Doppler echography in the evaluation of mitral valve function following Carpentier's valvuloplasty

In the present study Doppler-echocardiography was used to evaluate the quality of mitral valve regurgitation (MVR) repair by Carpentier valvuloplasty. Between January, 1984 and June, 1987, this operation was performed in 51 patients (39 men, 12 women; mean age 58 +/- 10.9 years) presenting with mitral valve regurgitation; 25 were in class III and 14 in class IV of the NYHA classification. Two patients died soon after the operation and 2 others some time later. The 47 survivors were followed up for a mean period of 20.5 +/- 11.2 months: 3 of them required mitral valve replacement for residual MVR or mitral stenosis, one developed cerebral embolism. At the latest control, 18 patients were in NYHA class I and 26 in NYHA class II. Doppler velocimetry showed no or little mitral valve dysfunction; the residual MVR was below grade 1 in 37 of the 44 survivors who were not reoperated upon. Mitral function was satisfactory after Carpentier valvuloplasty, with a mean transmitral gradient of 3.3 +/- 1.3 mmHg and a mean mitral valve area of 2.9 +/- 0.98 cm2. In 3 patients an intraventricular gradient of 10 to 20 mmHg, reflecting moderate ventricular obstruction, was detected by Doppler velocimetry. These data obtained with the combined Doppler-echocardiographic method confirm that the quality of mitral function is excellent after Carpentier mitral valvuloplasty.     

Transcatheter Mitral Valve Repair in Patients With Atrial Functional Mitral Regurgitation

BackgroundAmong patients with severe functional mitral regurgitation (FMR), atrial functional mitral regurgitation (aFMR) represents an underrecognized entity. Data regarding outcomes after mitral valve transcatheter edge-to-edge repair (M-TEER) in aFMR remain scarce.ObjectivesThe objective of this study was to analyze the outcome of aFMR patients undergoing M-TEER.MethodsUsing patients from the international EuroSMR (European Registry of Transcatheter Repair for Secondary Mitral Regurgitation) registry undergoing M-TEER for FMR, the authors analyzed baseline characteristics and 2-year outcomes in aFMR in comparison to non-aFMR and ventricular FMR. Additionally, the impact of right ventricular dysfunction (RVD) (defined as right ventricular to pulmonary artery uncoupling) on outcome after M-TEER was assessed.ResultsAmong 1,608 FMR patients treated by M-TEER, 126 (7.8%) were categorized as aFMR. All 126 aFMR patients had preserved left ventricular function without regional wall motion abnormalities, left arterial dilatation and Carpentier leaflet motion type I. Procedural success (defined as mitral regurgitation ≤2+ at discharge) was 87.2% (P < 0.001) and New York Heart Association (NYHA) functional class significantly improved during follow-up (NYHA functional class III/IV: 86.5% at baseline to 36.6% at follow-up; P < 0.001). The estimated 2-year survival rate in aFMR patients was 70.4%. Two-year survival did not differ significantly between aFMR, non-aFMR, and ventricular FMR. Besides NYHA functional class IV, RVD was identified as a strong independent predictor for 2-year survival (HR: 2.82 [95% CI: 1.24-6.45]; P = 0.014).ConclusionsaFMR is a frequent cause of FMR and can be effectively treated with M-TEER to improve symptoms at follow-up. Advanced heart failure symptoms and RVD were identified as important risk factors for survival in aFMR patients.     

