经导管二尖瓣修复术后，单个夹子的植入是否能提供可靠的耐久性？
Does implantation of a single clip provide reliable durability after transcatheter mitral repair?
机构信息
Department of Cardiac Surgery, San Raffaele Scientific Institute, Milan, Italy.
出版信息
Eur J Cardiothorac Surg. 2017 Jul 1;52(1):137-142. doi: 10.1093/ejcts/ezx044.
OBJECTIVES
A single MitraClip implant is often considered enough to achieve adequate mitral regurgitation (MR) reduction. The aim of this study was to compare MR recurrence in patients with an initial optimal result treated with a single clip versus those treated with two clips.
METHODS
From October 2008 to May 2016, 322 patients were treated with the MitraClip procedure at our institution. We retrospectively selected all patients treated for functional MR (FMR) and degenerative MR (DMR) aetiologies with residual MR ≤1+, excluding patients who required >2 clips. FMR and DMR were analysed separately.
RESULTS
In FMR, a single clip was used in 45 patients and 2 clips in 99 patients. The single clip group had smaller coaptation depth (1.1 ± 0.3 vs 1.3 ± 0.3 mm, P = 0.022) and jet extension (10.5 ± 2.1 vs 13.0 ± 3.6 mm, P = 0.026) as well as left ventricular end-diastolic diameter (64.4 ± 7.3 vs 69.0 ± 7.9 mm, P = 0.001). Freedom from MR ≥ 3+ after 4 years was 71.9 ± 8.9% in patients receiving a single clip vs 88.0 ± 5.2% in those receiving 2 clips, single clip use being an independent predictor of MR recurrence (HR 3.48, CI 1.24-9.81, P = 0.018). In DMR, a single clip was deployed in 24 patients and 2 clips in 30 patients. The single clip group had a smaller flail gap (3.6 ± 0.7 vs 6.8 ± 2.5, P = 0.002). Freedom from MR ≥ 3+ after 2 years was 82.5 ± 8% in patients with a single clip vs 100% in those with 2 clips, P = 0.014. The residual mitral area was reduced in patients with 2 clips compared with those with single clip, both in FMR ( P = 0.015) and DMR ( P = 0.039), but it was not associated with increased death rate during the follow-up period (all P > 0.05).
CONCLUSIONS
Despite favourable anatomical characteristics and an optimal initial result, implantation of a single clip was associated with an increased recurrence of MR compared with that of 2 clips, both in FMR and in DMR. Caution should be exercised with the implantation of a single clip.
目的
通常认为单次使用 MitraClip 植入物就足以实现足够的二尖瓣反流（MR）减少。本研究的目的是比较初始结果为最佳且接受单次夹合器治疗与接受两次夹合器治疗的患者的 MR 复发情况。
方法
从 2008 年 10 月至 2016 年 5 月，我院对 322 例患者进行了 MitraClip 手术治疗。我们回顾性地选择了所有因功能性 MR（FMR）和退行性 MR（DMR）病因且残留 MR≤1+而接受治疗的患者，不包括需要使用超过 2 个夹合器的患者。分别对 FMR 和 DMR 进行分析。
结果
在 FMR 中，45 例患者使用了单个夹合器，99 例患者使用了两个夹合器。单夹合器组的闭合深度（1.1±0.3 毫米 vs. 1.3±0.3 毫米，P=0.022）和射流延伸（10.5±2.1 毫米 vs. 13.0±3.6 毫米，P=0.026）以及左心室舒张末期直径（64.4±7.3 毫米 vs. 69.0±7.9 毫米，P=0.001）均较小。接受单夹合器治疗的患者在 4 年后 MR≥3+的无复发率为 71.9%±8.9%，而接受双夹合器治疗的患者为 88.0%±5.2%，单夹合器的使用是 MR 复发的独立预测因素（HR 3.48，95%CI 1.24-9.81，P=0.018）。在 DMR 中，24 例患者使用了单个夹合器，30 例患者使用了两个夹合器。单夹合器组的瓣叶撕裂间隙较小（3.6±0.7 毫米 vs. 6.8±2.5 毫米，P=0.002）。在接受单夹合器治疗的患者中，2 年后 MR≥3+的无复发率为 82.5%±8%，而接受双夹合器治疗的患者为 100%，P=0.014。与接受单夹合器治疗的患者相比，接受双夹合器治疗的患者二尖瓣残余面积减小，无论是在 FMR（P=0.015）还是 DMR（P=0.039）中，这与随访期间死亡率的增加无关（所有 P 值均>0.05）。
结论
尽管解剖学特征良好且初始结果最佳，但与接受两次夹合器治疗的患者相比，单次夹合器植入物与 FMR 和 DMR 患者的 MR 复发增加相关。在植入单夹合器时应谨慎。
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