Kalil R A, Lucchese F A, Prates P R, Sant'Anna J R, Faes F C, Pereira E, Nesralla I A
Department of Surgery, Sul/Fundação Universitária de Cardiologia, Porto Alegre, Brazil.
J Am Coll Cardiol. 1993 Dec;22(7):1915-20. doi: 10.1016/0735-1097(93)90779-z.
The aim of this study was to evaluate medium- and long-term (range 4 months to 17 years) clinical results in a series of patients treated surgically by unsupported mitral annuloplasty.
Mitral valve regurgitation has usually been treated by valve replacement or ring annuloplasty. A few series have reported plastic repair procedures without annular support or remodeling. Furthermore, in rheumatic lesions the results have been inferior to those in degenerative mitral insufficiency, and the majority of previous reports have provided information on short- or medium-term follow-up.
One hundred fifty-four patients were operated on (55 male [36%] and 99 female [64%]). The mean age +/- SD was 36 +/- 16 years (range 5 to 73). Associated lesions comprised 47 aortic and 21 tricuspid valve lesions and 2 atrial septal defects. Patients with concomitant mitral stenosis were not included. Preoperative functional class was I or II in 19% and III or IV in 81%. The cardiothoracic ratio was 0.61 +/- 0.10. All patients underwent an unsupported mitral annuloplasty procedure in which the mural portion of the annulus was reduced by applying two buttressed mattress sutures at the commissures without compromising the width of the septal leaflet. When necessary, additional chordal procedures were performed. No patients received ring or posterior annular support.
The early mortality rate was 1.9% (three patients; one of the three died of myocardial failure and two of pulmonary thromboembolism). The late mortality rate was 5.8% (nine patients; three of the nine died of myocardial failure, one each of septicemia, pulmonary thromboembolism and sudden arrhythmic death and three of unknown causes). Twenty-eight patients (18.2%) were reoperated on because of mitral valve dysfunction and 2 (1.3%) because of prosthetic aortic valve dysfunction. A residual late systolic murmur was present in 48% of patients. Late complications were systemic thromboembolism in 5.8% (one third with an aortic valve prosthesis), infective endocarditis in 1.3% and pulmonary thromboembolism in 0.6%. Postoperative functional class was I or II in 84% and III or IV in 16%. Cardiothoracic ratio was 0.58 +/- 0.10. Actuarial probability of late survival was 79.5 +/- 5.3% at 10 years and 71.0 +/- 7.4% at 14 years. Event-free survival was 67.9 +/- 8.9% at 10 years and 56.1 +/- 11.7% at 14 years.
Rheumatic mitral regurgitation can be effectively treated by annuloplasty without prosthetic annular support, with late results comparable to those obtained with more complicated procedures. This observation is particularly important for treatment of children and young adult patients.
本研究旨在评估一系列接受无支撑二尖瓣环成形术手术治疗患者的中长期（4个月至17年）临床结果。
二尖瓣反流通常通过瓣膜置换或环成形术治疗。少数系列报道了无瓣环支撑或重塑的整形修复手术。此外，在风湿性病变中，结果不如退行性二尖瓣关闭不全，并且大多数先前的报告提供了短期或中期随访信息。
154例患者接受了手术（55例男性[36%]和99例女性[64%]）。平均年龄±标准差为36±16岁（范围5至73岁）。相关病变包括47例主动脉瓣和21例三尖瓣病变以及2例房间隔缺损。不包括合并二尖瓣狭窄的患者。术前功能分级为I或II级的占19%，III或IV级的占81%。心胸比率为0.61±0.10。所有患者均接受了无支撑二尖瓣环成形术，在瓣环的壁部通过在瓣叶交界处应用两根带垫片的褥式缝线来缩小，同时不影响隔叶的宽度。必要时，进行额外的腱索手术。没有患者接受瓣环或后瓣环支撑。
早期死亡率为1.9%（3例患者；3例中的1例死于心肌衰竭，2例死于肺血栓栓塞）。晚期死亡率为5.8%（9例患者；9例中的3例死于心肌衰竭，1例死于败血症、1例死于肺血栓栓塞和1例死于心律失常性猝死，3例死因不明）。28例患者（18.2%）因二尖瓣功能障碍再次手术，2例（1.3%）因人工主动脉瓣功能障碍再次手术。48%的患者存在残余晚期收缩期杂音。晚期并发症包括5.8%的系统性血栓栓塞（三分之一伴有主动脉瓣人工瓣膜）、1.3%的感染性心内膜炎和0.6%的肺血栓栓塞。术后功能分级为I或II级的占84%，III或IV级的占16%。心胸比率为0.58±0.10。10年时晚期生存的精算概率为79.5±5.3%，14年时为71.0±7.4%。无事件生存10年时为67.9±8.9%，14年时为56.1±11.7%。
风湿性二尖瓣反流可通过无人工瓣环支撑的瓣环成形术有效治疗，晚期结果与更复杂手术相当。这一观察结果对儿童和年轻成年患者的治疗尤为重要。