Reconstructive surgery of pure mitral insufficiency. Operative results and follow-up in 128 patients]

Short and long-term results of valve repair for pure mitral insufficiency are reported in 128 consecutive patients with a mean age of 49 years (range 4-75). The etiology of the mitral valve dysfunction was degenerative in 54% of the cases, rheumatic in 30%, ischemic in 9.5%, endocarditic in 6.5%. Preoperatively, 91% of the patients were in NYHA class II or III. The anatomic lesions and the mechanism of mitral regurgitation were identified preoperatively by transthoracic and/or transesophageal echocardiography. Cardiac catheterization was performed only in patients with multiple valvular dysfunction and/or with evidence of concomitant coronary artery disease. Mitral repair was performed according to the techniques proposed by Carpentier. Only one patient died in the hospital (operative mortality: 0.8%). By actuarial methods, 96% of the patients were alive 4 years postoperatively, and 84% were reoperation free. Freedom from reoperation was significantly higher in patients who received a prosthetic ring than in those who had other types of anuloplasty (96% vs 67%; p < 0.05). During the follow-up period no patient had thromboembolic episodes. Ninety-seven per cent of the 112 patients who survived the operation and were not reoperated were in NYHA class I or II. These results confirm the validity of reconstructive surgery in pure mitral insufficiency. The use of a prosthetic ring gives stability to the repair and improves long-term results.     

CABG同期行左室成形术和二尖瓣成形术治疗左室室壁瘤并发二尖瓣关闭不全的效果

目的 评价冠状动脉旁路移植术（CABG）同期行左室成形术和二尖瓣成形术治疗左室室壁瘤并发二尖瓣关闭不全的近远期临床效果。 方法 自2000年1月~2008年12月,我院共32例患者因左室室壁瘤并发缺血性二尖瓣关闭不全同期进行左室成形术+二尖瓣成形术。左室成形术手术方式包括:线性缝合16例（50%）;心内膜环缩成形术9例（28%）;心室内环状补片成形术7例（22%）。二尖瓣成形术入路包括:左室入路20例（62%）,右房-房间隔入路11例（34%）,房间沟入路1例（3%）。全部患者均同期行CABG。本研究回顾性分析了上述患者手术中及围手术期的临床资料,并进行了46~175个月随访。 结果 围手术期死亡1例（3%）。术后1年和5年生存率分别为97%和74%。随访期间,9%（3例）出现二尖瓣中量及以上返流,9%（3例）出现NYHA心功能Ⅲ~IV级。左室成形方式及二尖瓣成形入路对远期效果无显著影响。 结论 左室成形术同期行二尖瓣成形术是治疗左室室壁瘤并发二尖瓣关闭不全的有效方法,术后的近远期临床结果令人满意。     

Aspekte der Mitralklappenrekonstruktion bei der chirurgischen Therapie der Mitralklappeninsuffizienz

Mitral valve repair (MVR) is the golden standard for the surgical treatment of mitral valve regurgitation and is superior to mitral valve replacement in terms of perioperative and long-term morbidity and mortality. However, the underlying disease has a significant impact on the functional long-term result of the repair. To evaluate the results of MVR, patients have to be divided by the underlying disease, degenerative mitral valve regurgitation, rheumatic mitral valve regurgitation, ischemic mitral valve regurgitation, and mitral valve regurgitation due to advanced cardiomyopathy. The best functional result for MVR can be achieved for degenerative mitral valve regurgitation (10-year freedom from reoperation for recurrent mitral regurgitation up to 94%) followed by patients with rheumatic mitral valve regurgitation (10-year freedom from reoperation for recurrent mitral regurgitation up to 82%). The progress in the underlying disease of the mitral valve is responsible for recurrent mitral valve regurgitation in these patients. For both underlying disease the 10-year survival rate is > 75%. For patients with ischemic mitral valve regurgitation the functional and survival rates are worse with a 5-year survival rate < 60% and recurrent mitral valve regurgitation > MI (mitral valve insufficiency) II degrees in 28% of patients within 6 months. However, ischemic mitral valve regurgitation is not a disease of the valve, it is a disease of the myocardium; thus, the myocardium is the key factor influencing the functional results of MVR and not pathologic changes in the mitral valve per se. There are no long-term results on patients operated on MI in conjunction with advanced cardiomyopathy; however, the initial mid-term results are encouraging with improved survival.Besides the underlying disease the timing of surgery is of utmost importance for the long-term survival; patients with preoperative NYHA functional class III/IV have a significantly worse short-term and long-term outcome compared to patients operated on for significant mitral valve regurgitation who have only minor or even no symptoms (NYHA class I/II). However, the compliance to undergo complex open-heart surgery via a median sternotomy in asymptomatic patients is very low. Minimally invasive endoscopic mitral valve repair may be an option to increase compliance in these patients, which will result in improved long-term survival with a normal life expectancy.     

