Failure of Guideline Adherence for Intervention in Patients With Severe Mitral Regurgitation
Failure of Guideline Adherence for Intervention in Patients With Severe Mitral Regurgitation
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DOI：
10.1016/j.jacc.2009.03.079
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发表时间：
2009-08-25
影响因子：
24
通讯作者：
Kohnstamm, Sarah
中科院分区：
文献类型：
--
作者：
Bach, David S.;Awais, Mazen;Kohnstamm, Sarah
目的探讨成人严重二尖瓣反流(MR)患者未接受手术治疗的发生率，以及相关因素导致不干预的情况。背景：尽管已有公认的指南，但许多严重症状性心脏瓣膜病患者可能不接受干预。方法在一个大型三级医学中心，对2005年间超声心动图检查中、重度或重度MR的患者进行回顾性分析。结果2005年间，有300例患者被确定为有意义的MR，其中188例为功能性MR，112例为器质性MR。在188例功能性MR患者中，有30例接受了二尖瓣手术，主要是为了治疗心力衰竭或在其他心脏外科手术中。在112例器质性MR患者中，59例(53%)接受了二尖瓣手术。在未手术的器质性MR患者中，常见的原因包括左心室大小或功能稳定、无症状和禁忌性合并症。根据美国心脏病学会/美国心脏协会的指南，在53名未手术患者中，39名(74%)出现了一种或多种干预指征。未接受手术的患者的围手术期死亡风险(中位数1.2%，四分位数范围[IQR]0.4%至3.3%)不高于接受手术的患者(中位数1.1%，IQR0.6%至5.3%；p=0.71)。在随访期间，有12例心脏病和2例原因不明的死亡。结论在严重器质性MR的患者中，大约一半的患者进行了手术治疗。然而，大多数未手术的患者都接受了干预的指导性指征。在许多未手术的患者中，客观评估的手术风险并不令人望而却步。(J Am Coll心脏ol 2009；54：860-5)c 2009，美国心脏病学会基金会
Objectives This study sought to evaluate the incidence with which adult patients with significant mitral regurgitation (MR) do not undergo surgical intervention despite guideline recommendations, and the associated considerations resulting in no intervention.Background Despite the existence of accepted guidelines, many patients with severe symptomatic heart valve disease might not undergo intervention.Methods At a single large tertiary medical center, patients were retrospectively identified who had moderate-to-severe or severe MR on echocardiographic imaging during 2005. Clinical data were reviewed to determine indications for intervention and whether surgery was performed.Results During 2005, 300 patients were identified with significant MR, including 188 with functional MR and 112 with organic MR. Mitral surgery was performed in 30 of 188 patients with functional MR, mostly to treat heart failure or during another cardiac surgical procedure. Mitral surgery was performed in 59 (53%) of 112 patients with organic MR. Among unoperated patients with organic MR, common reasons included stable left ventricular size or function, absence of symptoms, and prohibitive comorbidities. Using American College of Cardiology/American Heart Association guidelines, 1 or more indication for intervention was present in 39 (74%) of 53 unoperated patients. Perioperative mortality risk was not higher for patients who did not undergo surgery (median 1.2%, interquartile range [IQR] 0.4% to 3.3%) than for those who did (median 1.1%, IQR 0.6% to 5.3%; p = 0.71). During follow-up, there were 12 cardiac and 2 unexplained deaths.Conclusions Among patients with severe organic MR, surgical intervention occurred in approximately one-half. However, accepted guideline indications for intervention were present in the majority of unoperated patients. Objectively assessed operative risk was not prohibitive in many unoperated patients. (J Am Coll Cardiol 2009; 54: 860-5) c 2009 by the American College of Cardiology Foundation