Czer L S, Maurer G, Bolger A F, DeRobertis M, Chaux A, Matloff J M
Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California 90048, USA.
Tex Heart Inst J. 1996;23(4):270-8.
To determine the effectiveness of revascularization alone or combined with mitral valve repair for ischemic mitral regurgitation, we performed color Doppler echocardiography intraoperatively before and after cardiopulmonary bypass in 49 patients (mean age, 70 +/- 9 years) with concomitant mitral regurgitation and coronary artery disease (triple vessel or left main in 88%; prior infarction in 90%). After revascularization alone (n = 25), the mitral annulus diameter (2.88 +/- 0.44 cm vs 2.88 +/- 0.44 cm), leaflet-to-annulus ratio (1.44 +/- 0.30 vs 1.44 +/- 0.29), and mitral regurgitation grade (1.7 +/- 0.9 vs 1.8 +/- 0.7) remained unchanged (p = NS, postpump vs prepump); mitral regurgitation decreased by 2 grades in only 1 patient (4%). After combined revascularization and mitral valve suture annuloplasty (Kay-Zubiate; n = 24), the annulus diameter decreased (to 2.57 +/- 0.45 cm from 3.11 +/- 0.43 cm), the leaflet-to-annulus ratio increased (to 1.46 +/- 0.25 from 1.20 +/- 0.21), and the mitral regurgitation grade decreased significantly (to 0.9 +/- 0.9 from 2.8 +/- 1.0) (p < 0.01); mitral regurgitation decreased by 2 grades or more (successful repair) in 75%. The origin of the jet correlated with the site of prior infarction (p < 0.05), being inferior in cases of posterior or inferior infarction (67%), and central or broad in cases of combined anterior and inferior infarction (70%). Despite a slightly higher 30-day mortality in the repair group (p = 0.10), there was no significant difference in survival between the 2 surgical groups at 5 years or 8 years. Therefore, in this study of patients with mitral regurgitation and coronary artery disease, reduction in regurgitation grade with revascularization alone was infrequent. Concomitant suture annuloplasty significantly reduced regurgitation by reestablishing a more normal relationship between the leaflet and annulus sizes. The failure rate after suture annuloplasty was 25%; alternative repair techniques such as ring annuloplasty may have a lower failure rate.
为了确定单纯血运重建或联合二尖瓣修复治疗缺血性二尖瓣反流的有效性，我们对49例（平均年龄70±9岁）合并二尖瓣反流和冠状动脉疾病（88%为三支血管病变或左主干病变；90%有既往心肌梗死）的患者在体外循环前后进行了术中彩色多普勒超声心动图检查。单纯血运重建组（n = 25）中，二尖瓣环直径（2.88±0.44 cm对2.88±0.44 cm）、瓣叶与瓣环比值（1.44±0.30对1.44±0.29）和二尖瓣反流分级（1.7±0.9对1.8±0.7）均未改变（p =无显著性差异，体外循环后对体外循环前）；仅1例患者（4%）二尖瓣反流降低2级。血运重建联合二尖瓣瓣环缝合成形术（Kay-Zubiate法；n = 24）后，瓣环直径减小（从3.11±0.43 cm降至2.57±0.45 cm），瓣叶与瓣环比值增加（从1.20±0.21增至1.46±0.25），二尖瓣反流分级显著降低（从2.8±1.0降至0.9±0.9）（p < 0.01）；75%的患者二尖瓣反流降低2级或更多（修复成功）。反流束起源与既往梗死部位相关（p < 0.05），后下壁梗死时反流束起源于下方（67%），前下壁联合梗死时反流束起源于中央或范围较广（70%）。尽管修复组30天死亡率略高（p = 0.10），但两组手术患者在5年或8年时的生存率无显著差异。因此，在这项针对二尖瓣反流和冠状动脉疾病患者的研究中，单纯血运重建很少能降低反流分级。联合瓣环缝合成形术通过重建瓣叶与瓣环大小之间更正常的关系显著降低了反流。瓣环缝合成形术的失败率为25%；诸如人工瓣环成形术等替代修复技术可能失败率更低。