Immediate and long-term results of 790 mitral valve replacements]

A total of 790 patients underwent isolated (N = 520) or mitral valve replacement associated with a tricuspid valve procedure for lesions excluding post-myocardial infarction mitral regurgitation. The mean age was 54 years: the sex ratio was 1.9 +/- 1.1, female/male. Three hundred and four patients (38.5%) were in the NYHA functional class II and 406 patients (61.5%) were in classes III or IV. The operative mortality was 9.7% (77 patients). The factors associated with a high operative risk were, on multifactorial analysis: double valve replacement, age over 70 years, NYHA class IV, aortic clamp time over 68 minutes and the presence of mitral regurgitation. Seven hundred and four of the 713 survivors were contacted (98.7% follow-up). The average follow-up period was 5.05 years (range 11 to 219 months) giving a total of 3,997 patient-years. The 5 and 10 year actuarial survival rates were 74.7% and 64.7% respectively. The presence of a tricuspid lesion requiring surgical correction, a high NYHA classification and the presence of mitral regurgitation were poor prognostic factors of long-term survival. Three hundred and sixteen of the 533 survivors at the time of the inquiry were in NYHA class I (59.3%), 188 in NYHA class II (35.3%) and 29 in NYHA class III or IV (5.4%). Mitral valve replacement should be considered early as the immediate and long-term results are closely related to the preoperative myocardial function.     

Mitral repair in patients with severely calcified annulus: feasibility,surgery and results

BACKGROUND AND AIM OF THE STUDY: The study aim was to assess the feasibility and follow up data of extensive decalcification for mitral valve repair in patients with severely calcified mitral annulus, in order to avoid mitral replacement. METHODS: Between 1993 and 1998, among 2,318 patients who underwent mitral valve surgery at the Herz-Gefaess-Klinik GmbH, Bad Neustadt, a severely calcified mitral valve annulus was encountered in 30 patients (17 males, 13 females; mean age 60.7+/-14.6 years; range: 22 to 77 years). Nineteen patients (63%) were in NYHA class III or IV. Mitral valve repair was performed by temporary detachment of the leaflets, en-bloc resection of the annular calcium deposits and annular reconstruction. Concomitant procedures included coronary bypass grafting (n = 6), aortic valve replacement (n = 2) and tricuspid repair (n = 1). Follow up data were obtained by telephone interviews with cardiologists, family physicians and patients. RESULTS: Postoperative Doppler echocardiography at discharge from hospital showed satisfactory mitral valve function in all patients. No residual regurgitation was found in 25 patients (83%), and trivial regurgitation in five (17%). Follow up was 100% complete; mean follow up was 3.2+/-1.6 years (range: 4 months to 6 years). There was one early death, and one late death, but no instance of annulus dehiscence. There were no thromboembolic complications, but two anticoagulation-related events. At the time of follow up, echocardiography was performed in 26 patients, and showed no residual regurgitation in 21 patients (81%) and trivial regurgitation in five (19%). Twenty-eight patients (93%) were in NYHA class I or II, and all described their quality of life as normal. CONCLUSION: These results show that aggressive and complete annulus decalcification, including complete temporary detachment of the leaflets, can be performed safely in patients with a severely calcified mitral valve annulus. The study also showed that initially good results remained stable for up to six years postoperatively in these repair patients. Hence, decalcification is a safe and rapid procedure that produces excellent results.     

