冠狀動脈旁路移植術(shù)聯(lián)合二尖瓣成形術(shù)與經(jīng)皮冠狀動脈介入治療對缺血性二尖瓣關閉不全的療效分析

鄒程，姚星星，楊挺，劉豐豪，劉超

冠狀動脈旁路移植術(shù)聯(lián)合二尖瓣成形術(shù)與經(jīng)皮冠狀動脈介入治療對缺血性二尖瓣關閉不全的療效分析

鄒程，姚星星，楊挺，劉豐豪，劉超

鄭州大學第一附屬醫(yī)院心血管外科，河南鄭州 450052

分析冠狀動脈旁路移植術(shù)（coronary artery bypass graft，CABG）+二尖瓣成形術(shù)（mitral valvuloplasty，MVP）與僅行經(jīng)皮冠狀動脈介入治療（percutaneous coronary intervention，PCI）對重度慢性缺血性二尖瓣關閉不全（chronic ischemic mitral incompetence，CIMI）的療效。選取2018年1月至2020年1月于鄭州大學第一附屬醫(yī)院診治的重度CIMI患者115例，根據(jù)患者手術(shù)方式不同將其分為PCI組（=59）和CABG+MVP組（=56）。收集患者的性別、年齡、合并疾病等臨床基本特征及術(shù)前超聲參數(shù)，比較兩種手術(shù)對術(shù)后二尖瓣反流的療效。CABG+MVP組患者的年齡顯著小于PCI組，左室射血分數(shù)顯著大于PCI組（<0.05）。PCI組患者術(shù)后二尖瓣反流無改善或復發(fā)率是CABG+MVP組的6.01倍（=6.01，95%：2.450～15.132，<0.05）。CABG+MVP組患者術(shù)后二尖瓣反流的好轉(zhuǎn)程度優(yōu)于PCI組（<0.05）。針對重度CIMI，雖然外科手術(shù)治療伴隨著術(shù)后高死亡率，但行CABG+MVP的患者術(shù)后二尖瓣反流情況優(yōu)于僅行PCI的患者。

慢性缺血性二尖瓣關閉不全；二尖瓣反流；經(jīng)皮冠狀動脈介入治療；冠狀動脈旁路移植術(shù)；二尖瓣成形術(shù)

缺血性二尖瓣關閉不全是心肌梗死后的并發(fā)癥之一，與冠狀動脈疾病的不良預后相關[1-2]。研究表明二尖瓣反流的嚴重程度與長期生存時間呈負相關[3]；其中慢性缺血性二尖瓣關閉不全（chronic ischemic mitral incompetence，CIMI）是由左心室?guī)缀涡螒B(tài)的重塑導致[4-5]。經(jīng)皮冠狀動脈介入治療（percutaneous coronary intervention，PCI）已成為梗阻性冠狀動脈疾病最常用的治療手段，其不僅可減少心肌缺血面積，還可降低二尖瓣反流的程度，改善心室重塑，增加二尖瓣關閉力和乳頭肌同步性[6-8]。雖然PCI在治療CIMI時有利于左心室重塑，但術(shù)后仍可能出現(xiàn)二尖瓣反流程度加重[9]。而對重度CIMI的外科治療，通常采取冠狀動脈旁路移植術(shù)（coronary artery bypass graft，CABG）+二尖瓣成形術(shù)（mitral valvuloplasty，MVP）治療，雖然術(shù)后二尖瓣反流立刻消失，但術(shù)后中后期仍存在二尖瓣反流復發(fā)的可能[10]。本文比較CABG+MVP與單純PCI兩種方法治療重度CIMI患者的療效，為臨床工作提供參考。

1 資料與方法

1.1 一般資料

選取2018年1月至2020年1月于鄭州大學第一附屬醫(yī)院診治的重度CIMI患者115例，根據(jù)患者手術(shù)方式不同將其分為PCI組（=59）和CABG+MVP組（=56）。納入標準：①冠狀動脈造影提示冠狀動脈狹窄需手術(shù)治療；②經(jīng)胸心臟彩超提示二尖瓣重度關閉不全；③于本院接受CABG+MVP手術(shù)或患者家屬要求僅行PCI手術(shù)者。排除標準：①既往接受心臟手術(shù)者；②合并主動脈瓣疾病、主動脈疾病、其他病因?qū)е碌亩獍觋P閉不全；③診斷為急性心肌梗死；④術(shù)前左室射血分數(shù)（left ventricular ejection fraction，LVEF）<30%。本研究經(jīng)鄭州大學第一附屬醫(yī)院倫理委員會批準，患者均簽署知情同意書。

