经皮二尖瓣球囊扩张术治疗二尖瓣狭窄伴中度返流

目的　探讨经皮二尖瓣球囊扩张术 (PBMV)治疗二尖瓣狭窄 (MS)伴中度二尖瓣返流(MR)的近、远期疗效。方法　采用自制二尖瓣球囊导管治疗MS伴中度MR患者 6 2例 ,其中二尖瓣膜明显增厚、钙化者 7例 ,对左室最大前后径、二尖瓣口面积、左房平均压、二尖瓣跨瓣压差及心功能(NYHA分级 )等主要指标随访观察 12～ 36个月。结果　术后二尖瓣口面积明显增大 [(0 83± 0 18)cm2 比 (1 86± 0 2 4 )cm2 ,P <0 0 1],左房平均压 [(32± 8)mmHg比 (13± 8)mmHg ,P <0 0 1,1mmHg=0 133kPa]及二尖瓣跨瓣压差 [(18± 9)mmHg比 (5± 3)mmHg ,P <0 0 1]明显降低 ,心功能明显改善 [(2 81± 0 2 4 )级比 (1 4 6± 0 37)级 ,P <0 0 1],左室最大前后径无显著改变 [(4 5± 4 )mm比 (4 6± 4 )mm ,P >0 0 5 ]。对左室最大前后径、二尖瓣口面积及心功能等指标随访观察 12～ 36个月均无明显改变。结论　选择合适病例 ,严格把握球囊扩张终点 ,风湿性二尖瓣狭窄并中度返流患者PBMV的近、远期疗效显著。     

老年二尖瓣狭窄患者经皮气囊二尖瓣成形术

目的　观察老年风湿性心脏病二尖瓣狭窄患者经皮气囊二尖瓣成形术 (PBMV)的效果。方法　 34名患者 ,其中男 1 4例 ,女 2 0例 ,年龄 55～ 71 (61 5± 9 4)岁。采用Inoue管或国产导管进行PBMV并观察手术前后心功能 ,血流动力学和瓣膜超声形态变化及并发症。结果　二尖瓣面积由 (0 92± 0 2 3)cm2 增至 (1 97± 0 52 )cm2 (P <0 0 1 ) ;二尖瓣跨瓣压由 (2 54± 1 1 3)kPa下降至 (0 63± 0 52 )kPa(P <0 0 1 ) ;左心房压从 (3 0 2± 1 34)kPa降至 (1 67± 1 0 2 )kPa(P <0 0 1 ) ;术后新出现二尖瓣返流 7例 ,返流加重 6例 ,但不影响疗效。 3例术中发生脑栓塞。 1 5例在 0 5～ 3年内复诊的患者中有 3例因二尖瓣再狭窄伴心功能恶化而住院。结论　PBMV对老年二尖瓣狭窄亦能取得较好的效果 ,但病例选择、手术操作有其特殊性     

再次经皮球囊二尖瓣成形术治疗成形术后再狭窄的疗效观察

目的　评价再次经皮球囊二尖瓣成形术 (PBMV)治疗二尖瓣狭窄PBMV术后再狭窄的临床疗效。方法　采用Inoue法对 2 9例PBMV术后再狭窄患者进行再次PBMV ,并与 2 5 8例首次接受PBMV的患者进行疗效比较。结果　再次PBMV后二尖瓣口面积由 ( 0 98± 0 13)cm2 增至 ( 1 6 5±0 2 4)cm2 (P <0 0 0 1) ,二尖瓣跨瓣压差由 ( 2 6 5± 1 44 )kPa( 1kPa =7 5mmHg)降至 ( 0 79± 0 2 3)kPa(P<0 0 0 1) ,左房平均压由 ( 3 37± 0 6 2 )kPa降至 ( 1 6 6± 0 93)kPa(P <0 0 0 1) ,左房内径由 ( 4 5 2± 0 5 7)cm降至 ( 4 17± 0 5 0 )cm(P <0 0 5 )。再次PBMV组二尖瓣口面积增加值与左房平均压下降值小于首次PBMV组 [分别为 ( 0 6 7± 0 11)cm2 vs( 0 88± 0 32 )cm2 (P <0 0 5 )与 ( 1 71± 0 88)kPavs( 1 94± 0 5 6 )kPa(P <0 0 5 ) ]。再次PBMV组无心包填塞、死亡发生 ,主要并发症为重度二尖瓣反流 2例。结论只要选择合适病例 ,再次PBMV术仍可取得显著的即刻血流动力学改善 ,是PBMV术后再狭窄患者的一种安全而有效的治疗方法。     

老年风湿性二尖瓣狭窄伴中度返流PBMV治疗29例分析

目的探讨经皮二尖瓣球囊扩张术(PBMV)治疗老年性二尖瓣狭窄(MS)伴中度二尖瓣返流疗效。方法用Inoue球囊导管行PBMV治疗老年性二尖瓣狭窄伴中度返流患者29例。比较手术前后血流动力学变化。结果术后血流动力学明显改善,球囊扩张前后二尖瓣面积、跨膜压差、左房平均压及心功能比较有明显的变化(P<0.01)。左室最大前后径无明显改变(P>0.05)。结论只要掌握好病例选择,严格掌握操作技术,把握球囊扩张终点,球囊充盈时机,球囊直径,老年性二尖瓣狭窄伴中度返流患者PBMV术后可取得满意的疗效。     