Mitral Valve Repair for Anterior/Bi-leaflet Versus Posterior Leaflet Degenerative Mitral Valve Disease: A Systematic Review and Meta-analysis

Mitral valve repair (MVr) secondary to degenerative anterior/bi-leaflet mitral valve disease is more challenging than posterior leaflet repair. However, conclusive evidence is needed to make decisions based on the outcomes rather than technical difficulties. This meta-analysis compares anterior/bi-leaflet MVr with isolated posterior leaflet repair in patients with mitral regurgitation (MR) due to degenerative mitral valve disease. The outcomes of interest were long-term (≥ 5 years) survival and freedom from re-operation and moderate-to-severe MR. Meta-analysis of 10 studies showed that there was no significant difference in long-term survival (risk ratio, RR: 1.00; 95% confidence interval, 95% CI 0.96-1.04), freedom from moderate-to-severe MR (RR: 0.95; 95% CI 0.87-1.03), and freedom from re-operation (RR: 0.96; 95% CI 0.90-1.02) between anterior/bi-leaflet MVr and posterior leaflet repair. As outcomes of anterior/bilateral repair were comparable with those of isolated posterior leaflet repair, our findings do not support the inclination towards replacement over repair for MR caused by anterior/bilateral degenerative mitral disease.     

Long-Term Survival Following Transcatheter Mitral Valve Repair: Pooled Analysis of Prospective Trials with the Carillon Device

PurposeTo report long-term survival and to identify potential determinants of survival among patients receiving treatment for functional mitral regurgitation (FMR) with the Carillon device.MethodsThis was a post hoc analysis in which we pooled prospectively collected data from three studies of the Carillon device with available long-term vital status data. Patient eligibility in these trials specified symptomatic congestive heart failure despite guideline-directed medical therapy, grade 2 to 4 FMR, left ventricular enlargement, and reduced ejection fraction. Echocardiographic parameters were available through the 12-month visit and vital status was available through 5 years. The association of patient characteristics and changes in echocardiographic parameters at 6 and 12 months with long-term survival was analyzed using Cox proportional hazards regression.ResultsA total of 74 patients (mean age 67 years, 72% male, 59% MR grade 3 or 4) were treated with the Carillon device. Over 1 year of follow-up, the New York Heart Association (NYHA) class decreased in 64% of patients, distance on the 6-minute walk test increased, and echocardiographic measures indicated significant decreases in MR grade and favorable left ventricular remodeling. The Kaplan-Meier survival rate was 83.6% at 1 year, 73.1% at 2 years, 67.9% at 3 years, and 56.2% at 4 and 5 years of follow-up. Primary determinants of long-term survival were a decrease in NYHA class, an increase in 6-minute walk test distance, and a decrease in regurgitant volume during the first year of follow-up.ConclusionsAmong patients with congestive heart failure and grade 2 to 4 FMR who were symptomatic despite guideline-directed medical therapy, transcatheter mitral valve repair with the Carillon device resulted in a favorable 5-year survival rate. The survival benefit was greatest among patients with improvement in clinical and hemodynamic parameters during the first year of follow-up.     

State of the Art: Degenerative Mitral Valve Disease

Mitral valve repair is the treatment of choice for severe mitral regurgitation. It offers superior long-term survival, freedom from cardiac events and quality of life to mitral valve replacement, and medical management. As a result increasing numbers of minimally symptomatic patients with preserved left ventricular function are being referred for mitral valve repair: long term outcomes in these patients have been shown to be similar to that of the general population. A clear understanding of the aetiology, lesions and valve dysfunction is necessary to guide timing and choice of treatment.     