1.2 資料收集

記錄患者的性別、年齡、合并疾病、心功能分級、吸煙史、飲酒史、病變血管數(shù)量及術(shù)前左心室大小、左心房大小、LVEF和二尖瓣反流等級。術(shù)后二尖瓣反流復發(fā)定義：出院時沒有或輕微二尖瓣反流的患者，隨訪時二尖瓣反流等級≥2+。術(shù)后二尖瓣反流無改善定義：術(shù)后二尖瓣反流程度不改變或加重。

1.3 手術(shù)方法

CABG+MVP組患者常規(guī)麻醉后放置食管超聲探頭，確認二尖瓣存在病變。手術(shù)在深低溫體外循環(huán)下進行，通過右心房–房間隔切口暴露二尖瓣。所有患者均進行瓣環(huán)成形術(shù)，瓣環(huán)大小取決于二尖瓣前瓣大小，在可能的情況下適當縮小瓣環(huán)，必要時進行瓣下結(jié)構(gòu)的修復或三尖瓣成形術(shù)[11]。所有患者前降支均與左側(cè)乳內(nèi)動脈吻合，其余血管采用大隱靜脈進行吻合。心臟復跳后經(jīng)食管超聲確定二尖瓣無反流。PCI組單支或雙支冠狀動脈病變患者均一次性進行冠狀動脈的狹窄再疏通，對三支冠狀動脈病變患者或狹窄再疏通困難的雙支冠狀動脈病變患者分多次進行血運重建。

1.4 統(tǒng)計學方法

2 結(jié)果

2.1 兩組患者的一般資料比較

CABG+MVP組患者的年齡顯著小于PCI組，LVEF顯著大于PCI組（<0.05）。兩組患者的性別、合并疾病、術(shù)前心功能分級與病變血管數(shù)比較差異均無統(tǒng)計學意義（>0.05），見表1。

表1 兩組患者的一般資料比較

2.2 兩組患者術(shù)后二尖瓣反流情況比較

CABG+MVP組中4例（7.14%）患者院內(nèi)死亡，術(shù)后隨訪128.50（97.25，237.00）d，8例（15.38%）患者出現(xiàn)術(shù)后二尖瓣反流。PCI組患者術(shù)后隨訪128.00（95.00，210.00）d，31例（52.54%）患者出現(xiàn)二尖瓣反流。PCI組患者術(shù)后二尖瓣反流無改善或復發(fā)率是CABG+MVP組的6.01倍（=6.01，95%：2.450～15.132，<0.05）。兩組患者在單支病變血管中，術(shù)后二尖瓣反流情況比較差異無統(tǒng)計學意義（>0.05）。在雙支病變和三支病變中，PCI組患者術(shù)后二尖瓣反流無改善或復發(fā)率均高于CABG+MVP組（<0.05），見表2。CABG+MVP組患者術(shù)后二尖瓣反流的好轉(zhuǎn)程度優(yōu)于PCI組（<0.05），見表3。

表2 不同病變血管數(shù)的術(shù)后二尖瓣反流無改善或復發(fā)率比較[%（n）]

表3 兩組患者術(shù)后好轉(zhuǎn)程度比較[n（%）]

3 討論

CIMI主要是心肌梗死后左心室重構(gòu)導致二尖瓣結(jié)構(gòu)的改變、乳頭肌位移和瓣環(huán)擴張[12-13]。針對CIMI的治療仍存在爭議，但不論如何治療，與單純的冠狀動脈疾病或單純二尖瓣手術(shù)相比預后較差[2,14]。二尖瓣瓣膜功能依賴于整個二尖瓣結(jié)構(gòu)的正常，心室功能同時也依賴于二尖瓣功能正常，當兩種病變交錯時，導致患者承受缺血再灌注損傷的能力變差，增加術(shù)后不良預后的風險[15]。CABG+MVP治療CIMI，手術(shù)風險及術(shù)后并發(fā)癥發(fā)生率較高[10]。雖然心臟復跳后進行食管超聲確認二尖瓣無反流或極少量反流，但術(shù)后隨訪仍出現(xiàn)二尖瓣反流的復發(fā)，可能是由于術(shù)中體外循環(huán)降低心臟的前、后負荷，一定程度上使二尖瓣反流分級降低。CABG+MVP失敗的原因可能是二尖瓣成型環(huán)裂開、感染性心內(nèi)膜炎、術(shù)后出現(xiàn)心力衰竭或未發(fā)現(xiàn)的二尖瓣病理性改變等[16]。冠狀動脈疾病導致的左心室重塑會隨著PCI治療得到改善，缺血心肌區(qū)域的血運重建將改善局部室壁運動，有可能糾正CIMI，且血運重建后殘留的二尖瓣關閉不全不會影響患者的生存質(zhì)量[17]。但PCI術(shù)后有可能因左室充盈壓力增高，激活神經(jīng)–體液系統(tǒng)導致二尖瓣反流程度不變或增加，增加不良預后的風險[18]。

