Dion R, Benetis R, Elias B, Guennaoui T, Raphael D, Van Dyck M, Noirhomme P, Van Overschelde J L
Department of Cardiovascular and Thoracic Surgery, University Clinic St. Luc, Brussels, Belgium.
J Heart Valve Dis. 1995 Oct;4 Suppl 2:S124-9; discussion S129-31.
A restrictive definition of ischemic mitral regurgitation (IMR) has allowed us to select a more uniform cohort of 41 patients having undergone mitral valve surgery for IMR between January 1993 and March 1995. Thirty-six patients (88%) presented with chronic and five with acute IMR. All patients had at least one significant stenosis in the circumflex area. Left ventricular ejection fraction averaged 35%. Transesophageal echocardiography (TEE) revealed a > or = 3+ MR in 30 patients and an intermittent, fluctuating or grade 2+ MR in 11 (27%). Annulus dilatation was found in all cases, and it was the only mechanism in 10 (24.4%). Leaflet restrictive motion was clearly seen in 17 cases (41.5%) and leaflet prolapse in 14 (34%). In doubtful cases, an intra-operative dynamic testing using TEE, and associating a loading test and an afterload test, led to the indication of a valve procedure in 11/19 patients (58%). An average of three distal coronary anastomoses per patient were constructed. Mitral valve replacement (MVR) was unavoidable in four patients (9.8%); at least the posterior leaflet subvalvular apparatus was preserved in all. Repair of the mitral valve (Mvrep) was achieved in 37 cases (90%). Ring annuloplasty alone was performed in 27 cases (73%). In the remaining 10 cases, leaflet prolapse was corrected by various artifices such as flip-over technique, quadrangular resection, papillary muscle plication or commissuroplasty. At the 10th postoperative day, a residual MR was found in 4/34 cases (11.8%), only after isolated ring annuloplasty. The four patients who have died in the ICU after MVrep belonged to the same group of isolated ring annuloplasty; this mortality of 4/27 (14.8%) illustrates the mediocre prognosis of marked annulus dilatation and impaired LV function with restrictive leaflet motion. Overall, the hospital mortality (14.6%) more reflected the mode of presentation of the patients than the type of operative technique: when a short and definitive procedure is required by a precarious general condition, one should not hesitate to prefer a rapid MVR to a complicated repair. At 4.5 months, there was no significant improvement in LV dimensions. At six months, 80.5% of the patients survived, with 88% of them being in NYHA class I or II.
对缺血性二尖瓣反流（IMR）采用严格的定义，使我们能够选出1993年1月至1995年3月间因IMR接受二尖瓣手术的41例患者组成一个更具同质性的队列。36例患者（88%）表现为慢性IMR，5例为急性IMR。所有患者在回旋支区域至少有一处明显狭窄。左心室射血分数平均为35%。经食管超声心动图（TEE）显示30例患者存在≥3+级的二尖瓣反流，11例（27%）为间歇性、波动性或2+级二尖瓣反流。所有病例均发现瓣环扩张，其中10例（24.4%）仅存在瓣环扩张这一机制。17例（41.5%）可见瓣叶活动受限，14例（34%）可见瓣叶脱垂。在诊断存疑的病例中，术中使用TEE进行动态测试，并结合负荷试验和后负荷试验，结果显示19例患者中有11例（58%）适合进行瓣膜手术。平均每位患者构建了3处远端冠状动脉吻合口。4例患者（9.8%）不可避免地进行了二尖瓣置换术（MVR）；所有患者至少保留了后叶瓣下结构。37例（90%）患者成功进行了二尖瓣修复术（Mvrep）。仅进行瓣环成形术的有27例（73%）。其余10例中，通过各种方法纠正了瓣叶脱垂，如翻转技术、四边形切除术、乳头肌折叠术或交界成形术。术后第10天，仅在单纯进行瓣环成形术的病例中有4/34例（11.8%）发现残余二尖瓣反流。4例在二尖瓣修复术后于重症监护病房死亡的患者均属于单纯瓣环成形术组；4/27（14.8%）的死亡率表明，对于瓣环明显扩张且左心室功能受损伴瓣叶活动受限的患者，预后较差。总体而言，医院死亡率（14.6%）更多反映的是患者的病情表现方式，而非手术技术类型：当患者总体状况不稳定需要进行简短且确定性的手术时，应毫不犹豫地优先选择快速二尖瓣置换术而非复杂的修复术。术后4.5个月，左心室大小无明显改善。术后6个月，80.5%的患者存活，其中88%的患者纽约心脏协会（NYHA）心功能分级为I级或II级。
