合并三尖瓣反流的中度缺血性二尖瓣关闭不全患者的外科处理策略  

Surgical management strategy for patients with moderate ischemic mitral regurgitation complicated with tricuspid regurgitation

作　　者：刘小希 吴子宁 宋民 王水云[1] 孙寒松[1] 陈亮 蒙延海[1] 何莉 然鋆[1] 常硕 郑哲[1] LIU Xiaoxi;WU Zining;SONG Min;WANG Shuiyun;SUN Hansong;CHEN Liang;MENG Yanhai;HE Li;RAN Jun;CHANG Shuo;ZHENG Zhe(Peking Union Medical College,Chinese Academy of Medical Sciences Department of Adult Cardiac Surgery,Fuwai Hospital,National Center for Cardiovascular Diseases,Beijing 100083,China)

机构地区：[1]北京协和医学院中国医学科学院国家心血管病中心阜外医院成人心脏外科,100083

出　　处：《心肺血管病杂志》2022年第4期384-390,共7页Journal of Cardiovascular and Pulmonary Diseases

基　　金：首都卫生发展科研专项基金(首发2020-2-4036)。

摘　　要：目的:本研究旨在获得合并三尖瓣反流的中度缺血性二尖瓣关闭不全行冠状动脉旁路移植术的患者是否同期行二尖瓣手术的远期预后临床证据,从而寻找最佳手术策略。方法:本研究连续回顾性纳入了2013年至2018年,在我中心行外科治疗的伴有三尖瓣反流的中度缺血性二尖瓣关闭不全的患者,依据手术方式分为单纯行冠状动脉旁路移植术和同期行外科二尖瓣干预两组。通过长期随访分析两组间远期全因死亡率、主要心血管不良事件(MACCE)发生率的差异,并分析围术期超声心动变化和远期不良事件发生情况的差异。通过多因素Cox回归分析寻找合并三尖瓣反流的中度缺血性二尖瓣关闭不全患者行冠状动脉旁路移植术后发生远期全因死亡及MACCE事件的危险因素。结果:通过平均时间为56个月的远期随访,同期行外科二尖瓣干预组的远期全因死亡率更低(P=0.028),远期MACCE事件发生率也更低(P=0.011)。同期行外科二尖瓣干预患者远期发生出血事件和心律失常风险更高。多因素回归发现,同期行外科二尖瓣干预是此类患者远期全因死亡事件的保护因素(OR=0.03,95%CI:0.00~0.40),而术前左心房较大及术前肌酐水平较高是其危险因素。对于远期MACCE事件发生率,同期行外科二尖瓣干预也是其保护因素(OR=0.29,95%CI:0.09~0.95),而年龄较大、术前肌酐水平较高是其危险因素。结论:合并三尖瓣反流可以作为此类患者积极行外科二尖瓣干预的有效临床指标。Objective:The purpose of this study was to obtain the clinical evidence of long-term prognosis of patients with moderate ischemic mitral regurgitation combined with tricuspid regurgitation who underwent coronary artery bypass grafting,so as to find the best surgical strategy.Methods:We continuously enrolled patients with moderate ischemic mitral regurgitation combined with tricuspid regurgitation who underwent coronary artery bypass in our center from 2013 to 2018.They were divided into two groups:isolated coronary artery bypass grafting and simultaneous mitral valve surgery.Through long-term follow-up,the differences of long-term all-cause mortality and incidence of MACCE events between the two groups were analyzed,and the differences of perioperative echocardiographic changes and adverse events were analyzed.Multivariate Cox regression analysis was used to find the risk factors of long-term all-cause death and MACCE events in patients with ischemic mitral regurgitation combined with tricuspid regurgitation after coronary artery bypass grafting.Results:Through the long-term follow-up with an average time of 56 months,The long-term all-cause mortality(P=0.028)and the incidence of long-term MCCE events(P=0.011)was lower in the mitral valve surgery group.The risk of long-term bleeding events and arrhythmia was higher in the mitral valve surgery group.Multivariate regression found that the surgical Mitral valve surgery was the protective factor of long-term all-cause mortality(HR=0.03,95%CI:0.00-0.40)and long-term MACCE events(HR=0.29,95%CI:0.09-0.95).Older age,higher SCr level and larger left atrium suggest a relatively poor long-term prognosis.Conclusions:Tricuspid regurgitation can be used as an effective clinical index for more radical surgical mitral intervention in such patients.

关 键 词：中度缺血性二尖瓣关闭不全 冠状动脉旁路移植术 三尖瓣反流 手术策略 危险因素 

分 类 号：R54[医药卫生—心血管疾病]