Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy; Department of Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, Paris, France.
Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy; Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, United Kingdom.
J Thorac Cardiovasc Surg. 2017 Feb;153(2):286-295.e2. doi: 10.1016/j.jtcvs.2016.09.050. Epub 2016 Sep 24.
The symmetry of mitral valve tethering and regional left ventricle wall dysfunction are reported to play a fundamental role in the outcomes and long-term durability of surgical repair in ischemic mitral regurgitation (IMR). We recently demonstrated in a randomized clinical trial (the Papillary Muscle Approximation trial) the superiority of papillary muscle approximation (PMA) in combination with standard restrictive annuloplasty (RA) in severe IMR over annuloplasty alone in terms of adverse left ventricular remodeling and mitral regurgitation (MR) recurrence. This approach, however, failed to produce a survival advantage and was still plagued by a high incidence of reoperation. We therefore performed a subanalysis of the PMA trial on the basis of preoperative parameters to elucidate the value of subvalvular surgery in certain subcategories of patients with the aim of creating a decisional algorithm on the best operative strategy.
We performed a subanalysis of PMA trial, evaluating 96 patients with severe IMR and eligible for myocardial revascularization randomized to PMA + RA (n = 48) versus RA alone (n = 48) in association with coronary artery bypass grafting. Endpoints included left ventricular remodeling, MR recurrence, overall mortality, reoperation, and a composite cardiac endpoint (cardiac death, stroke, reintervention, hospitalization for heart failure, or New York Heart Association class worsening). Stratification variables were preoperative symmetry of mitral valve tethering and regional wall motion abnormality.
PMA improved ventricular remodeling and recurrence of MR in both preoperative symmetric and asymmetric tethering and in case of inferior wall dyskinesia but did not produce an additional benefit in anterolateral wall dysfunction.
Preoperative symmetric and asymmetric tethering and isolated inferior wall dyskinesia are an indication for subvalvular apparatus surgery in IMR.
据报道，二尖瓣连枷的对称性和区域性左心室壁功能障碍在缺血性二尖瓣反流（IMR）的手术修复结果和长期耐久性中起着至关重要的作用。我们最近在一项随机临床试验（乳头肌近似试验）中证明，在严重 IMR 中，与单独行瓣环成形术相比，乳头肌近似术（PMA）与标准限制性瓣环成形术（RA）联合应用在不良左心室重构和二尖瓣反流（MR）复发方面具有优越性。然而，这种方法并没有产生生存优势，仍然存在高再手术率的问题。因此，我们根据术前参数对 PMA 试验进行了亚组分析，以阐明瓣下手术在某些特定患者亚组中的价值，旨在制定最佳手术策略的决策算法。
我们对 PMA 试验进行了亚组分析，评估了 96 例严重 IMR 且适合行心肌血运重建的患者，这些患者被随机分为 PMA+RA 组（n=48）和单独 RA 组（n=48），并与冠状动脉旁路移植术相关联。终点包括左心室重构、MR 复发、总死亡率、再手术和复合心脏终点（心脏死亡、中风、再次介入、心力衰竭住院或纽约心脏协会分级恶化）。分层变量为术前二尖瓣连枷的对称性和区域性壁运动异常。
PMA 改善了对称性和非对称性连枷以及下壁运动障碍的术前 MR 复发和心室重构，但在前外侧壁功能障碍中并未产生额外的益处。
术前对称和非对称连枷以及孤立性下壁运动障碍是 IMR 行瓣下装置手术的指征。
Zotero 插件