在本研究中，CABG+MVP組與PCI組患者的年齡與術(shù)前LVEF存在顯著差異，可能與高齡及心功能較差的患者多選擇風險較小的介入手術(shù)有關。對比兩種手術(shù)對重度CIMI患者術(shù)后二尖瓣的影響，PCI組患者術(shù)后二尖瓣反流程度無改善或復發(fā)率是CABG+MVP組的6.01倍。在冠狀動脈單支病變中，兩組患者術(shù)后二尖瓣反流無改善或復發(fā)率差異無統(tǒng)計學意義，說明冠狀動脈血運重建可促進左室重構(gòu)，增加左心室的收縮力，改善乳頭肌的運動從而糾正局部室壁異常運動，減少二尖瓣反流。在冠狀動脈雙支病變與三支病變中，PCI組患者的術(shù)后二尖瓣反流無改善或復發(fā)率均高于CABG+MVP組。相較于PCI，CABG+MVP不僅可在術(shù)中直接糾正二尖瓣反流，且CABG還可使PCI無法治療的小血管得到血運重建，更有利于心肌局部室壁的運動從而促進心室重構(gòu)[19]。CABG+MVP組患者的二尖瓣反流好轉(zhuǎn)程度優(yōu)于PCI組，與Campwala等[20]的研究結(jié)果類似。

對重度CIMI的治療，雖然外科手術(shù)伴隨著術(shù)后高死亡率及術(shù)后并發(fā)癥的發(fā)生，但CABG+MVP術(shù)后患者二尖瓣反流改善情況優(yōu)于僅行PCI的患者。對高齡且心功能較差的單支病變患者，PCI可降低二尖瓣的反流程度。

[1] ACKER M A, PARIDES M K, PERRAULT L P, et al. Mitral-valve repair versus replacement for severe ischemic mitral regurgitation[J]. N Engl J Med, 2014, 370(1): 23–32.

[2] LAMAS G A, MITCHELL G F, FLAKER G C, et al. Clinical significance of mitral regurgitation after acute myocardial infarction. Survival and ventricular enlargement investigators[J]. Circulation, 1997, 96(3): 827–833.

[3] BURSI F, ENRIQUEZ-SARANO M, JACOBSEN S J, et al. Mitral regurgitation after myocardial infarction: A review[J]. Am J Med, 2006, 119(2): 103–112.

[4] IZUMI S, MIYATAKE K, BEPPU S, et al. Mechanism of mitral regurgitation in patients with myocardial infarction: A study using real-time two-dimensional Doppler flow imaging and echocardiography[J]. Circulation, 1987, 76(4): 777–785.

[5] AGRICOLA E, OPPIZZI M, PISANI M, et al. Ischemic mitral regurgitation: Mechanisms and echocardiographic classification[J]. Eur J Echocardiogr, 2008, 9(2): 207–221.

[6] KAWASHIMA H, SERRUYS P W, ONO M, et al. Impact of optimal medical therapy on 10-year mortality after coronary revascularization[J]. J Am Coll Cardiol, 2021, 78(1): 27–38.

[7] MICHLER R E, SMITH P K, PARIDES M K, et al. Two-year outcomes of surgical treatment of moderate ischemic mitral regurgitation[J]. N Engl J Med, 2016, 374(20): 1932–1941.

[8] VASSILEVA C M, BOLEY T, MARKWELL S, et al. Meta- analysis of short-term and long-term survival following repair versus replacement for ischemic mitral regurgitation[J]. Eur J Cardiothorac Surg, 2011, 39(3): 295–303.

[9] PASTORIUS C A, HENRY T D, HARRIS K M. Long-term outcomes of patients with mitral regurgitation undergoing percutaneous coronary intervention[J]. Am J Cardiol, 2007, 100(8): 1218–1223.

