功能性二尖瓣反流对非缺血性心肌病心脏再同步治疗患者反应性及长期预后的影响

Effect of functional mitral regurgitation on reactivity and long-term prognosis in patients with nonischemic cardiomyopathy treated with cardiac resynchronization therapy

目的:探讨术前功能性二尖瓣反流(FMR)及术后二尖瓣反流(MR)是否改善对非缺血性心肌病心脏再同步治疗(CRT)患者的反应性及长期预后的影响。方法:入选2010年1月—2017年6月首次接受CRT的非缺血性心肌病患者256例,根据基线MR程度分为无或轻度MR组(MR-组,73例)和中重度MR组(MR+组,183例)。术后6个月复查超声心动图评估CRT疗效及MR程度,根据术后MR程度变化分为MR改善组(156例)及MR无改善组(100例),以全因死亡为主要终点,绘制生存曲线,评价各组预后。结果:纳入的256例患者中,156例(60.9%)为CRT有反应,MR-组与MR+组的反应率差异无统计学意义(68.5%∶57.9%,P=0.118),MR改善组反应率高于MR无改善组(74.4%∶40.0%,P<0.01)。CRT术后MR-组与MR+组左心室射血分数(LVEF)、左心室舒张末期容积(LVEDV)及收缩末期容积(LVESV)均改善(均P<0.01),MR-组改善更为显著(均P<0.05)。中位随访58个月,55例(21.4%)患者出现终点事件,生存分析提示MR改善组及MR无改善组差异有统计学意义(P=0.001)。多因素Cox回归分析结果显示,MR改善是非缺血性心肌病CRT患者预后的独立影响因素。结论:CRT术后6个月,基线MR无或轻度患者较中重度患者心脏逆重构更为显著,MR改善是非缺血性心肌病CRT患者预后的独立影响因素。

Objective:To explore the effects of preoperative functional mitral regurgitation(FMR)and postoperative improvement of mitral regurgitation(MR)on the reactivity and long-term prognosis of cardiac resynchronization therapy(CRT)in patients with nonischemic cardiomyopathy.Methods:A total of 256 patients with nonischemic cardiomyopathy who underwent CRT for the first time from January 2010 to June 2017 were enrolled and divided into no or mild MR group(MR-group,n=73)and moderate-severe MR group(MR+group,n=183)according to baseline MR degree.Echocardiography was performed 6 months after the operation to evaluate the effects of CRT and the degree of MR.The patients were divided into MR improvement group(n=156)and MR non-improvement group(n=100)according to the change of MR degree after operation.The primary end point was all-cause mortality.Kaplan-Meier survival curve was used to assess the prognosis.Results:Among the 256 patients,156(60.9%)were CRT responders.There was no significant difference in CRT response rate between MR-group and MR+group(68.5%vs 57.9%,P=0.118).The CRT response rate in MR improved group was higher than that in MR non-improved group(74.4%vs 40.0%,P<0.01).Left ventricular ejection fraction(LVEF),left ventricular end-diastolic volume(LVEDV)and left ventricular end-systolic volume(LVESV)were improved after CRT in both MR-and MR+group(all P<0.01),especially in MR-group(P<0.05).During a median follow-up of 58 months,55 patients(21.4%)had endpoint events.Survival analysis showed that there was a significant difference between MR improvement group and MR non-improvement group(P=0.001).Multivariate Cox regression analysis showed that MR improvement was an independent prognostic factor for CRT patients with non-ischemic cardiomyopathy.Conclusion:Six months after CRT,patients with no or mild baseline MR degree have more significant cardiac reverse remodeling than those with moderate to severe MR degree.MR improvement is an independent prognostic factor for CRT patients with non-ischemic cardiomyopathy.