Enriquez-Sarano M, Tajik A J, Schaff H V, Orszulak T A, Bailey K R, Frye R L
Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, MN 55905.
Circulation. 1994 Aug;90(2):830-7. doi: 10.1161/01.cir.90.2.830.
Left ventricular dysfunction is a frequent cause of death after successful surgical repair of mitral regurgitation. The role of preoperative echocardiographic left ventricular variables in the prediction of postoperative survival and thus their clinical implications remain uncertain.
The survival of 409 patients operated on between 1980 and 1989 for pure, isolated, organic mitral regurgitation and with a preoperative echocardiogram (within 6 months of operation) was analyzed. The overall survival was 75% at 5 years (90% of expected), 58% at 10 years (88% of expected), and 44% at 12 years (73% of expected). Operative mortality was 6.6% and markedly improved from 1980 to 1984 (10.7%) to 1985 to 1989 (3.7%). Multivariate analysis showed that age (P = .0003), date of operation (P = .003), and functional class (P = .016) but not left ventricular function were predictors of operative mortality. In the most recent period (1985 to 1989), operative mortality was 12.3% in patients age 75 years or older and 1.1% in patients younger than 75 years. Late survival was analyzed in the operative survivors. Multivariate analysis showed that the most powerful predictor was echocardiographic ejection fraction (EF) (P = .0004), followed by age (P = .0031), creatinine level (P = .0062), systolic blood pressure (P = .0164), and presence of coronary artery disease (P = .0237). The late survival at 10 years was 32 +/- 12% for patients with EF < 50%, 53 +/- 9% for EF 50% to 60%, and 72 +/- 4% for EF > or = 60%. The hazard ratio compared with EF > or = 60% was 2.79 (95% confidence interval, 1.65 to 4.72) for EF < 50% and 1.81 (95% confidence interval, 1.11 to 2.95) for EF 50% to 60%. Echocardiographic EF remained the best predictor of late survival, even when combined with left ventricular angiographic variables. The survival of patients with EF > or = 60% was 100% of expected at 10 years but was better in patients in class I or II than in those in class III or IV (82 +/- 6% versus 59 +/- 6%, respectively, at 10 years; P = .0021). The preoperative predictors of operative and late mortality remained significant independent of the type of surgical correction performed in combined multivariate analyses.
In organic mitral regurgitation, (1) operative mortality has markedly decreased recently, being at a low 1.1% in patients younger than 75 years, and is predicted by age and symptoms and not by left ventricular function, and (2) left ventricular EF measured by echocardiography is the most powerful predictor of late survival. These results suggest that surgical treatment should be considered early, even in the absence of severe symptoms, in patients with severe mitral regurgitation, before left ventricular dysfunction occurs.
左心室功能障碍是二尖瓣反流成功手术修复后常见的死亡原因。术前超声心动图左心室变量在预测术后生存率及其临床意义方面的作用仍不确定。
分析了1980年至1989年间接受单纯、孤立性、器质性二尖瓣反流手术且术前有超声心动图检查（手术前6个月内）的409例患者的生存率。5年总生存率为75%（预期的90%），10年为58%（预期的88%），12年为44%（预期的73%）。手术死亡率为6.6%，从1980年至1984年的10.7%到1985年至1989年的3.7%有显著改善。多变量分析显示，年龄（P = 0.0003）、手术日期（P = 0.003）和功能分级（P = 0.016）而非左心室功能是手术死亡率的预测因素。在最近时期（1985年至1989年），75岁及以上患者的手术死亡率为12.3%，75岁以下患者为1.1%。对手术幸存者进行了晚期生存分析。多变量分析显示，最有力的预测因素是超声心动图射血分数（EF）（P = 0.0004），其次是年龄（P = 0.0031）、肌酐水平（P = 0.0062）、收缩压（P = 0.0164）和冠状动脉疾病的存在（P = 0.0237）。EF<50%的患者10年晚期生存率为32±12%，EF 50%至60%的患者为53±9%，EF≥60%的患者为72±4%。与EF≥60%相比，EF<50%的风险比为2.79（95%置信区间，1.65至4.72），EF 50%至60%的风险比为1.81（95%置信区间，1.11至2.95）。即使与左心室血管造影变量相结合，超声心动图EF仍然是晚期生存的最佳预测因素。EF≥60%的患者10年生存率为预期的100%，但I级或II级患者比III级或IV级患者更好（10年时分别为82±6%和59±6%；P = 0.0021）。在联合多变量分析中，手术和晚期死亡率的术前预测因素仍然是独立于所进行的手术矫正类型的显著因素。
在器质性二尖瓣反流中，（1）手术死亡率最近显著下降，75岁以下患者低至1.1%，其预测因素是年龄和症状而非左心室功能；（2）超声心动图测量的左心室EF是晚期生存的最有力预测因素。这些结果表明，对于严重二尖瓣反流患者，即使在没有严重症状的情况下，在左心室功能障碍发生之前也应尽早考虑手术治疗。
