经皮球囊二尖瓣成形术与外科闭式及直视二尖瓣交界切开术：一项随机试验的七年随访结果

Percutaneous balloon versus surgical closed and open mitral commissurotomy: seven-year follow-up results of a randomized trial.

作者信息

Ben Farhat M, Ayari M, Maatouk F, Betbout F, Gamra H, Jarra M, Tiss M, Hammami S, Thaalbi R, Addad F

机构信息

Department of Medicine, Fattouma Bourguiba University Hospital, Monastir, Tunisia.

出版信息

Circulation. 1998 Jan 27;97(3):245-50. doi: 10.1161/01.cir.97.3.245.

DOI:10.1161/01.cir.97.3.245

PMID:9462525

Abstract

BACKGROUND

Percutaneous balloon mitral commissurotomy (BMC) has been proposed as an alternative to surgical closed mitral commissurotomy (CMC) and open mitral commissurotomy (OMC) for the management of rheumatic mitral valve stenosis (MS).

METHODS AND RESULTS

We conducted a prospective, randomized trial comparing the results of the 3 procedures in 90 patients (30 patients in each group) with severe pliable MS. Cardiac catheterization was performed in all patients before and at 6 months after each procedure. All patients had clinical and echocardiographic evaluation initially and throughout the 7-year follow-up period. Gorlin mitral valve area (MVA) increased much more after BMC (from 0.9+/-0.16 to 2.2+/-0.4 cm2) and OMC (from 0.9+/-0.2 to 2.2+/-0.4 cm2) than after CMC (from 0.9+/-0.2 to 1.6+/-0.4 cm2). Residual MS (MVA <1.5 cm2) was 0% after BMC or OMC and 27% after CMC. There was no early or late mortality or thromboembolism among the three groups. At 7-year follow-up, echocardiographic MVA was similar and greater after BMC and OMC (1.8+/-0.4 cm2) than after CMC (1.3+/-0.3 cm2; P<.00l). Restenosis (MVA <1.5 cm2) rate was 6.6% after BMC or OMC versus 37% after CMC. Residual atrial septal defect was present in 2 patients and severe grade 3 mitral regurgitation was present in 1 patient in the BMC group. Eighty-seven percent of patients after BMC and 90% of patients after OMC were in New York Heart Association functional class I versus 33% (P<.0001) after CMC. Freedom from reintervention was 90% after BMC, 93% after OMC, and 50% after CMC.

CONCLUSIONS

In contrast to surgical CMC, BMC and OMC produce excellent and comparable early hemodynamic improvement and are associated with a lower rate of residual stenosis and restenosis and need for reintervention. However, the good results, lower cost, and elimination of drawbacks of thoracotomy and cardiopulmonary bypass indicate that BMC should be the treatment of choice for patients with tight pliable rheumatic MS.

摘要

背景

经皮气囊二尖瓣交界切开术（BMC）已被提议作为外科闭式二尖瓣交界切开术（CMC）和直视二尖瓣交界切开术（OMC）的替代方法，用于治疗风湿性二尖瓣狭窄（MS）。

方法与结果

我们进行了一项前瞻性随机试验，比较了90例重度柔韧性MS患者（每组30例）接受这三种手术的结果。所有患者在每次手术后即刻及术后6个月均进行了心导管检查。所有患者在初始时以及整个7年随访期内均进行了临床和超声心动图评估。与CMC术后（从0.9±0.2增至1.6±0.4 cm²）相比，BMC术后（从0.9±0.16增至2.2±0.4 cm²）和OMC术后（从0.9±0.2增至2.2±0.4 cm²）的戈林二尖瓣瓣口面积（MVA）增加更为明显。BMC或OMC术后残余MS（MVA＜1.5 cm²）发生率为0%，而CMC术后为27%。三组患者均未发生早期或晚期死亡或血栓栓塞事件。在7年随访时，BMC和OMC术后的超声心动图MVA相似且大于CMC术后（分别为1.8±0.4 cm²、1.3±0.3 cm²；P＜0.001）。BMC或OMC术后再狭窄（MVA＜1.5 cm²）发生率为6.6%，而CMC术后为37%。BMC组有2例患者存在残余房间隔缺损，1例患者存在重度3级二尖瓣反流。BMC术后87%的患者和OMC术后90%的患者纽约心脏协会心功能分级为I级，而CMC术后为33%（P＜0.0001）。BMC术后无需再次干预的比例为90%，OMC术后为93%，CMC术后为50%。