Rutledge R, McIntosh C L, Morrow A G, Picken C A, Siwek L G, Zwischenberger J B, Schier J J
Circulation. 1982 Aug;66(2 Pt 2):I162-6.
Closed mitral commissurotomy (CMC) was performed at the National Heart Institute in 303 patients (73% women, 27% men; mean age 40 years) with acquired isolated mitral stenosis between 1954 and 1980. The average mean mitral valve gradient decreased from 14.2 +/- 0.4 to 5.3 +/- 0.4 mm Hg (p less than 0.001), and mitral valve area index increased from 0.7 +/- 0.03 to 1.4 +/- 0.9 cm2/m2 (p less than 0.001). The perioperative mortality was 2%. Ninety-two percent of patients improved one or more functional classes after CMC. Actuarial survival was 95%, 82% and 70% at 5, 10 and 15 years after CMC, respectively. Fifty-four patients (18%) required mitral valve replacement (MVR) a mean of 9.6 years after commissurotomy (range 1-26 years). Before CMC, factors associated with later MVR included preoperative functional class, calcification of the mitral valve, and the absence of an opening snap. After CMC, poor functional improvement, congestive heart failure, atrial fibrillation, and the necessity for a repeat CMC were associated with late MVR. Catheterization after CMC showed that patients who later required MVR had a smaller decrease in left atrial pressure (p less than 0.001), more mitral regurgitation (p less than 0.001), and were more likely to have pulmonary hypertension (p less than 0.05). The indications for MVR were residual stenosis with or without mild mitral regurgitation in 33 patients (61%), restenosis in 15 (28%), and moderate-to-severe regurgitation in six (11%). Perioperative mortality for valve replacement was 13%. Among survivors, 88% improved at least one functional class after valve replacement. Actuarial survival was estimated to be 95% at 5 years and 74% at 10 years after MVR. This study confirms that CMC provides excellent long-term hemodynamic and clinical improvement in appropriately selected patients. When symptomatic deterioration occurs late after CMC, MVR restores clinical and hemodynamic improvement in many patients. CMC continues to be performed at the National Heart Institute in selected patients with acquired mitral stenosis.
1954年至1980年间，国立心脏研究所对303例获得性单纯二尖瓣狭窄患者（73%为女性，27%为男性；平均年龄40岁）实施了闭式二尖瓣交界切开术（CMC）。二尖瓣平均压差从14.2±0.4毫米汞柱降至5.3±0.4毫米汞柱（p<0.001），二尖瓣面积指数从0.7±0.03平方厘米/平方米增至1.4±0.9平方厘米/平方米（p<0.001）。围手术期死亡率为2%。92%的患者在CMC术后功能分级改善一级或更多。CMC术后5年、10年和15年的精算生存率分别为95%、82%和70%。54例患者（18%）在交界切开术后平均9.6年（范围1至26年）需要进行二尖瓣置换术（MVR）。在CMC术前，与后期MVR相关的因素包括术前功能分级、二尖瓣钙化以及无开瓣音。在CMC术后，功能改善不佳、充血性心力衰竭、心房颤动以及再次进行CMC的必要性与后期MVR相关。CMC术后的心导管检查显示，后期需要MVR的患者左心房压力下降较小（p<0.001），二尖瓣反流更多（p<0.001），且更易出现肺动脉高压（p<0.05）。MVR的适应证为33例患者（61%）存在残余狭窄伴或不伴轻度二尖瓣反流，15例（28%）为再狭窄，6例（11%）为中重度反流。瓣膜置换术的围手术期死亡率为13%。在幸存者中，88%在瓣膜置换术后功能分级至少改善一级。MVR术后5年的精算生存率估计为95%，10年为74%。本研究证实，对于适当选择的患者，CMC可带来出色的长期血流动力学和临床改善。当CMC术后出现症状性恶化时，MVR可使许多患者恢复临床和血流动力学改善。国立心脏研究所仍在对部分获得性二尖瓣狭窄患者进行CMC手术。
