术方式方面没有差异。出院后，需要和不需要术中修复再次手术的患者的生存趋势没有差异。
在经验丰富的中心，对于退行性二尖瓣反流，无论瓣膜复杂程度如何，“全面修复”策略的修复率接近100%且效果良好。必要时，大多数患者可进行初始修复的术中再次手术，且不会显著增加风险，从而进一步提高修复率。
