Bolling S F, Deeb G M, Brunsting L A, Bach D S
Department of Thoracic Surgery, University of Michigan, Ann Arbor, USA.
J Thorac Cardiovasc Surg. 1995 Apr;109(4):676-82; discussion 682-3. doi: 10.1016/S0022-5223(95)70348-9.
Uncontrollable severe mitral regurgitation is a frequent complication of end-stage cardiomyopathy, significantly contributing to heart failure in these patients, and predicts a poor survival. Although elimination of mitral valve regurgitation could be most beneficial in this group, corrective mitral valve surgery has not been routinely undertaken in these very ill patients because of the presumed prohibitive operative mortality. We studied the early outcome of mitral valve reconstruction in 16 consecutive patients with cardiomyopathy and severe, refractory mitral regurgitation operated on between June 1993 and April 1994. There were 11 men and five women, aged 44 to 78 years (64 +/- 8 years) with left ventricular ejection fractions of 9% to 25% (16% +/- 5%). Preoperatively all patients were in New York Heart Association class IV, had severe mitral regurgitation (graded 0 to 4+ according to color flow Doppler transesophageal echocardiography) and two were listed for transplantation. Operatively, a flexible annuloplasty ring was implanted in all patients. Four patients also had single coronary bypass grafting for incidental coronary disease. In four patients the operation was performed through a right thoracotomy because of prior coronary bypass grafting, and four patients also underwent tricuspid valve reconstruction for severe tricuspid regurgitation. No patient required support with an intraaortic balloon pump. There were no operative or hospital deaths and mean hospital stay was 10 days. There were three late deaths at 2, 6, and 7 months after mitral valve reconstruction, and the 1-year actuarial survival has been 75%. At a mean follow-up of 8 months, all remaining patients are in New York Heart Association class I or II, with a mean postoperative ejection fraction of 25% +/- 10%. There have been no hospitalizations for congestive heart failure, and a decrease in medications required has been noted. For patients with cardiomyopathy and severe mitral regurgitation, mitral valve reconstruction as opposed to replacement can be accomplished with low operative and early mortality. Although longer term follow-up is mandatory, mitral valve reconstruction may allow new strategies for patients with end-stage cardiomyopathy and severe mitral regurgitation, yielding improvement in symptomatic status and survival.
无法控制的严重二尖瓣反流是终末期心肌病常见的并发症，在这些患者中显著导致心力衰竭，并预示着生存预后不良。尽管消除二尖瓣反流对这组患者可能最为有益，但由于推测手术死亡率过高，二尖瓣矫正手术在这些病情严重的患者中尚未常规开展。我们研究了1993年6月至1994年4月期间连续接受手术的16例患有心肌病且伴有严重难治性二尖瓣反流患者二尖瓣重建的早期结果。其中男性11例，女性5例，年龄44至78岁（平均64±8岁），左心室射血分数为9%至25%（平均16%±5%）。术前所有患者均处于纽约心脏协会心功能IV级，有严重二尖瓣反流（根据彩色多普勒经食管超声心动图分级为0至4+），其中2例已列入心脏移植名单。手术中，所有患者均植入了可弯曲的瓣环成形环。4例患者因合并冠心病还接受了单支冠状动脉搭桥术。4例患者因既往有冠状动脉搭桥术史，通过右胸切口进行手术，4例患者因严重三尖瓣反流还接受了三尖瓣重建术。无一例患者需要主动脉内球囊泵支持。无手术死亡或住院死亡病例，平均住院时间为10天。二尖瓣重建术后2个月、6个月和7个月有3例晚期死亡，1年预期生存率为75%。平均随访8个月时，所有存活患者均处于纽约心脏协会心功能I级或II级，术后平均射血分数为25%±10%。无因充血性心力衰竭住院的情况，且所需药物有所减少。对于患有心肌病和严重二尖瓣反流的患者，与二尖瓣置换相比，二尖瓣重建手术的手术死亡率和早期死亡率较低。尽管需要长期随访，但二尖瓣重建可能为终末期心肌病和严重二尖瓣反流患者带来新的治疗策略，改善症状状态和生存率。
