Хирургическое лечение вторичной митральной регургитации при сердечной недостаточности: современный взгляд

Актуальность. Вторичная, или функциональная, митральная регургитация является наиболее распространенным осложнением сердечной недостаточности. У 39–74% больных встречается дисфункция одной или нескольких структур митрального клапана, что осложняет течение болезни и существенно ухудшает прогноз у пациентов с дилатацией левого желудочка. Неблагоприятный прогноз у больных при развитии митральной регургитации обусловлен прогрессирующими изменениями, образующими порочный круг: продолжающаяся объемная перегрузка и дилатация левого желудочка вызывают его ремоделирование, приводящее к дальнейшей дилатации кольца митрального клапана. Дисфункции папиллярных мышц приводят к усилению напряжения стенки левого желудочка и усилению митральной регургитации. Клинически этот процесс проявляется прогрессированием застойной сердечной недостаточности и ухудшением прогноза дальнейшего течения, что в последующем может привести к постановке вопроса о включении данной группы пациентов в лист ожидания для трансплантации сердца.
Цель. Целью данной статьи является рассмотрение роли хирургического лечения пациентов с сердечной недостаточностью, осложненной митральной регургитацией.
Выводы. Основными принципами лечения функциональной митральной регургитации являются обратное ремоделирование левого желудочка и реконструкция или протезирование митрального клапана, которые приводят к улучшению качества жизни, переходу пациентов в меньший функциональный класс, уменьшению частоты госпитализаций, а также к регрессии или замедлению прогрессирования сердечной недостаточности и улучшению выживаемости.

1. Kim ICh, Youn JCh, Kobashigawa JA. The past, present and future of heart transplantation. Korean Circ J. 2018;48(7):565–590. PMID: 29968430 https://doi.org/10.4070/kcj.2018.0189

2. Bolling SF. Mitral valve reconstruction in the patient with heart failure. Heart Fail Rev. 2001;6(3):177–185. PMID: 11391035 https://doi.org/10.1023/a:1011421014480

3. Ray S. The echocardiographic assessment of functional mitral regurgitation. Eur J Echocardiogr. 2010;11(10):i11– i17. PMID: 21078834 https://doi.org/10.1093/ejechocard/jeq121

4. Kumanohoso T, Otsuji Y, Yoshifuku S, Matsukida K, Koriyama C, Kisanuki A, et al.Mechanism of higher incidence of ischemic mitral regurgitation in patients with inferior myocardial infarction: quantitative analysis of left ventricular and mitral valve geometry in 103 patients with prior myocardial infarction. J Thorac Cardiovasc Surg. 2003;125(1):135–143. PMID: 12538997 https://doi.org/10.1067/mtc.2003.78

5. Bursi F, Barbieri A, Grigioni F, Reggianini L, Zanasi V, Leuzzi C, et al. Prognostic implications of functional mitral regurgitation according to the severity of the underlying chronic heart failure: a long-term outcome study. Eur J Heart Fail. 2020;12(4):382–388. PMID: 20197266 https://doi.org/10.1093/eurjhf/hfq014

6. Grigioni F, Enriquez-Sarano M, Zehr KJ, Bailey KR, Tajik AJ. Ischemic mitral regurgitation: long-term outcome and prognostic implications with quantitative Doppler assessment. Circulation. 2001;103(13):1759–1764. PMID: 11282907 https://doi.org/10.1161/01.CIR.103.13.1759

7. Gertz ZM, Raina A, Saghy L, Zado ES, Callans DJ, Marchlinski FE, et al. Evidence of atrial functional mitral regurgitation due to atrial fibrillation: reversal with arrhythmia control. J Am Coll Cardiol. 2011;58(14):1474–1481. PMID: 21939832 https://doi.org/10.1016/j.jacc.2011.06.032

8. Lancellotti P, Moura L, Pierard LA, Agricola E, Popescu BA, Tribouilloy Ch, et al. European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 2: mitral and tricuspid regurgitation (native valve disease). Eur J Echocardiogr. 2010;11(4):307–332. PMID: 20435783 https://doi.org/10.1093/ejechocard/jeq031

