Zhao Wei, Tiemuerniyazi Xieraili, Song Yangwu, Nan Yifeng, Yang Zi'ang, Xu Fei, Feng Wei
Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
J Thorac Dis. 2022 Aug;14(8):2771-2780. doi: 10.21037/jtd-22-278.
Controversies exist on the treatment of moderate functional mitral regurgitation (FMR) in patients with severe aortic valve disease undergoing the aortic valve replacement (AVR). While a substantial proportion of these patients can be complicated with heart failure with midrange ejection fraction (HFmrEF), established studies show that the latter might compromise the patient outcome. This study was aimed to evaluate the prognostic value of concomitant mitral valve surgery during AVR in patients with severe aortic valve disease followed by moderate FMR and HFmrEF.
A total of 78 consecutive patients were retrospectively recruited. Patients were divided into control (isolated AVR) and treatment (AVR + mitral valve surgery) groups. Follow-up outcomes were compared by Kaplan-Meier method, followed by multiple adjustment with inverse probability treatment weighting (IPTW) analysis. The primary outcome was the occurrence of major adverse cardiovascular and cerebrovascular events (MACCE).
Thirty-six patients received isolated AVR, while 42 received AVR with mitral valve repair or replacement. The median follow-up time was 28.7 months. Unadjusted analysis showed that there was no significant difference in the rate of MACCE between the two groups [hazard ratio (HR): 1.14, 95% confidence interval (CI): 0.48-2.69, P=0.770], which was sustained in IPTW analysis (HR: 1.64, 95% CI: 0.59-4.55, P=0.342). In addition, while concomitant mitral valve surgery improved follow-up FMR more completely (P=0.026) in the IPTW analysis, the ejection fraction was comparable between the two groups (P=0.276). Furthermore, IPTW analysis also showed that mitral valve surgery was associated with the increased risk of postoperative acute kidney injury (P=0.007).
In patients with aortic valve disease followed by moderate FMR and HFmrEF, mitral valve surgery concomitant to AVR may not bring extra benefit in the MACCE-free survival and the improvement of HFmrEF. However, while concomitant mitral valve surgery has priority on the complete improvement of FMR, it might increase the risk of postoperative acute kidney injury.
对于重度主动脉瓣疾病患者在接受主动脉瓣置换术（AVR）时，中度功能性二尖瓣反流（FMR）的治疗存在争议。虽然这些患者中有很大一部分可能并发射血分数中等范围的心力衰竭（HFmrEF），但现有研究表明，后者可能会影响患者的预后。本研究旨在评估在重度主动脉瓣疾病伴中度FMR和HFmrEF患者中，AVR同期行二尖瓣手术的预后价值。
回顾性纳入78例连续患者。患者分为对照组（单纯AVR）和治疗组（AVR + 二尖瓣手术）。采用Kaplan-Meier法比较随访结果，随后采用逆概率处理加权（IPTW）分析进行多重调整。主要结局是主要不良心血管和脑血管事件（MACCE）的发生。
36例患者接受单纯AVR，42例接受AVR并二尖瓣修复或置换。中位随访时间为28.7个月。未调整分析显示，两组MACCE发生率无显著差异[风险比（HR）：1.14，95%置信区间（CI）：0.48 - 2.69，P = 0.770]，IPTW分析结果一致（HR：1.64，95% CI：0.59 - 4.55，P = 0.342）。此外，虽然在IPTW分析中，同期二尖瓣手术能更彻底地改善随访期FMR（P = 0.026），但两组射血分数相当（P = 0.276）。此外，IPTW分析还显示，二尖瓣手术与术后急性肾损伤风险增加相关（P = 0.007）。
对于重度主动脉瓣疾病伴中度FMR和HFmrEF患者，AVR同期行二尖瓣手术在无MACCE生存和改善HFmrEF方面可能不会带来额外益处。然而，同期二尖瓣手术虽在完全改善FMR方面具有优势，但可能会增加术后急性肾损伤的风险。
