Prediction of mitral regurgitation resolution after coronary bypass graft surgery and cardiac resynchronization therapy by late gadolinium enhancement magnetic resonance imaging: a case report
Prediction of mitral regurgitation resolution after coronary bypass graft surgery and cardiac resynchronization therapy by late gadolinium enhancement magnetic resonance imaging: a case report
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通过晚期钆增强磁共振成像预测冠状动脉搭桥手术和心脏再同步治疗后二尖瓣反流的缓解：病例报告
DOI：
10.1093/ehjcr/yty129
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发表时间：
2018
期刊：
影响因子：
--
通讯作者：
Tamura K.
中科院分区：
文献类型：
--
作者：
Azuma M;Kato S;Fukui K;Tamura K.
冠状动脉旁路移植术(CABG)时中度功能性二尖瓣反流(MR)的恰当外科处理仍然存在争议。最近的一项研究表明，对于中等功能MR的患者，在CABG中加入二尖瓣修补术对生存没有好处。术前预测反向重塑对于做出决定是否在CABG中加入二尖瓣修补术至关重要。晚期Gd增强磁共振成像(LGE MRI)为评估心肌存活率提供了一种参考方法。病例概要1例60岁男性缺血性心肌病患者因心力衰竭症状加重而入院。经胸超声心动图显示左心室(LV)扩张，左心室收缩功能严重受损，以及因栓系所致的中度MR。二尖瓣返流是中心部位。开始静脉注射速尿和人心钠素。患者经历了一次室性心动过速，冠状动脉造影显示为三支血管病变。LGE MRI显示心内膜下壁、后壁和侧壁均有25%~50%的心肌梗死。LGE MRI检查结果提示，心肌活力已被保存。在接受冠状动脉搭桥术和心脏再同步化治疗后，在没有手术二尖瓣修补术的情况下，左室容量显著减少，中度MR显著改善。术前斑点跟踪超声心动图显示，侧壁(462ms)和下壁(17ms)的径向应变峰值时间有显著差异，提示存在左室不同步。在CABG和心脏再同步化治疗除颤器置入后，左室不同步性显著改善。讨论在缺血性心肌病和中等功能MR患者中，LGE MRI扫描可用于评价左室心肌的存活性。左心室的LGE MRI检查结果可能会影响手术策略。在保留左室心肌存活的患者中，冠状动脉旁路移植术后功能MR可以得到改善，而不需要任何手术修复。
BackgroundAppropriate surgical management of moderate functional mitral regurgitation (MR) at the time of coronary artery bypass graft (CABG) surgery remains controversial. A recent study demonstrated no survival benefit from adding mitral repair to CABG for patients with moderate functional MR. Preoperative prediction of reverse remodelling is crucial in making the decision to add mitral valve repair to CABG. Late gadolinium-enhanced magnetic resonance imaging (LGE MRI) offers a reference method to assess myocardial viability.Case summaryA 60-year-old man with ischaemic cardiomyopathy was admitted to our hospital with exacerbation of heart failure symptoms. Left ventricular (LV) dilatation, severe impairment of LV systolic function, and moderate MR due to tethering were noted on transthoracic echocardiography. The mitral regurgitant jet was central. Intravenous administration of furosemide and human atrial natriuretic peptide was initiated. The patient experienced an episode of ventricular tachycardia, and coronary angiography demonstrated triple-vessel disease. On LGE MRI, subendocardial infarction with a transmural extent of 25–50% was revealed in the inferior, posterior, and lateral walls. Findings from LGE MRI suggested that myocardial viability had been preserved. After performing CABG and cardiac resynchronization therapy, LV volume was substantially decreased and moderate MR was significantly improved without surgical mitral repair. On speckle tracking echocardiography before surgery, a significant difference in the times to peak radial strain between the lateral wall (462 ms) and inferior wall (17 ms) indicated the presence of LV dyssynchrony. Left ventricular dyssynchrony was substantially improved after CABG and cardiac resynchronization therapy defibrillator implantation.DiscussionIn patients with ischaemic cardiomyopathy and moderate functional MR, acquisition of LGE MRI of the LV should be considered to evaluate the viability of LV myocardium. Findings from LGE MRI of the LV can potentially influence the surgical strategy. In patients with preserved viability of LV myocardium, functional MR could be improved after CABG without any surgical repair.