9. Calafiore AM, Iaco AL, Gallina S, Al-Amri H, Penco M, Di Mauro M, et al. Surgical treatment of functional mitral regurgitation. Int J Cardiol. 2013;166(3):559–571. PMID: 22633664 https://doi.org/10.1016/j.ijcard.2012.05.027

10. Milano CA, Daneshmand MA, Rankin JS, Honeycutt E, Williams ML, Swaminathan M, et al. Survival prognosis and surgical management of ischemic mitral regurgitation. Ann Thorac Surg. 2008;86(3):735–744. PMID: 18721554 https://doi.org/10.1016/j.athoracsur.2008.05.017

11. Hu X, Zhao Q. Systematic evaluation of the flexible and rigid annuloplasty ring after mitral valve repair for mitral regurgitation. Eur J Cardiothorac Surg. 2011;40(2):480–487. PMID: 21295489 https://doi.org/10.1016/j.ejcts.2010.11.080

12. Acker MA, Parides MK, Perrault LP, Moskowitz AJ, Gelijns AC,Voisine P, et al. Mitral-valve repair versus replacement for severe ischemic mitral regurgitation. N Engl J Med. 2014;370(1):23–32. PMID: 24245543 https://doi.org/10.1056/NEJMoa1312808

13. Bach DS, Bolling SF. Improvement following correction of secondary mitral regurgitation in end-stage cardiomyopathy with mitral annuloplasty. Am J Cardiol. 1996;78(8):966–969. PMID: 8888680 https://doi.org/10/1016/S0002-9149(96)00481-X

14. Kwon MH, Lee LS, Cevasco M, Couper GS, Shekar PS, Cohn LH, et al. Recurrence of mitral regurgitation after partial versus complete mitral valve ring annuloplasty for functional mitral regurgitation. J Thorac Cardiovasc Surg. 2013;146(3):616–622. PMID: 22921822 https://doi.org/10.1016/j.jtcvs.2012.07.049

15. Bonis MD, Taramasso M, Verzini A, Ferrara D, Lapenna E, Calabrese MCh, et al. Long-term results of mitral repair for functional mitral regurgitation in idiopathic dilated cardiomyopathy. Eur J Cardiothorac Surg. 2012;42(4):640– 646. PMID: 22447810 https://doi.org/10.1093/ejcts/ezs078

16. Acker MA, Bolling S, Shemin R, Kirklin J, Oh JK, Mann DL, et al. Mitral valve surgery in heart failure: insights from the Acorn Clinical Trial. J Thorac Cardiovasc Surg. 2006;132(3):568–577. PMID: 16935112 https://doi.org/10.1016/j.jtcvs.2006.02.062

17. Mann DL, Kubo SH, Sabbah HN, Starling RC, Jessup M, Oh JK, et al. Beneficial effects of the Cor Cap cardiac support device: five-year results from the Acorn Trial. J Thorac Cardiovasc Surg. 2012;143(5):1036–1042. PMID: 21762937 https://doi.org/10.1016/j.jtcvs.2011.06.014

18. Vassileva CM, Boley T, Markwell S, Hazelrigg S. Meta-analysis of shortterm and long-term survival following repair versus replacement for ischemic mitral regurgitation. Eur J Cardiothorac Surg. 2011;39(3):295–303. PMID: 20727782 https://doi.org/10.1016/j.ejcts.2010.06.034

19. Bonis MD, Ferrara D, Taramasso M, Calabrese MC, Verzini A, Buzzatti N, et al. Mitral replacement or repair for functional mitral regurgitation in dilated and ischemic cardiomyopathy: is it really the same? Ann Thorac Surg. 2012;94(1):44–51. PMID: 22440363 https://doi.org/10.1016/j.athoracsur.2012.01.047

20. Maltais S, Schaff HV, Daly RC, Suri RM, Dearani JA, Sundt TM 3rd, et al. Mitral regurgitation surgery in patients with ischemic cardiomyopathy and ischemic mitral regurgitation: factors that influence survival. J Thorac Cardiovasc Surg. 2011;142(5):995–1001. PMID: 21855899 https://doi.org/10.1016/j.jtcvs.2011.07.044