缺血性二尖瓣关闭不全的外科治疗

目的：本文旨在回顾性研究单中心外科治疗缺血性二尖瓣关闭不全的临床经验。 方法：回顾性分析279例缺血性二尖瓣关闭不全患者的临床资料。平均年龄59.2±7.4岁。心功能分级II级141例，III级117例，IV级21例。左室舒末内径57~91mm ，左室射血分数20%~59%。二尖瓣反流程度：中度156例，中-重度75例，重度48例。冠脉造影结果三支病变240例，两支病变30例，单支病变9例。 结果：二尖瓣成形术224例，术后即刻TEE示无返流152例，微量返流43例，微量-轻度21例，轻度8例。二尖瓣置换术75例，IABP辅助37例。冠状动脉旁路移植远端吻合口3.6±0.5个。手术死亡13例，死亡率4.7%（13/279）。出院时左室舒末内径46~86mm，左室射血分数20%~62% 。二尖瓣无反流232例，微量26例，轻度12例，轻-中度7例，中度2例。 结论：外科治疗冠心病合并缺血性二尖瓣关闭不全可获得满意的治疗效果，尤其是对于射血分数降低、左心增大、心力衰竭的患者，获益更大。     

Mitral valve repair for nonrheumatic mitral regurgitation

BACKGROUND: We studied the results of mitral valve repair in patients with severe mitral regurgitation of nonrheumatic etiology. METHODS AND RESULTS: Between January 1988 and April 2002, 116 patients, of which 59 were male and 57 female, with severe mitral regurgitation of nonrheumatic etiology, underwent mitral valve repair using a variety of techniques. Their mean age was 26.4 years (range 2-67 years). The cause of mitral regurgitation was congenital in 56 patients, myxomatous in 44, infective endocarditis in 7, and ischemic in 9. Ninety patients were in preoperative New York Heart Association class III, and 26 in class IV. Reparative procedures included posterior teflon felt collar annuloplasty (modified Cooley's) in 80 patients, chordal shortening in 37, cusp excision in 34, cleft closure in 8, chordal transfer in 6, and neochordae in 3. The early mortality was 3.4% (4 patients). Follow-up ranged from 1 to 167 months (mean 47 months), and was 95% complete. There were 2 late deaths (1.7%). Six patients (5.2%) underwent reoperation for severe mitral regurgitation post-repair. Of the remaining 104 patients, 90 (86.5%) had no or trivial mitral regurgitation at the last follow-up. Actuarial, reoperation-free, and event-free survival at 130 months was 93%+/-3.6%, 89.9%+/-6%, and 69.7%+/-13.7%, respectively. Ninety-two patients (88.5%) were in New York Heart Association class I at the last follow-up. CONCLUSIONS: Mitral valve repair in nonrheumatic mitral regurgitation patients provides satisfactory results with current surgical techniques, and is the preferred option in this subset of patients.     

Mid-term results of mitral valve repair for complicated active bacterial endocarditis in high-risk patients

Mitral valve repair in endocarditis achieves a competent valve and prevents septic embolization and acute left ventricular failure, in which operative mortality could be increased. Early and mid-term results were examined to establish whether emergency mitral valve repair offers an advantage in complicated active endocarditis. Ten patients with complicated active native valve endocarditis underwent mitral valve repair. The mean age was 45.8 ± 18.5 years; two patients were female (20%). All patients had severe mitral regurgitation, which combined in one patient with mitral valve stenosis. New York Heart Association (NYHA) functional class was IV in all patients. The macroscopically infected tissue with vegetation in all patients was excised. Multiple techniques were required to achieve valve competence. There was one (10%) hospital death in a patient with persistent congestive heart failure, and a reoperation in another (10%) after 2 years. Mean follow-up was 32.1 ± 12.7 months (range 1–45 months) and was complete. There were no late deaths, recurrent endocarditis, or thromboembolic events. Seven patients (77.7%) were in NYHA functional class I, and two (22.2%) were in class II. Mitral valve repair in complicated active bacterial endocarditis limited to leaflet tissues has a low operative mortality and valve-related morbidity, with promising mid-term survival in high-risk patients.     

