Chua Y L, Schaff H V, Orszulak T A, Morris J J
Section of Cardiovascular Surgery, Mayo Clinic, Rochester, MN 55905.
J Thorac Cardiovasc Surg. 1994 Feb;107(2):408-15.
To examine late outcome of mitral valve repair in patients with preoperative atrial fibrillation, we reviewed the cases of 323 consecutive patients who underwent mitral valvuloplasty for mitral regurgitation from 1980 to 1991; average age of 215 men and 108 women was 64 years (range 14 to 88 years), and 224 patients (70%) were in New York Heart Association class III or IV before operation. The main indications for operation were severe mitral regurgitation (76%), coronary artery disease with associated mitral regurgitation (15%), and aortic valve disease (6%). At the time of mitral valve repair, coronary artery bypass grafting was done in 35% of patients, aortic valve replacement was done in 7%, and multiple other procedures were done in 10%. For all patients, the 30-day mortality rate was 2.5% (70% confidence limits 1.6% to 3.4%) and survivorships at 3 and 5 years were 81% and 76%, respectively. Before operation, 216 patients were in sinus rhythm and 97 patients had atrial fibrillation; in the latter group, 11 had recent onset of atrial fibrillation within 3 months preceding mitral valve repair. Comparing patients with preoperative atrial fibrillation to those with sinus rhythm, we found no significant difference in operative mortality (3% versus 1.9%) or 5-year survivorship (74.3% +/- 6.3% versus 76.9% +/- 4.0%). At late follow-up, atrial fibrillation was present in 5% of patients with preoperative sinus rhythm, 80% of patients with preoperative chronic atrial fibrillation, and 0% of patients with preoperative recent onset atrial fibrillation (p < 0.01). The left atrial size by echocardiography was larger in patients with preoperative atrial fibrillation compared with that in those with sinus rhythm (59 +/- 1.4 mm versus 50.9 +/- 0.7 mm; p < 0.05). There was, however, only a weak correlation between preoperative left atrial size and late atrial fibrillation. Further, age, gender, and associated coronary artery disease did not correlate with presence of atrial fibrillation at late follow-up. Prevalence of late thromboembolic events was similar in patients with preoperative sinus rhythm compared with that in those with atrial fibrillation. These data suggest that mitral valve repair should be done before or soon after the onset of atrial fibrillation to maximize the chance of postoperative sinus rhythm and avoid long-term anticoagulation with warfarin. However, the early and late results of mitral valve repair in patients with chronic atrial fibrillation are good, and concomitant operation for supraventricular arrhythmia must have negligible morbidity and no adverse effect on operative mortality.
为了研究术前房颤患者二尖瓣修复的远期疗效，我们回顾了1980年至1991年间连续323例行二尖瓣成形术治疗二尖瓣反流患者的病例；215例男性和108例女性的平均年龄为64岁（范围14至88岁），224例患者（70%）术前为纽约心脏协会III或IV级。手术的主要适应证为重度二尖瓣反流（76%）、合并二尖瓣反流的冠状动脉疾病（15%）和主动脉瓣疾病（6%）。在二尖瓣修复时，35%的患者同期行冠状动脉旁路移植术，7%的患者行主动脉瓣置换术，10%的患者行其他多种手术。所有患者的30天死亡率为2.5%（70%可信区间1.6%至3.4%），3年和5年生存率分别为81%和76%。术前，216例患者为窦性心律，97例患者有房颤；在后一组中，11例在二尖瓣修复前3个月内新近发生房颤。将术前有房颤的患者与窦性心律的患者进行比较，我们发现手术死亡率（3%对1.9%）或5年生存率（74.3%±6.3%对76.9%±4.0%）无显著差异。在远期随访时，术前窦性心律的患者中有5%存在房颤，术前慢性房颤的患者中有80%存在房颤，术前新近发生房颤的患者中无房颤发生（p<0.01）。术前有房颤的患者经超声心动图测量的左房大小较窦性心律患者大（59±1.4mm对50.9±0.7mm；p<0.05）。然而，术前左房大小与远期房颤之间仅存在弱相关性。此外，年龄、性别和合并的冠状动脉疾病与远期随访时房颤的存在无关。术前窦性心律的患者与房颤患者的远期血栓栓塞事件发生率相似。这些数据表明，二尖瓣修复应在房颤发作之前或之后不久进行，以最大限度地提高术后窦性心律的机会并避免长期使用华法林抗凝。然而，慢性房颤患者二尖瓣修复的早期和远期效果良好，同时进行的室上性心律失常手术的发病率必须可忽略不计且对手术死亡率无不良影响。
