冠状动脉旁路移植术联合二尖瓣成形术与经皮冠状动脉介入治疗对缺血性二尖瓣关闭不全的疗效分析

邹程，姚星星，杨挺，刘丰豪，刘超

冠状动脉旁路移植术联合二尖瓣成形术与经皮冠状动脉介入治疗对缺血性二尖瓣关闭不全的疗效分析

邹程，姚星星，杨挺，刘丰豪，刘超

郑州大学第一附属医院心血管外科，河南郑州 450052

分析冠状动脉旁路移植术（coronary artery bypass graft，CABG）+二尖瓣成形术（mitral valvuloplasty，MVP）与仅行经皮冠状动脉介入治疗（percutaneous coronary intervention，PCI）对重度慢性缺血性二尖瓣关闭不全（chronic ischemic mitral incompetence，CIMI）的疗效。选取2018年1月至2020年1月于郑州大学第一附属医院诊治的重度CIMI患者115例，根据患者手术方式不同将其分为PCI组（=59）和CABG+MVP组（=56）。收集患者的性别、年龄、合并疾病等临床基本特征及术前超声参数，比较两种手术对术后二尖瓣反流的疗效。CABG+MVP组患者的年龄显著小于PCI组，左室射血分数显著大于PCI组（<0.05）。PCI组患者术后二尖瓣反流无改善或复发率是CABG+MVP组的6.01倍（=6.01，95%：2.450～15.132，<0.05）。CABG+MVP组患者术后二尖瓣反流的好转程度优于PCI组（<0.05）。针对重度CIMI，虽然外科手术治疗伴随着术后高死亡率，但行CABG+MVP的患者术后二尖瓣反流情况优于仅行PCI的患者。

慢性缺血性二尖瓣关闭不全；二尖瓣反流；经皮冠状动脉介入治疗；冠状动脉旁路移植术；二尖瓣成形术

缺血性二尖瓣关闭不全是心肌梗死后的并发症之一，与冠状动脉疾病的不良预后相关[1-2]。研究表明二尖瓣反流的严重程度与长期生存时间呈负相关[3]；其中慢性缺血性二尖瓣关闭不全（chronic ischemic mitral incompetence，CIMI）是由左心室几何形态的重塑导致[4-5]。经皮冠状动脉介入治疗（percutaneous coronary intervention，PCI）已成为梗阻性冠状动脉疾病最常用的治疗手段，其不仅可减少心肌缺血面积，还可降低二尖瓣反流的程度，改善心室重塑，增加二尖瓣关闭力和乳头肌同步性[6-8]。虽然PCI在治疗CIMI时有利于左心室重塑，但术后仍可能出现二尖瓣反流程度加重[9]。而对重度CIMI的外科治疗，通常采取冠状动脉旁路移植术（coronary artery bypass graft，CABG）+二尖瓣成形术（mitral valvuloplasty，MVP）治疗，虽然术后二尖瓣反流立刻消失，但术后中后期仍存在二尖瓣反流复发的可能[10]。本文比较CABG+MVP与单纯PCI两种方法治疗重度CIMI患者的疗效，为临床工作提供参考。

1 资料与方法

1.1 一般资料

选取2018年1月至2020年1月于郑州大学第一附属医院诊治的重度CIMI患者115例，根据患者手术方式不同将其分为PCI组（=59）和CABG+MVP组（=56）。纳入标准：①冠状动脉造影提示冠状动脉狭窄需手术治疗；②经胸心脏彩超提示二尖瓣重度关闭不全；③于本院接受CABG+MVP手术或患者家属要求仅行PCI手术者。排除标准：①既往接受心脏手术者；②合并主动脉瓣疾病、主动脉疾病、其他病因导致的二尖瓣关闭不全；③诊断为急性心肌梗死；④术前左室射血分数（left ventricular ejection fraction，LVEF）<30%。本研究经郑州大学第一附属医院伦理委员会批准，患者均签署知情同意书。

1.2 资料收集

记录患者的性别、年龄、合并疾病、心功能分级、吸烟史、饮酒史、病变血管数量及术前左心室大小、左心房大小、LVEF和二尖瓣反流等级。术后二尖瓣反流复发定义：出院时没有或轻微二尖瓣反流的患者，随访时二尖瓣反流等级≥2+。术后二尖瓣反流无改善定义：术后二尖瓣反流程度不改变或加重。