21. Lorusso R, Gelsomino S, Vizzardi E, D'Aloia A, De Cicco G, Lucà F, et al. Mitral valve repair or replacement for ischemic mitral regurgitation? The Italian study on the treatment of ischemic mitral regurgitation. J Thorac Cardiovasc Surg. 145(1):128–139. PMID: 23127376 https://doi.org/10.1016/j.jtcvs.2012.09.042

22. Kron IL, Hung J, Overbey JR, Bouchard D, Gelijns AC, Moskowitz AJ, et al. Predicting recurrent mitral regurgitation after mitral valve repair for severe ischemic mitral regurgitation. J Thorac Cardiovasc Surg. 2015;149(3):752– 761. PMID: 25500293 https://doi.org/110.1016/j.jtcvs.2014.10.120

23. Alfieri O, Maisano F, De Bonis M, Stefano PL, Torracca L, Oppizzi M, et al. The double-orifice technique in mitral valve repair: a simple solution for complex problems. J Thorac Cardiovasc Surg. 2001;122(4):674–681. PMID: 11581597 https://doi.org/10.1067/mtc.2001.117277

24. Campwala SZ, Bansal RC, Wang N, Razzouk A, Paiet RG. Factors affecting regression of mitral regurgitation following isolated coronary artery bypass surgery. Eur J Cardiothorac Surg. 2005;28(5):783–787. PMID: 16329167 https://doi.org/10.1016/j.ejcts.2005.10.010

25. Aklog L, Filsoufi F, Flores KQ, Chen RH, Cohn LH, Nathanet NS, et al. Does coronary artery bypass grafting alone correct moderate ischemic mitral regurgitation? Circulation. 2001;104(12 Suppl 1):I68–I75. PMID: 11568033 https://doi.org/10.1161/circ.104.suppl_1.I-68

26. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP 3rd, Guyton RA, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American college of cardiology/American heart association task force on practice guidelines. J Am Coll Cardiol. 2014;63(22):e57–e185. PMID: 24603191 https://doi.org/10.1016/j.jacc.2017.03.011

27. Privitera S, Butany J, Cusimano RJ, Silversides C, Ross H, Leask R, et al. Images in cardiovascular medicine. Alfieri mitral valve repair: clinical outcome and pathology. Circulation. 2002;106(21):e173–e174. PMID: 12438304 https://doi.org/10.1161/01.CIR.0000042760.92490.13

28. Feldman T, Foster E, Glower DD, Kar S, Rinaldi MJ, Fail PS, et al. Percutaneous repair or surgery for mitral regurgitation. N Engl J Med. 2011;364(15):1395–1406. PMID: 21463154 https://doi.org/10.1056/NEJMoa1009355

29. Mauri L, Foster E, Glower DD, Apruzzese P, Massaro JM, Herrmannet HC, et al. 4-year results of a randomized controlled trial of percutaneous repair versus surgery for mitral regurgitation. J Am Coll Cardiol. 2013;62(4):317–328. PMID: 23665364 https://doi.org/10.1016/j.jacc.2013.04.030

30. Yeo KK, Yap J, Yamen E, Muda N, Tay E, Walters DL, et al. Percutaneous mitral valve repair with the MitraClip: early results from the MitraClip AsiaPacific Registry (MARS). Euro Intervention. 2014;10(5):620–625. PMID: 24425362 https://doi.org/10.4244/EIJV10I5A107

31. Taramasso M, Maisano F, Latib A, Denti P, Buzzatti N, Cioni M, et al. Clinical outcomes of MitraClip for the treatment of functional mitral regurgitation. Euro Intervention. 2014;10(5):746–752. PMID: 24469474 https://doi.org/10.4244/EIJV10I6A128

32. Bozdag-Turan I, Paranskaya L, Birkemeyer R, Turan RG, Kische S, Akin I, et al. Percutaneous mitral repair with the MitraClip system in patients with mildto-moderate and severe heart failure: a single-centre experience. Cardiovasc Ther. 2014;3(2):66–73. PMID: 24354948 https://doi.org/10.1111/1755-5922.12058

33. Braun D, Lesevic H, Orban M, Michalk F, Barthel P, Hoppe K, et al. Percutaneous edge-to-edge repair of the mitral valve in patients with degenerative versus functional mitral regurgitation. Catheter Cardiovasc Interv. 2014;84(1):137–146. PMID: 24323541 https://doi.org/10.1002/ccd.25331

