Department of Cardiac Surgery, Cardiothoracic Center of Monaco, Monte Carlo, Monaco.
Department of Cardiac Surgery, Cardiothoracic Center of Monaco, Monte Carlo, Monaco.
J Thorac Cardiovasc Surg. 2018 Nov;156(5):1856-1866.e3. doi: 10.1016/j.jtcvs.2018.05.017. Epub 2018 May 28.
Avoiding resection to treat posterior leaflet prolapse has become popular to repair degenerative mitral regurgitation. We never subscribed to such simplification but advocated an alternative approach based on the "respect when you can, resect when you should" concept. The present study reviewed posterior leaflet prolapse in degenerative disease with the aim to expose the 10-year experience with this surgical policy, in particular long-term outcomes such as survival, recurrent/severe mitral regurgitation, and reoperation.
From January 2005 to December 2015, 701 consecutive patients with severe mitral regurgitation underwent mitral valve repair in 2 distinct institutions. Mitral regurgitation was degenerative in 441 patients, of whom the 376 with posterior leaflet prolapse constituted the study population. Patients were followed up by echocardiograms until December 2017. Longitudinal data stratified by institution were analyzed by mixed-effects models. Outcome measures were analyzed by Kaplan-Meier test.
Patients with posterior leaflet prolapse (24.7% isolated P2 and 75.3% P2 associated with other segments) were aged 65.8 ± 13 years, and 70.5% were male. Median follow-up was 61.1 months. There were 3 hospital deaths (0.8%). Reoperation was necessary in 7 patients (1.9%). After 1, 5, and 10 years, overall survival was 97.8%, 93.6%, and 86.7%, respectively; the overall survival of the proportion of patients with recurrent/residual >2+ mitral regurgitation was estimated at 0.7%, 1.9%, and 5.9% and that of patients with New York Heart Association III/IV at 0.8%, 1.9%, and 5.3%.
The "resect with respect" approach yields low operative mortality, no systolic anterior motion, good surface of coaptation, and low incidence of residual/recurrent mitral regurgitation and of reoperation, thus supporting resection when required concept.
避免切除以治疗后瓣叶脱垂已成为修复退行性二尖瓣反流的流行方法。我们从不接受这种简化，但主张基于“能保留时保留，应切除时切除”的理念采用另一种方法。本研究回顾了退行性疾病中的后瓣叶脱垂，旨在揭示该手术策略的 10 年经验，特别是长期结果，如存活率、复发性/严重二尖瓣反流和再次手术。
2005 年 1 月至 2015 年 12 月，在 2 家不同的机构中，701 例严重二尖瓣反流患者接受了二尖瓣修复术。441 例二尖瓣反流为退行性，其中 376 例后瓣叶脱垂患者构成研究人群。通过超声心动图对患者进行随访，直至 2017 年 12 月。通过混合效应模型对机构分层的纵向数据进行分析。采用 Kaplan-Meier 检验分析结果。
后瓣叶脱垂患者（24.7%孤立性 P2 和 75.3% P2 伴其他节段）年龄为 65.8±13 岁，70.5%为男性。中位随访时间为 61.1 个月。有 3 例院内死亡（0.8%）。7 例患者需要再次手术（1.9%）。1、5 和 10 年时，总生存率分别为 97.8%、93.6%和 86.7%；估计复发性/残留>2+二尖瓣反流患者的总体生存率分别为 0.7%、1.9%和 5.9%，纽约心脏协会心功能 III/IV 级患者的总体生存率分别为 0.8%、1.9%和 5.3%。
“保留但切除”的方法可降低手术死亡率、无收缩期前向运动、获得良好的对合面，且降低残余/复发性二尖瓣反流和再次手术的发生率，因此支持在需要时进行切除的理念。