1.3 手术方法

CABG+MVP组患者常规麻醉后放置食管超声探头，确认二尖瓣存在病变。手术在深低温体外循环下进行，通过右心房–房间隔切口暴露二尖瓣。所有患者均进行瓣环成形术，瓣环大小取决于二尖瓣前瓣大小，在可能的情况下适当缩小瓣环，必要时进行瓣下结构的修复或三尖瓣成形术[11]。所有患者前降支均与左侧乳内动脉吻合，其余血管采用大隐静脉进行吻合。心脏复跳后经食管超声确定二尖瓣无反流。PCI组单支或双支冠状动脉病变患者均一次性进行冠状动脉的狭窄再疏通，对三支冠状动脉病变患者或狭窄再疏通困难的双支冠状动脉病变患者分多次进行血运重建。

1.4 统计学方法

2 结果

2.1 两组患者的一般资料比较

CABG+MVP组患者的年龄显著小于PCI组，LVEF显著大于PCI组（<0.05）。两组患者的性别、合并疾病、术前心功能分级与病变血管数比较差异均无统计学意义（>0.05），见表1。

表1 两组患者的一般资料比较

2.2 两组患者术后二尖瓣反流情况比较

CABG+MVP组中4例（7.14%）患者院内死亡，术后随访128.50（97.25，237.00）d，8例（15.38%）患者出现术后二尖瓣反流。PCI组患者术后随访128.00（95.00，210.00）d，31例（52.54%）患者出现二尖瓣反流。PCI组患者术后二尖瓣反流无改善或复发率是CABG+MVP组的6.01倍（=6.01，95%：2.450～15.132，<0.05）。两组患者在单支病变血管中，术后二尖瓣反流情况比较差异无统计学意义（>0.05）。在双支病变和三支病变中，PCI组患者术后二尖瓣反流无改善或复发率均高于CABG+MVP组（<0.05），见表2。CABG+MVP组患者术后二尖瓣反流的好转程度优于PCI组（<0.05），见表3。

表2 不同病变血管数的术后二尖瓣反流无改善或复发率比较[%（n）]

表3 两组患者术后好转程度比较[n（%）]

3 讨论

CIMI主要是心肌梗死后左心室重构导致二尖瓣结构的改变、乳头肌位移和瓣环扩张[12-13]。针对CIMI的治疗仍存在争议，但不论如何治疗，与单纯的冠状动脉疾病或单纯二尖瓣手术相比预后较差[2,14]。二尖瓣瓣膜功能依赖于整个二尖瓣结构的正常，心室功能同时也依赖于二尖瓣功能正常，当两种病变交错时，导致患者承受缺血再灌注损伤的能力变差，增加术后不良预后的风险[15]。CABG+MVP治疗CIMI，手术风险及术后并发症发生率较高[10]。虽然心脏复跳后进行食管超声确认二尖瓣无反流或极少量反流，但术后随访仍出现二尖瓣反流的复发，可能是由于术中体外循环降低心脏的前、后负荷，一定程度上使二尖瓣反流分级降低。CABG+MVP失败的原因可能是二尖瓣成型环裂开、感染性心内膜炎、术后出现心力衰竭或未发现的二尖瓣病理性改变等[16]。冠状动脉疾病导致的左心室重塑会随着PCI治疗得到改善，缺血心肌区域的血运重建将改善局部室壁运动，有可能纠正CIMI，且血运重建后残留的二尖瓣关闭不全不会影响患者的生存质量[17]。但PCI术后有可能因左室充盈压力增高，激活神经–体液系统导致二尖瓣反流程度不变或增加，增加不良预后的风险[18]。

在本研究中，CABG+MVP组与PCI组患者的年龄与术前LVEF存在显著差异，可能与高龄及心功能较差的患者多选择风险较小的介入手术有关。对比两种手术对重度CIMI患者术后二尖瓣的影响，PCI组患者术后二尖瓣反流程度无改善或复发率是CABG+MVP组的6.01倍。在冠状动脉单支病变中，两组患者术后二尖瓣反流无改善或复发率差异无统计学意义，说明冠状动脉血运重建可促进左室重构，增加左心室的收缩力，改善乳头肌的运动从而纠正局部室壁异常运动，减少二尖瓣反流。在冠状动脉双支病变与三支病变中，PCI组患者的术后二尖瓣反流无改善或复发率均高于CABG+MVP组。相较于PCI，CABG+MVP不仅可在术中直接纠正二尖瓣反流，且CABG还可使PCI无法治疗的小血管得到血运重建，更有利于心肌局部室壁的运动从而促进心室重构[19]。CABG+MVP组患者的二尖瓣反流好转程度优于PCI组，与Campwala等[20]的研究结果类似。

对重度CIMI的治疗，虽然外科手术伴随着术后高死亡率及术后并发症的发生，但CABG+MVP术后患者二尖瓣反流改善情况优于仅行PCI的患者。对高龄且心功能较差的单支病变患者，PCI可降低二尖瓣的反流程度。

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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

刘超，电子信箱：liubeilun@me.com

（2023–02–14）

（2023–08–27）