Restrictive mitral annuloplasty cures ischemic mitral regurgitation and heart failur
Restrictive mitral annuloplasty cures ischemic mitral regurgitation and heart failur
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DOI：
10.1016/j.athoracsur.2007.08.040
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发表时间：
2008-02-01
影响因子：
4.6
通讯作者：
Dion, Robert A. E.
中科院分区：
文献类型：
--
作者：
Braun, Jerry;van de Veire, Nico R.;Dion, Robert A. E.
背景。限制性二尖瓣成形术联合血运重建被认为是治疗伴有心力衰竭的缺血性二尖瓣反流的最佳方法，但后期结果存在争议。我们报告了与术前左心室舒张末期内径 (LVEDD) 截止值相关的晚期结果，该值先前被确定用于预测中期左心室逆重构。方法。一百名连续缺血性二尖瓣反流患者接受了限制性二尖瓣成形术（严格缩小两个环尺寸；中位尺寸为 26）和冠状动脉血运重建。在中期（18 个月）和晚期（平均 46 个月）随访时对幸存者进行临床和超声心动图评估。结果。早期死亡率为8%，晚期死亡率为18%。精算的 1 年、3 年和 5 年生存率为 87% +/- 3.4%、80% +/- 4.1% 和 71% +/- 5.1%。死亡率预测因子（Cox 回归）为术前正性肌力支持（风险比，6.2；95% 置信区间，2.3 至 16.9）和术前 LVEDD 大于 65 mm（风险比，4.5%；95% 置信区间，1.9 至 10.9）。 LVEDD 等于或小于 65 mm 的患者的五年生存率为 80% +/- 5.2%，而 LVEDD 大于 65 mm 的患者的五年生存率为 49% +/- 11% (p = 0.002)。在 4.3 年的随访中，纽约心脏协会功能分级从 2.9 +/- 0.8 改善至 1.6 +/- 0.6 (p < 0.01)。二尖瓣反流等级为 0.8 +/- 0.7，85% 的患者低于 2+ 级。对于LVEDD为65mm或以下的组，左心室逆重构随着时间的推移而持续。晚期死亡并未表现出中期收缩期左心室逆重塑，表明更广泛的内在左心室异常。结论。在 4.3 年的随访中，左心室逆重构的中期截止值被证明是晚期死亡率的预测因素。对于术前 LVEDD 为 65 mm 或更低的患者，限制性二尖瓣环成形术联合血运重建可以治愈缺血性二尖瓣反流和心力衰竭；然而，当 LVEDD 超过 65 mm 时，结果较差，应考虑心室入路。
Background. Restrictive mitral annuloplasty with revascularization is considered the best approach to ischemic mitral regurgitation with heart failure, but late results are controversial. We report late outcome in relation to preoperative left ventricular end-diastolic diameter (LVEDD) cutoff values, previously identified to predict intermeidate-term left ventricular reverse remodeling.Methods. One hundred consecutive ischemic mitral regurgitation patients underwent restrictive mitral annuloplasty (stringent downsizing by two ring sizes; median size, 26) and coronary revascularization. Survivors were clinically and echocardiographically assessed at intermediate (18 months) and late (mean, 46 months) follow-up.Results. Early mortality was 8%, and late mortality was 18%. Actuarial 1-, 3-, and 5-year survival rates were 87% +/- 3.4%, 80% +/- 4.1%, and 71% +/- 5.1%. Mortality predictors (Cox regression) were preoperative inotropic support (hazard ratio, 6.2; 95% confidence interval, 2.3 to 16.9) and preoperative LVEDD greater than 65 mm (hazard ratio, 4.5%; 95% confidence interval, 1.9 to 10.9). Five-year survival rate for patients with LVEDD of 65 mm or less was 80% +/- 5.2%, versus 49% +/- 11% for LVEDD greater than 65 mm (p = 0.002). At 4.3 years' follow-up, New York Heart Association functional class had improved from 2.9 +/- 0.8 to 1.6 +/- 0.6 (p < 0.01). Mitral regurgitation grade was 0.8 +/- 0.7, and was less than grade 2+ in 85% of patients. Left ventricular reverse remodeling was sustained with time for the LVEDD of 65 mm or less group. Late deaths did not show intermediate-term systolic left ventricular reverse remodeling, indicating a more extensive intrinsic left ventricular abnormality.Conclusions. At 4.3 years' follow-up, intermediate-term cutoff values for left ventricular reverse remodeling proved to be predictors for late mortality. For patients with preoperative LVEDD of 65 mm or less, restrictive mitral annuloplasty with revascularization provides a cure for ischemic mitral regurgitation and heart failure; however, when LVEDD exceeds 65 mm, outcome is poor and a ventricular approach should be considered.