Mitral valve annuloplasty with Carpentier-Edwards physio ring: mid-term results

The mid-term results of mitral valve repair with the Carpentier-Edwards Physio annuloplasty ring were assessed in 97 consecutive patients in a single tertiary-referral cardiothoracic surgical center. The mean follow-up time was 3.9 years (range, 1 month to 8.9 years). Most patients were in functional class II and III before the operation. Ejection fraction was < 40% in 8 patients. Causes of mitral regurgitation included degenerative disease (66%), infective endocarditis (13.4%), rheumatic disease (10.3%), and ischemic heart disease (9.3%). Thirty-day mortality was 2.1%. Actuarial survival and freedom from re-operation at 8 years were 91% and 90.8%, respectively. The only significant risk factor for re-operation was residual mitral regurgitation. Four patients suffered thromboembolic complications, giving an overall event-free survival of 93% +/- 3.7% during the follow-up period. The Carpentier-Edwards Physio ring provides safe and effective repair of mitral regurgitation on mid-term follow-up.     

Mitral valve relpair and revascularization for ischemic mitral regurgitation: predictors of operative mortality and survival

BACKGROUND AND AIMS OF THE STUDY: Surgery for ischemic mitral regurgitation (IMR) is required in 4-5% of patients subjected to coronary artery surgery, and may be challenging. The study aim was to determine outcome following mitral valve repair and myocardial revascularization for moderate-to-severe IMR. METHODS: A total of 102 patients (mean age 68+/-7 years) underwent mitral valve repair for IMR between 1998 and 2001 at the authors' unit. Among patients, 28 had acute and 74 chronic mitral regurgitation (MR). Valve repair was achieved with an annuloplasty ring in all 102 patients, while 99 underwent concomitant myocardial revascularization. Preoperatively, 69 patients had MR grade III-IV, 62 had CCS angina class III-IV, 59 were in NYHA class II-IV, 81 had impaired left ventricular function, and 10 were in cardiogenic shock.Follow up was 100% complete (mean 14+/-7 months; range: 0-38 months). RESULTS: Overall operative mortality was 8.8% (n = 9) (17.8% for acute IMR, 5.4% for chronic, p = 0.048). On multiple logistic regression analysis, cardiogenic shock (p = 0.028) was the only significant risk factor for operative death. There were 11 late deaths. Kaplan-Meier survival at one and three years was 82+/-4% and 79+/-4%, respectively. On Cox proportional hazards regression model, preoperative left ventricular end-systolic diameter (LVESD) >4.5 cm (p = 0.01) and NYHA class III-IV (p = 0.02) were independent adverse predictors of survival. Three patients required reoperation. Kaplan-Meier three-year freedom from reoperation was 97+/-2%. CONCLUSION: Surgery for IMR carries a considerable, but acceptable, operative risk and provides satisfactory freedom from reoperation and mid-term survival. Cardiogenic shock before surgery is the major determinant of an unfavorable in-hospital outcome. LVESD >4.5 cm and poor preoperative NYHA status limit the probability of late survival. The study results support early surgical intervention for IMR, before ventricular dilatation occurs.     

Valve repair for rheumatic mitral disease

BACKGROUND AND AIM OF STUDY: Mitral valve repair is the standard reparative technique for degenerative mitral disease, but results of valve repair in rheumatic disease are also encouraging. The outcomes after mitral valve repair for rheumatic disease at young age was evaluated for suitability of repair. METHODS: A total of 319 patients (246 females, 73 males; mean age 31.3+/-0.5 years) underwent mitral valve repair for rheumatic mitral disease at the authors' institution between 1991 and 1998. Mean follow up was 51.9+/-1.2 months (range: 9-98 months), and was 88.7% complete. RESULTS: Preoperatively, 47.6% of patients were in NYHA classes III and IV. Mitral stenosis was present in 87.5%, insufficiency in 5.3%, and stenosis/insufficiency in 7.2%. Concomitant procedures were performed in 32% of patients who had associated cardiac lesions. The intraoperative mortality, reoperation and reoperation mortality rates were 0.9%, 6.7% and 0%, respectively. During follow up there were 10 late deaths (3.5%), six of which were cardiac disease-related (2.1%). Postoperatively, 98% of patients were in NYHA classes I and II. CONCLUSION: Valve repair in mitral disease is a standard technique, with low mortality, complication and reoperation rates, and good cardiac function and late survival. This approach is equally applicable to rheumatic mitral valve repair; hence, rheumatic mitral valves should also be repaired.     

