Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich.
Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich.
J Thorac Cardiovasc Surg. 2021 Oct;162(4):1087-1096.e3. doi: 10.1016/j.jtcvs.2019.11.148. Epub 2020 Mar 5.
Mitral valve repair is superior to replacement for degenerative disease, but long-term outcomes of anterior versus posterior leaflet repair remain poorly defined. We propensity matched anterior and posterior repairs to compare long-term outcomes.
Patients undergoing first-time degenerative mitral repair between 1992 and 2018 were identified. Primary outcome was overall survival. Secondary outcomes were postprocedural residual mitral regurgitation and reoperation. From 1025 patients, 1:1 propensity score matching was performed, yielding 309 anterior (isolated anterior = 85, bileaflet = 224) and 309 isolated posterior repairs.
Age was 58 ± 15 years, ejection fraction was 57% ± 10%, and matched groups were well balanced. Anterior repairs had longer bypass (122 ± 53 vs 109 ± 43 minutes, P = .001) and crossclamp (94 ± 44 vs 85 ± 62 minutes, P = .033) times. Mean residual mitral regurgitation grade was 0.44 (95% confidence interval, 0.24-0.65) for anterior repair and 0.30 (95% confidence interval, 0.13-0.47) for posterior repair (P = .31). Overall, 92% (569/618) of matched patients had no residual mitral regurgitation, with no differences in mitral regurgitation grade between groups (P = .77). Survival did not differ between anterior (10 years: 72% ± 7%; 15 years: 63% ± 7%) and posterior (10 years: 74% ± 7%; 15 years: 60% ± 8%) groups (log-rank P = .93). Linearized incidence of reoperation was 0.62% per patient-year, including 0.74% for anterior and 0.48% for posterior repairs. Cumulative incidence of reoperation at 15 years was 7.5% after anterior repair and 4.9% after posterior repair (Gray's test P = .26).
No long-term survival or reoperation difference was found between posterior and anterior repair. On the basis of these findings, surgeons at centers of excellence should aim for repair of both anterior and posterior leaflet pathology with the same decision-making threshold over valve replacement for degenerative mitral disease.
二尖瓣修复在退行性疾病中优于置换，但前瓣和后瓣修复的长期结果仍不清楚。我们通过倾向评分匹配比较了前瓣和后瓣修复的长期结果。
回顾性分析 1992 年至 2018 年间接受首次退行性二尖瓣修复的患者。主要结局是总生存率。次要结局是术后残余二尖瓣反流和再次手术。从 1025 例患者中，进行了 1:1 的倾向评分匹配，得到 309 例前瓣（单纯前瓣修复=85 例，双瓣修复=224 例）和 309 例单纯后瓣修复。
年龄为 58±15 岁，射血分数为 57%±10%，匹配组之间平衡良好。前瓣修复的体外循环时间（122±53 分钟比 109±43 分钟，P=0.001）和阻断时间（94±44 分钟比 85±62 分钟，P=0.033）较长。前瓣修复的残余二尖瓣反流程度平均为 0.44（95%置信区间，0.24-0.65），后瓣修复为 0.30（95%置信区间，0.13-0.47）（P=0.31）。总体而言，618 例匹配患者中有 92%（569/618）无残余二尖瓣反流，两组之间的二尖瓣反流程度无差异（P=0.77）。前瓣组（10 年：72%±7%；15 年：63%±7%）和后瓣组（10 年：74%±7%；15 年：60%±8%）的生存率无差异（对数秩 P=0.93）。线性化再手术发生率为 0.62%/患者年，其中前瓣为 0.74%，后瓣为 0.48%。前瓣修复后 15 年的累积再手术发生率为 7.5%，后瓣修复为 4.9%（Gray 检验 P=0.26）。
在后瓣和前瓣修复之间未发现长期生存或再手术差异。基于这些发现，在二尖瓣退行性疾病的治疗中，卓越中心的外科医生应在瓣膜置换和前瓣和后瓣修复之间采用相同的决策阈值，以修复前瓣和后瓣的病理。
