缺血性二尖瓣关闭不全的治疗（英文）.ppt

ISCHEMIC MITRAL REGURGITATION 首都医科大学附属北京安贞医院心外科 甘辉立 PURPOSE Is valve repair superior to valve replacement for ischemic mitral regurgitation? DEFINITION Previous MI Normal MV MECHANISM Ruptured papillary muscle Infarcted papillary muscle Functional MECHANISM REGURGITANT JET WALL MOTION ABNORMALITIES MITRAL VALVE PROCEDURE REPAIR TECHNIQUES % Annuloplasty 98 Pap muscle shortening 10 Chordal shortening 8 Leaflet resection 5 Pap muscle reimplant 2 ANNULOPLASTY SIZE OPERATIVE MORTALITY OPERATIVE MORTALITY Replacement 26% Repair 8% RISK FACTORS Advanced Age Higher NYHA functional class Greater LV dysfunction Renal dysfunction Atrial fibrillation Mitral valve replacement RISK FACTORS AFTER MITRAL REPAIR Complex regurgitant jet Lateral infarct Bovine pericardial annuloplasty No ITA graft REPAIR vs REPLACEMENT MATCHED QUINTILES CONCLUSIONS Survival is poor Most benefit from repair In sickest patients, survival similar with repair and replacement REMAINING QUESTIONS Intermittent ischemic MR 2 + ischemic MR at CABG Chordal preservation at MVR Mechanisms of ischemic MR Functional Pap Infarct Pap Rupture 27% 8% 65 % Central Posterior Complex Anterior 7% 58% 15% 20% Anterior 40% Inferior 73% Posterior 63% Septal 42% Lateral 44% 397 85 SIZE (mm) 8% 26% P.0001 P.0001 SURVIVAL % Years 71 60 49 Years SURVIVAL % Years 60 54 46 Years 74 61 50 Repair Replacement SURVIVAL Pap rupture Pap infarct Functional MR % Years % I % III – V % Emergent Status 33 0.3 Functional MR 16 86 Ruptured Pap 48 13 Infarcted Pap 38 2 ITA Graft 16 55 Repair 41 96 0 0 20 40 60 80 100 0 1 2 3 4 5 6 7 0 20 40 60 80 100 0 1 2 3 4 5 6 7 0 20 40 60 80 100 1 2 3 4 5 6 7 SURVIVAL: MATCHEDQUINTILES I II III - V Repair Replace PREDICTED SURVIVAL repair replacement % Years replacement repair PREDICTED SURVIVAL % Years Difference Repair Benefit Replace Benefit 7 YEAR SURVIVAL % REPAIR FAILURE 95 92 88 % Years * *