Risk assessment of mitral valve surgery combined with myocardial revascularization]

INTRODUCTION AND OBJECTIVES: Patients with combined mitral valve operation and coronary artery surgery represent a high risk group. The aim of this retrospective study was to evaluate which factors affect early and late postoperative results in this particular group of considered high risk patients. PATIENTS AND METHOD. Between 1984 and 1997, 264 patients (mean age: 63 +/- 7.3 years) underwent mitral valve surgery (199 patients; 75% mitral valve replacement, 25% mitral valve repair) in combination with coronary revascularization (mean 2.4 +/- 1.3 grafts). Follow-up comprised a mean of 69 +/- 42 months and was 98.3% complete. RESULTS: Early mortality was 10.6% (28/264). Ischemic mitral regurgitation operated on in emergent status, moderate to severe reduced left ventricular function and advanced age (> 60 years) were independently associated with early hospital mortality (p < 0.05). Ischemic etiology of mitral valve disease (emergency and elective operations), severity of mitral regurgitation and New York Heart Association (NYHA) functional class IV were related to early hospital mortality, only with univariate statistics. Actuarial survival was 86, 69 and 48% at 1, 5 and 10 years, respectively. The preoperative NYHA functional class was the only variable independently related to late survival. Eighty-five percent of the surviving patients were in NYHA functional class I and II. CONCLUSIONS: Mitral valve operation combined with coronary artery bypass grafting is associated with a high early hospital mortality. Independent risk factors of early mortality are emergency operation of ischemic mitral valve disease, reduced left ventricular function and advanced age. Long term survival is independently influenced only by preoperative NYHA functional class IV.     

“缘对缘”联合人工瓣环修复术治疗二尖瓣关闭不全42例分析

【】 目的 探讨“缘对缘”联合人工瓣环修复二尖瓣成形术治疗二尖瓣关闭不全的手术效果。方法 回顾性分析2004年1月至2008年12月对42例非风湿性二尖瓣关闭不全患者行“缘对缘”联合人工瓣环修复二尖瓣成形术的临床资料,男25例,女17例;年龄12～69岁(36.42±14.28岁),其中先天性二尖瓣病变12例,瓣膜退行性病变20例,缺血性二尖瓣关闭不全7例,感染性心内膜炎3例。术前心脏彩超提示：前叶病变27例,前叶 后叶病变17例;二尖瓣重度反流19例,中度至重度14例,中度反流9例;42例患者均在全身麻醉低温体外循环下应用“缘对缘”联合人工瓣环修复术进行二尖瓣成形术。术中应用250mL注射器向左心室注冰盐水观察评价成形后二尖瓣反流情况,脱离体外循环后经食管超声心动图观察成形结果。分别测量术前及术后二尖瓣反流面积、二尖瓣开口面积、左房内径及左室舒张末期内径,左室射血分数,应用t检验,研究手术前后二尖瓣反流、心脏大小变化、心功能改善情况。检验水准α=0.05。结果 全组无死亡病例,出院时心脏功能(NYHA分级)I级32例,Ⅱ级10例。随访39例,随访时间1-60(24.6±18.2)个月。超声心动图提示：术前二尖瓣反流面积为11.0cm₂±3.8cm₂,术后1年无或微量反流13例,轻度反流17例,轻度至中度反流9例,轻度二尖瓣狭窄1例,反流面积为4.1cm₂±1.4cm₂;术前二尖瓣开口面积4.14 cm₂±1.54cm₂,术后一年为3.58 cm₂±1.10cm₂;术前左心房内径为48.6mm±12.4mm,术后1年为36.5 mm±9.4mm;术前左心室舒张末径为64.3 mm±11.4mm,术后1年为50.6 mm±7.6mm;术前左心室射血分数为54.6%±6.2％,术后1年提高为63.4%±4.0％。结论“缘对缘”联合人工瓣环修复二尖瓣成形术治疗二尖瓣关闭不全手术方法安全、有效,可获得良好的治疗效果。     

