Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Hamburg, Germany.
Eur J Cardiothorac Surg. 2021 Jul 14;60(1):122-130. doi: 10.1093/ejcts/ezab048.
Functional mitral regurgitation (FMR) is a sequel of left ventricular (LV) remodelling in heart failure patients. Relocation of both papillary muscles aims to specifically address mitral leaflet tethering to improve long-term durability of modern FMR repair. Nevertheless, the prognostic impact of the underlying cardiomyopathy on the outcome after FMR repair is unknown.
We analysed 84 consecutive heart failure patients with severe FMR, LV ejection fraction <40%, LV end-diastolic diameter ≥55 mm and tenting height >10 mm, who underwent ring annuloplasty and simultaneous bilateral papillary muscles relocation between June 2016 and March 2019. One-year outcome of 54 patients with ischaemic cardiomyopathy ('ICM group') was prospectively compared to the remaining 30 patients with dilated cardiomyopathy ('DCM group').
One-year survival was similar in both groups (96% in the 'ICM group' vs 97% in the 'DCM group'; P = 0.93). Furthermore, primary composite outcome (i.e. freedom from death or mitral regurgitation ≥ 2) at 1-year postoperatively was comparable between the study groups (94%in the 'ICM group' vs 87% in the 'DCM group'; P = 0.10). LV end-diastolic diameter 1-year after surgery was significantly reduced, as compared to preoperative values, in the 'DCM group' (P = 0.018), but not in the 'ICM group' (P = 0.058). Improvement of New York Heart Association functional class and reduction of serum levels of N-terminal pro-B natriuretic peptide at 1 year was comparable in both study groups.
Standardized relocation of both papillary muscles to correct FMR resulted in very satisfactory in-hospital and 1-year outcomes, in both ICM and DCM. DCM patients showed similar improvement in heart failure symptoms and LV re-remodelling compared to ICM patients. Subannular repair is developing towards a valid therapeutic option in heart failure patients presenting with severe FMR.
功能性二尖瓣反流（FMR）是心力衰竭患者左心室（LV）重构的后果。将两个乳头肌进行移位的目的是专门解决二尖瓣瓣叶的牵张，以提高现代 FMR 修复的长期耐久性。然而，基础心肌病对 FMR 修复后结局的预后影响尚不清楚。
我们分析了 2016 年 6 月至 2019 年 3 月间连续 84 例因严重 FMR、LV 射血分数 <40%、LV 舒张末期直径≥55mm 和游离壁高度>10mm 而行环形瓣环成形术和双侧乳头肌同时移位的心力衰竭患者。前瞻性比较了 54 例缺血性心肌病（“ICM 组”）和 30 例扩张型心肌病（“DCM 组”）患者的 1 年结果。
两组患者 1 年生存率相似（ICM 组 96% vs DCM 组 97%；P=0.93）。此外，两组患者术后 1 年主要复合终点（即无死亡或二尖瓣反流≥2 级）无显著差异（ICM 组 94% vs DCM 组 87%；P=0.10）。与术前相比，DCM 组患者术后 1 年 LV 舒张末期直径明显减小（P=0.018），而 ICM 组患者则无明显变化（P=0.058）。两组患者在 1 年时纽约心功能分级的改善和血清 N 端脑钠肽前体水平的降低均无显著差异。
标准化的双侧乳头肌移位术纠正 FMR 可获得非常满意的住院和 1 年结果，在 ICM 和 DCM 患者中均如此。与 ICM 患者相比，DCM 患者心力衰竭症状和 LV 再重构的改善情况相似。对于存在严重 FMR 的心力衰竭患者，瓣下修复正在发展成为一种有效的治疗选择。
