Gimpel Damian, Cheung Michael, Bassin Levi, Jennings Scott, Weiss Beatrix, Akhunji Zakir, Grant Peter, Wolfenden Hugh
School of Medicine Sydney, University of Notre Dame Australia, Sydney, NSW, Australia; Department of Cardiothoracic Surgery, The Prince of Wales Hospital, Sydney, NSW, Australia.
School of Medicine Sydney, University of Notre Dame Australia, Sydney, NSW, Australia.
Heart Lung Circ. 2020 Nov;29(11):1713-1724. doi: 10.1016/j.hlc.2020.03.007. Epub 2020 Apr 9.
Ischaemic mitral regurgitation (IMR) carries significant morbidity and mortality. Surgical management includes coronary artery bypass surgery alone or concomitant with mitral valve repair or replacement. There is ongoing debate regarding the appropriate approach to the mitral valve in relation to long-term outcomes. This review examines our early and late follow-up, with operative and echocardiographic outcomes for mitral valve repair and mitral replacement for chronic IMR.
A retrospective review was performed on prospectively collected data of 119 consecutive patients who either underwent mitral repair (n=101) or mitral replacement (n=18) for chronic IMR at Prince Henry and The Prince of Wales hospitals in Sydney between 1999-2016. All patients had pre and postoperative transthoracic echocardiograms. Follow-up echocardiographic data was obtained from the most recent clinical appointment. Follow-up mortality outcomes were obtained with ethics approval from the Australian National Death Index (NDI).
There was no statistical difference between cardiopulmonary bypass (CPB) time, cross-clamp time, time spent in intensive care unit (ICU) and time to discharge between cohorts. The replacement cohort was noted to have higher preoperative pulmonary artery (PA) pressures and a higher severity of IMR. Seven (7) deaths were in the mitral valve (MV) repair group within 30 days (6.9%) and three deaths in the MV replacement group within 30 days (16.7%). Echocardiographic follow-up was complete in 78% of the MV repair cohort at an average of 4.06±2.66 years, and 73% complete in the MV replacement cohort at an average of 6.09±4.3 years. Three (3) patients had prior MV repair before MV replacement early at days zero and 17, and late at 8 years respectively. Follow-up echocardiography showed mitral regurgitation (MR) in the mitral valve repair cohort as ≤ mild in 83.5% and ≤ trivial in 35.6%. In the MV replacement cohort MR ≤ mild in 100% and ≤ trivial in 82% with no moderate or severe MR. Preoperative tricuspid regurgitation (TR) and a flexible annuloplasty were predictive of an MR grade > mild in the repair cohort at discharge. Five-year (5-year) survival for the repair cohort was 85% with a mean follow-up time of 7.1±3.83 years. For the replacement cohort, five-year survival was 77.8% with a mean follow-up time of 5.35±1.54 years.
Mitral valve repair and replacement for chronic IMR has acceptable mortality, reintervention rates and excellent postoperative echocardiographic degrees of IMR in this cohort. Further evaluation is required into quality of life post intervention for IMR and of preoperative predictive factors of significant MR postoperatively to help guide the appropriate choice of treatment. The presence of preoperative tricuspid regurgitation of moderate grade or higher, and the use of a flexible annuloplasty may indicate patients more likely to have a higher grade of MR at follow-up following mitral valve repair in patients with IMR.
缺血性二尖瓣反流（IMR）具有较高的发病率和死亡率。手术治疗包括单独进行冠状动脉搭桥手术或同时进行二尖瓣修复或置换。关于二尖瓣的合适治疗方法及其长期疗效，目前仍存在争议。本综述探讨了我们对慢性IMR患者进行二尖瓣修复和二尖瓣置换后的早期及晚期随访情况，包括手术及超声心动图结果。
对1999年至2016年间在悉尼的亨利王子医院和威尔士王子医院连续接受慢性IMR二尖瓣修复（n = 101）或二尖瓣置换（n = 18）的119例患者的前瞻性收集数据进行回顾性分析。所有患者均有术前和术后经胸超声心动图检查。随访超声心动图数据来自最近的临床检查。随访死亡率数据经伦理批准后从澳大利亚国家死亡指数（NDI）获取。
两组患者在体外循环（CPB）时间、主动脉阻断时间、重症监护病房（ICU）停留时间和出院时间方面无统计学差异。置换组患者术前肺动脉（PA）压力较高，IMR程度较严重。二尖瓣修复组30天内有7例（6.9%）死亡，二尖瓣置换组30天内有3例（16.7%）死亡。二尖瓣修复组78%的患者完成了平均4.06±2.66年的超声心动图随访，二尖瓣置换组73%的患者完成了平均6.09±4.3年的随访。3例患者分别在术后第0天、第17天和第8年早期进行二尖瓣置换前曾接受过二尖瓣修复。随访超声心动图显示，二尖瓣修复组二尖瓣反流（MR）≤轻度的占83.5%，≤微量的占35.6%。二尖瓣置换组MR≤轻度的占100%，≤微量的占82%，无中度或重度MR。术前三尖瓣反流（TR）和采用可弯曲成形环是修复组出院时MR分级>轻度的预测因素。修复组5年生存率为85%，平均随访时间为7.1±3.83年。置换组5年生存率为77.8%，平均随访时间为5.35±1.54年。
对于慢性IMR患者，二尖瓣修复和置换具有可接受的死亡率、再次干预率，术后IMR的超声心动图程度良好。需要进一步评估IMR干预后的生活质量以及术后显著MR的术前预测因素，以帮助指导合适的治疗选择。术前存在中度或更高等级的三尖瓣反流以及采用可弯曲成形环，可能提示IMR患者二尖瓣修复术后随访时MR等级较高的可能性更大。
