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中度缺血性二尖瓣反流的外科治疗
Surgical Treatment of Moderate Ischemic Mitral Regurgitation


Peter K. Smith ... 心脑血管疾病 • 2014.12.04
相关阅读
• 经导管二尖瓣边对边修补术是否对所有继发性二尖瓣反流患者均有帮助

摘要


背景

缺血性二尖瓣反流与发病率及死亡率的升高相关。在冠状动脉旁路移植术(CABG)时增加二尖瓣修复手术对于中度二尖瓣反流的外科患者的获益尚不确定。

 

方法

我们将301例具有中度缺血性二尖瓣反流的患者随机分为CABG组或CABG同时接受二尖瓣修复术组(联合手术)。主要终点事件是术后1年的左心室收缩末期容积指数(LVESVI),其可反映左心室重构的程度。该终点用威尔科克森秩和检验进行分析,其中死亡事件作为最低LVESVI等级。

 

结果

术后1年,单独CABG组中存活患者中平均LVESVI为(46.1±22.4)mL/m2体表面积,而联合手术组为(49.6±31.5)mL/m2体表面积(基线平均变化值分别为-9.4及-9.3 mL/m2)。联合手术组死亡率为6.7%,而单独CABG组为7.3%(二尖瓣修复风险比为0.90;95%可信区间,0.38~2.12;P=0.81)。在1年内,基于秩次的LVESVI比较(包括死亡事件)显示组间没有显著性差异(z评分,0.50;P=0.61)。同时进行二尖瓣修复术与更长的体外循环时间(P<0.001)、更长的术后住院时间(P=0.002)及更多的神经功能事件(P=0.03)相关。联合手术组二尖瓣中或重度返流发生率(低于单独CABG组[11.2%对31.0%],P<0.001)。术后1年时,两组间在严重不良心脑血管事件、死亡、再次入院、功能状态或生活质量方面无显著性差异。

 

结论

在中度缺血性二尖瓣反流的患者中,进行CABG同时实施二尖瓣修复术并不能更大程度逆转左心室重构过程。二尖瓣修复和减少的中重度反流发生率以及数量增多的意外事件相关。因此,本试验术后1年,同时进行二尖瓣修复比起单独CABG,未显示出有意义的临床优势。更长期的随访也许能够确定二尖瓣反流发生率降低是否转变成净临床获益(由美国国家卫生研究院[National Institutes of Health]及加拿大健康研究院[Canadian Institutes of Health Research]资助;ClinicalTrials.gov注册号为NCT00806988)。





作者信息

Peter K. Smith, M.D., John D. Puskas, M.D., Deborah D. Ascheim, M.D., Pierre Voisine, M.D., Annetine C. Gelijns, Ph.D., Alan J. Moskowitz, M.D., Judy W. Hung, M.D., Michael K. Parides, Ph.D., Gorav Ailawadi, M.D., Louis P. Perrault, M.D., Michael A. Acker, M.D., Michael Argenziano, M.D., Vinod Thourani, M.D., James S. Gammie, M.D., Marissa A. Miller, D.V.M., Pierre Pagé, M.D., Jessica R. Overbey, M.S., Emilia Bagiella, Ph.D., François Dagenais, M.D., Eugene H. Blackstone, M.D., Irving L. Kron, M.D., Daniel J. Goldstein, M.D., Eric A. Rose, M.D., Ellen G. Moquete, R.N., Neal Jeffries, Ph.D., Timothy J. Gardner, M.D., Patrick T. O'Gara, M.D., John H. Alexander, M.D., and Robert E. Michler, M.D., for the Cardiothoracic Surgical Trials Network Investigators*
The authors' affiliations are listed in the Appendix. Address reprint requests to Dr. Gelijns at the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl., Box 1077, New York, NY 10029, or atannetine.gelijns@mssm.edu. *The Cardiothoracic Surgical Trials Network investigators are listed in the Supplementary Appendix, available at NEJM.org.

 

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