Mitral insufficiency caused by floppy valve: results of conservative surgical treatment

Between January 1986 and November 1987, 31 patients (pt.) underwent reconstructive surgery for mitral regurgitation secondary to floppy valve. Six pt. were in NYHA functional class IV, 22 in III class and 3 in II class. The mitral valve prolapse was posterior in 20 cases, anterior in 7 cases and bilateral in 4 cases. Chordal rupture was present in 18 pt. The mitral valve was repaired by quadrangular excision of the mural leaflet and posterior annuloplasty performed by insertion of polytetrafluoroethylene graft. The anterior prolapse was managed by transposition of chordae from the mural leaflet to the prolapsed part of the anterior leaflet (11 cases). One patient died perioperatively from myocardial infarction. Subsequent follow-up (length: 12.1 +/- 4.9 months) revealed good functional and clinical results: all pt. were alive, in NYHA class I or II (3 pt.). Echocardiographic studies revealed a decrease in diastolic (3.68 +/- 0.6 vs. 3.17 +/- 0.3 cm/m2) and systolic (2.4 +/- 0.5 vs. 2.15 +/- 0.4 cm/m2) diameter. The shortening fraction did not decline significantly. The mitral area fell from 6.0 +/- 2.0 cm2 to 3.1 +/- 1.1 cm2. A moderate residual regurgitation was present in two pt. and a severe regurgitation was found in only one pt. Our experience suggests that valve repair may be considered the most suitable type of operation for mitral regurgitation secondary to floppy valve.     

Mitral regurgitation surgery in heart failure due to ischemic cardiomyopathy: a 24-year experience

BACKGROUND AND AIM OF THE STUDY: The long-term benefits of mitral regurgitation (MR) surgery in ischemic cardiomyopathy (ICM) are controversial. Herein are reported the results and trends of this surgical approach over the past 24-year period. METHODS: Patients were identified in refractory heart failure due to ICM with NYHA functional class III/IV symptoms, left ventricular ejection fraction < or =35% and MR who underwent mitral surgery between 1979 and 2002. The early and late outcomes were analyzed and compared for the different surgical eras classified as early (1979 to 1986), middle (1987 to 1994), and late (1995 to 2002). RESULTS: Mitral repair (70%) and replacement (30%) were performed with coronary artery bypass grafting (CABG) (85%) and tricuspid valve repair (7%) in 179 patients (mean age 68 +/- 9 years). The overall one- and five-year survival rates were 84% and 51%, respectively, and the corresponding freedom from recurrent MR after repair 86% and 55%. An increasing number of patients underwent surgery from the early to the late era. Whereas patients more frequently presented with cardiomegaly and renal failure during the early era, they were older, more often had prior CABG, concurrent tricuspid regurgitation and underwent mitral repair during the late era. A progressive improvement was observed in operative mortality from the early to late eras (24%, 11% and 5%, respectively; p = 0.009), and also for the one-and five-year survivals (68%, 85% and 89%; 46%, 43% and 57%, respectively; p = 0.06). Preoperative renal failure and concomitant tricuspid valve repair were predictors of late mortality. CONCLUSION: During the past 24 years, operative results for the surgical correction of MR in patients with heart failure due to ICM have steadily improved. Currently, while the early and mid-term survival are satisfactory the long-term survival is limited, especially when heart failure is complicated by renal failure and severe tricuspid regurgitation.