[10] BAX J J, BRAUN J, SOMER S T, et al. Restrictive annuloplasty and coronary revascularization in ischemic mitral regurgitation results in reverse left ventricular remodeling[J]. Circulation, 2004, 110(11 Suppl 1): 103–108.

[11] LANG R M, BIERIG M, DEVEREUX R B, et al. Recommendations for chamber quantification: A report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology [J]. J Am Soc Echocardiogr, 2005, 18(12): 1440–1463.

[12] KOIKE T, EJIMA K, KATAOKA S, et al. Prognostic significance of diastolic dysfunction in patients with systolic dysfunction undergoing atrial fibrillation ablation[J]. Int J Cardiol Heart Vasc, 2022, 41: 101079.

[13] BOLTWOOD C M, TEI C, WONG M, et al. Quantitative echocardiography of the mitral complex in dilated cardiomyopathy: The mechanism of functional mitral regurgitation[J]. Circulation, 1983, 68(3): 498–508.

[14] GOLDSTEIN D, MOSKOWITZ A J, GELIJNS A C, et al. Two-year outcomes of surgical treatment of severe ischemic mitral regurgitation[J]. N Engl J Med, 2016, 374(4): 344–353.

[15] CRABTREE T D, BAILEY M S, MOON M R, et al. Recurrent mitral regurgitation and risk factors for early and late mortality after mitral valve repair for functional ischemic mitral regurgitation[J]. Ann Thorac Surg, 2008, 85(5): 1537–1542.

[16] ANYANWU A C, ADAMS D H. Why do mitral valve repairs fail?[J]. J Am Soc Echocardiogr, 2009, 22(11): 1265–1268.

[17] CHAN K M, PUNJABI P P, FLATHER M, et al. Coronary artery bypass surgery with or without mitral valve annuloplasty in moderate functional ischemic mitral regurgitation: Final results of the randomized ischemic mitral evaluation (RIME) trial[J]. Circulation, 2012, 126(21): 2502–2510.

[18] BEHR T M, WANG X, AIYAR N, et al. Monocyte chemoattractant protein-1 is upregulated in rats with volume-overload congestive heart failure[J]. Circulation, 2000, 102(11): 1315–1322.

[19] FAN Q, LIU J, XU Y, et al. Real-world outcomes of revascularization strategies in patients with left ventricular dysfunction and three-vessel coronary disease stratified by mitral regurgitation[J]. Front Cardiovasc Med, 2021, 8: 675722.

[20] CAMPWALA S Z, BANSAL R C, WANG N, et al. Factors affecting regression of mitral regurgitation following isolated coronary artery bypass surgery[J]. Eur J Cardiothorac Surg, 2005, 28(1): 104–108.

Analysis of the efficacy of coronary artery bypass graft combined with mitral valvuloplasty and percutaneous coronary intervention in ischemic mitral valve incompetence

Department of Cardiovascular Surgery, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan, China

To analyze the effects of coronary artery bypass graft (CABG) +mitral valvuloplasty (MVP) and percutaneous coronary intervention (PCI) alone on severe chronic ischemic mitral incompetence (CIMI).A total of 115 patients with severe CIMI treated in the First Affiliated Hospital of Zhengzhou University from January 2018 to January 2020 were selected and divided into PCI group (=59) and CABG+MVP group (=56) according to different surgical methods. The clinical characteristics of the patients, such as gender, age, complicated diseases, and preoperative ultrasound parameters were collected, and compare the effect of two kinds of operation on mitral regurgitation after operation.The age of patients in CABG+MVP group was significantly lower than that in PCI group, and left ventricular ejection fraction was significantly higher than that in PCI group (<0.05). The rate of no improvement or recurrence of mitral regurgitation in PCI group was 6.01 times that in CABG+MVP group (=6.01, 95%: 2.450-15.132,<0.05). The improvement of mitral regurgitation in CABG+MVP group was better than that in PCI group (<0.05).For severe CIMI, mitral regurgitation in patients undergoing CABG + MVP is better than that in patients undergoing PCI alone, although surgical treatment is associated with high mortality after operation for severe CIMI.

Chronic ischemic mitral incompetence; Mitral regurgitation; Percutaneous coronary intervention; Coronary artery bypass graft; Mitral valvuloplasty

R654.2

A

10.3969/j.issn.1673-9701.2023.25.014

劉超，電子信箱：liubeilun@me.com

（2023–02–14）

（2023–08–27）