Clinical outcome after surgical correction of mitral regurgitation due to papillary muscle rupture
Clinical outcome after surgical correction of mitral regurgitation due to papillary muscle rupture
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DOI：
10.1161/circulationaha.107.747949
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发表时间：
2008-10-07
期刊：
影响因子：
37.8
通讯作者：
Enriquez-Sarano, Maurice
中科院分区：
文献类型：
--
作者：
Russo, Antonio;Suri, Rakesh M.;Enriquez-Sarano, Maurice
背景-乳头肌破裂（PMR）是急性心肌梗死（MI）的一种罕见但灾难性的并发症。尽管一直考虑进行手术治疗，但由于手术死亡率高，手术治疗常常被拒绝。此外，PMR手术对长期结果的影响，特别是与MI后的预期结果相比，尚不清楚。方法和结果——从1980年1月到2000年12月，连续54名患者（年龄，70+/-8岁；74%男性）因MI后PMR接受二尖瓣手术。91%的术前出现严重症状（心源性休克、肺水肿或心脏骤停）。冠状动脉旁路移植术的表现与较低的手术死亡率相关（比值比，0.18；95% CI，0.04至0.83；P = 0.011），而1990年后手术后死亡率有降低的趋势（比值比，0.28；95% CI，0.06至1.3）。因此，手术死亡率（总体为 18.5%）从 1990 年不进行冠状动脉旁路移植术时的 67% 下降到 1990 年采用冠状动脉旁路移植术后的 8.7%。总体 5 年生存率为 65 +/- 7%，无充血性心力衰竭的生存率为 52 +/- 7%。 30 天手术幸存者的五年生存率为 79 +/- 4%，与 MI 匹配对照组相同（P = 0.24）（相似的年龄、性别、射血分数、MI 位置和 MI 年份）。 PMR 病例和 MI 对照的无充血性心力衰竭生存率相似（10 年生存率，28 +/- 8% 对比 36 +/- 6%；P = 0.46）。 结论：MI 后 PMR 的手术死亡率显着，但最近有手术风险降低的趋势，特别是相关冠状动脉旁路移植术。术后长期来看，结果可恢复到无 PMR 的类似 MI 的水平。这些令人鼓舞的观察结果强调了及时诊断和积极治疗方法对于 MI 后发生 PMR 的患者的重要性。
Background-Papillary muscle rupture (PMR) is an infrequent but catastrophic complication of acute myocardial infarction (MI). Although always considered, surgical treatment is often denied because of high operative mortality. Moreover, the effects of surgery for PMR on long-term outcome, particularly compared with expected outcome after MI, are undefined.Methods and Results-Fifty-four consecutive patients (age, 70 +/- 8 years; 74% male) underwent mitral surgery for post-MI PMR from January 1980 through December 2000. Severe presentation (cardiogenic shock, pulmonary edema, or cardiac arrest) was noted in 91% preoperatively. Performance of coronary artery bypass graft was associated with lower operative mortality (odds ratio, 0.18; 95% CI, 0.04 to 0.83; P = 0.011), whereas there was a trend for lower mortality after surgery after 1990 (odds ratio, 0.28; 95% CI, 0.06 to 1.3). Thus, operative mortality (overall, 18.5%) decreased from 67% up to 1990 without coronary artery bypass graft to 8.7% after 1990 with coronary artery bypass graft. Overall 5-year survival was 65 +/- 7%, and survival free of congestive heart failure was 52 +/- 7%. Five-year survival of 30-day operative survivors was 79 +/- 4%, identical (P = 0.24) to that of matched controls with MI (similar age, sex, ejection fraction, MI location, and MI year). Survival free of congestive heart failure was similar in PMR cases and MI controls (10-year survival, 28 +/- 8% versus 36 +/- 6%; P = 0.46).Conclusions-Surgery for post-MI PMR involves a notable operative mortality, but there are recent trends for lower operative risk, particularly with associated coronary artery bypass graft. Long term after surgery, outcome is restored to that of similar MI without PMR. These encouraging observations emphasize the importance of prompt diagnosis and aggressive therapeutic approach for patients incurring PMR after MI.