Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany.
Department of Medicine, Faculty of Medicine, Imperial College London, London, UK.
J Card Surg. 2021 Sep;36(9):3195-3204. doi: 10.1111/jocs.15787. Epub 2021 Jul 5.
Redo surgical mitral valve replacement (SMVR) remains the gold standard treatment in patients with a history of mitral valve surgery presenting with recurrent mitral valve pathologies. Whilst this procedure is demanding, it is an inevitable intervention for some indications, such as infective endocarditis, thrombosis, or multivalve procedures. In this study, we aim to evaluate our institutional experience with SMVR on a real-life cohort, identifying the factors that contribute to poor surgical outcomes whilst avoiding selection bias.
Between March 2012 and November 2020, 58 consecutive high-risk patients underwent a redo SMVR at our institution. The primary endpoints of this study were 30-day and 1-year mortality. The secondary endpoint was the development of any postoperative adverse events. We analyzed and compared the survival in patients undergoing an isolated SMVR and in those that required at least one concomitant procedure.
The overall operative, 30-day, and 1-year mortality were 3.4%, 22.4%, and 25.9%, respectively. The mortality in patients undergoing isolated SMVR was significantly lower than in patients requiring concomitant procedures. The multivariable regression model showed that NYHA Class IV, infective endocarditis, and postoperative dialysis were significantly associated with 30-day mortality. Society of Thoracic Surgeons Score, infective endocarditis, concomitant procedures, and mechanical valve implantation appeared to predict long-term mortality.
This study illustrates that SMVR after prior mitral valve surgery presents a demanding procedure with high operative risk, significant mortality, and morbidity. Whilst this procedure is inevitable for some indications, a careful patient selection and risk stratification provides acceptable surgical results in this cohort.
对于既往行二尖瓣手术且再次出现二尖瓣病变的患者，再次行二尖瓣置换术（SMVR）仍然是金标准治疗方法。虽然该手术具有挑战性，但对于某些适应证，如感染性心内膜炎、血栓形成或多瓣膜手术，这是一种不可避免的干预措施。本研究旨在评估我们机构对真实队列中 SMVR 的经验，确定导致手术结果不佳的因素，同时避免选择偏倚。
2012 年 3 月至 2020 年 11 月，我院连续 58 例高危患者行再次 SMVR。本研究的主要终点为 30 天和 1 年死亡率。次要终点为任何术后不良事件的发生。我们分析并比较了行单纯 SMVR 和至少行 1 次同期手术患者的生存率。
总手术、30 天和 1 年死亡率分别为 3.4%、22.4%和 25.9%。行单纯 SMVR 的患者死亡率明显低于需要同期手术的患者。多变量回归模型显示，NYHA 心功能分级 IV 级、感染性心内膜炎和术后透析与 30 天死亡率显著相关。胸外科医师协会评分、感染性心内膜炎、同期手术和机械瓣植入似乎可预测长期死亡率。
本研究表明，既往二尖瓣手术后再次行 SMVR 是一项具有挑战性的手术，手术风险高，死亡率和发病率高。虽然对于某些适应证来说，该手术是不可避免的，但对患者进行仔细的选择和风险分层可以为该队列提供可接受的手术结果。