34. Schillinger W, Hunlich M, Baldus S, Ouarrak T, Boekstegers P, Hink U, et al. Acute outcomes after MitraClip therapy in highly aged patients: results from the German TRAnscatheter Mitral valve Interventions (TRAMI) Registry. Euro Intervention. 2013;9(1):84–90. PMID: 23579108 https://doi.org/10.4244/EIJV9I1A13

35. Raza F, Grayburn P, Choi J. Use of a MitraClip for severe mitral regurgitation in a cardiac transplant patient. Proc (Bayl Univ Med Cent). 2017;30(2):226– 227. PMID: 28405092https://doi.org/10.1080/08998280.2017.11929597

36. Maisano F, Franzen O, Stephan B, Schäfer U, Hausleiter J, Butter Ch, et al. Percutaneous mitral valve interventions in the real world: early and 1-year results from the ACCESS-EU, a prospective, multicenter, nonrandomized post-approval study of the MitraClip therapy in Europe. J Am Coll Cardiol. 2013;62(12):1052–1061. PMID: 23747789 https://doi.org/10.1016/j.jacc.2013.02.094

37. Auricchio A, Schillinger W, Meyer S, Maisano F, Hoffmann R, Ussia GP, et al. Correction of mitral regurgitation in nonresponders to cardiac resynchronization therapy by MitraClip improves symptoms and promotes reverse remodeling. J Am Coll Cardiol. 2011;58(12):2183– 2189. PMID: 22078424 https://doi.org/10.1016/j.jacc.2011.06.061

38. Grossi EA, Patel N, Woo YJ, Goldberg JD, Schwartz ChF, Subramanian V, et al. Outcomes of the RESTORMV trial (Randomized evaluation of a surgical treatment for off-pump repair of the mitral valve). J Am Coll Cardiol. 2010;56(24):1984–1993. PMID: 21126639 https://doi.org/10.1016/j.jacc.2010.06.051

39. Godino C, Munafò A, Scotti A, Estévez-Loureiro R, Portolés Hernández A, Arzamendi D, et al. MitraClip in secondary mitral regurgitation as a bridge to heart transplantation: 1-year outcomes from the International MitraBridge Registry. J Heart Lung Transplant. 2020;39(12):1353–1362. PMID: 33008726 https://doi.org/10.1016/j.healun.2020.09.005

40. Cleland John GF, Daubert J-C, Erdmann E, Freemantle N, Gras D, Kappenberger L, et al. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med. 2005;352(15):1539–1549. PMID: 15753115 https://doi.org/10.1056/NEJMoa050496

41. Sutton MG St John, Plappert T, Abraham WT, Smith AL, DeLurgio DB, Leonet AR, et al. Effect of cardiac resynchronization therapy on left ventricular size and function in chronic heart failure. Circulation. 2003;107(15):1985– 1990. PMID: 12668512 https://doi.org/10.1161/01.CIR.0000065226.24159.E9

42. Sutton MSt John, Ghio S, Plappert T, Tavazzi L, Scelsi L, Daubert C, et al. Resynchronization reverses Remodeling in Systolic left ventricular dysfunction (REVERSE) Study Group Cardiac resynchronization induces major structural and functional reverse remodeling in patients with New York Heart Association class I/II heart failure. Circulation. 2009;120(19):1858–1865. PMID: 19858419 https://doi.org/10.1161/CIRCULATIONAHA.108.818724

43. Ypenburg C, Lancellotti P, Tops LF, Bleeker GB, Holman ER, Piérard LA, et al. Acute effects of initiation and withdrawal of cardiac resynchronization therapy on papillary muscle dyssynchronyand mitral regurgitation. J Am Coll Cardiol. 2007;50(21):2071–2077. PMID: 18021876 https://doi.org/10.1016/j.jacc.2007.08.019

44. Rossi A, Dini FL, Faggiano P, Agricola E, Cicoira M, Frattini S, et al. Independent prognostic value of functional mitral regurgitation in patients with heart failure. A quantitative analysis of 1256 patients with ischaemic and nonischaemic dilated cardiomyopathy. Heart. 2011;97(20):1675–1680. PMID: 21807656 https://doi.org/10.1136/hrt.2011.225789