经皮二尖瓣球囊成形术治疗二尖瓣狭窄伴主动脉瓣关闭不全的疗效评价

目的　探讨风湿性心脏病 (RHD)二尖瓣狭窄 (MS)合并轻、中度主动脉瓣关闭不全 (AR)患者行经皮二尖瓣球囊成形术 (PBMV)的效果。方法　将 2 6例MS合并轻、中度AR患者 (A组 )和 34例单纯MS患者 (B组 )的PBMV术后即刻及随访结果作对比研究。结果　A组左心房平均压力(MLAP)从术前 2 3 5± 4 6mmHg降至 11 2± 2 9mmHg(P <0 0 1) ,二尖瓣跨瓣压差 (MVG)从 17 2±7 7mmHg降至 2 3± 2 6mmHg(P <0 0 1) ,二尖瓣口面积 (MVA)从 1 1± 0 2cm2 增至 2 1± 0 2cm2(P <0 0 1) ,左心房内径 (LAD)从 43 3± 5 0mm降至 36 4± 3 7mm(P <0 0 1)。二尖瓣区舒张期杂音消失率为 73%。心功能分级 (NYHA)从术前 2 7± 0 5级改善至 1 1± 0 7级 (P <0 0 1)。随访与术后比较 ,除MVA外各项指标均无显著性差异 (P >0 0 5 )。以上各项参数与B组比较 ,差异均无显著性(P >0 0 5 )。且A组随访左心室内径 (LVD)仍在正常范围 ,亦无主动脉瓣返流增加。结论　对于MS合并轻、中度AR ,PBMV是一种有效和安全的治疗措施 ,应列入PBMV的手术适应症。     

经皮二尖瓣球囊扩张术394例随访结果

目的　观察经皮二尖瓣球囊扩张术(PBMV)治疗风湿性心脏病(风心病)二尖瓣狭窄的中、远期疗效。方法　采用Inoue单球囊对680例风心病二尖瓣狭窄者行PBMV术治疗,其中394例进行了随访。平均随访时间(36±14)个月。结果　二尖瓣平均跨瓣压差由(18.2±6.8)mmHg降至(7.2±3.8)mmHg,瓣口面积由(1.04±0.21)cm2增至(1.98±0.55)cm2,左房内径由(44±8)mm降至(38±6)mm;8例出现明显再狭窄,其中5例再次PBMV术,3例行瓣膜置换术。结论　随访结果证实,PBMV治疗风心病二尖瓣狭窄的中、远期效果良好,瓣膜条件特别是瓣下病变的程度是影响中、远期疗效的重要因素。     

经皮二尖瓣扩张术治疗老年及老年前期患者二尖瓣狭窄

目的　探讨经皮经房间隔穿刺二尖瓣扩张治疗老年和老年前期患者二尖瓣狭窄的临床意义。方法　 86例患者采用一步法经皮经房间隔穿刺球囊扩张治疗二尖瓣狭窄。手术前后分别记录右心房压、左心房压、肺动脉压 ,二尖瓣口面积 ,并进行手术后随防。结果　 86例患者中 83例治疗成功 ,3例失败 ,其中 1例为术中急性心包填塞 ,2例术后出现中度二尖瓣反流。术后即刻 ,左心房压、肺动脉压下降 ,二尖瓣口面积增加 ,心功能改善。 4 2例患者随访(4 .4± 2 .1)年 ,1例出现再狭窄 ,1例原因不明猝死 ,1例因二尖瓣反流行瓣膜置换术 ,其余患者心功能和生活质量明显改善。结论　对年龄≥ 5 0岁伴轻度二尖瓣和 (或 )主动脉瓣反流 ,瓣膜钙化或瓣下结构病变的二尖瓣狭窄患者 ,可安全有效地施行球囊二尖瓣成形术。     

经皮球囊二尖瓣成形术治疗二尖瓣分离术后再狭窄

经皮球囊二尖瓣成型术 (PBMV)对二尖瓣分离术后再狭窄的治疗 ,各家意见不一。我们对 12例二尖瓣分离术后再狭窄患者行 PBMV,并对其血流动力学、超声心动图及临床疗效进行了观察 ,以探讨其可行性。临床资料 :本组男 3例、女 9例 ;年龄 33～ 5 6 (平均 4 7±5 .2 )岁 ;病程 11～ 2 6年 ,平均 19.5± 5 .6年 ;距二尖瓣分离术时间 8～ 13(平均 9.5± 2 .3)年。 3例合并轻度二尖瓣返流 ,2例合并轻度主动脉瓣返流 ,1例合并冠心病。心功能 级 8例、 级 4例 ,心房颤动 5例 ,术前平均心胸比例为 0 .5 8±0 .0 6 (0 .4 6± 0 .6 8)。二尖瓣口面积…     

68例二尖瓣狭窄合并轻度主动脉瓣关闭不全患者经皮球囊形成术后5年随访结果分析

目的评价经皮二尖瓣球囊形成术(PBMV)对二尖瓣狭窄合并轻度主动脉瓣关闭不全患者的安全性和有效性。方法对68例二尖瓣狭窄合并轻度主动脉瓣关闭不全患者行PBMV,术后随访5年,平均随访时间(5.4±1.2)年,内容包括心胸比率、超声心动图及心功能评价。结果PBMV术前、术后一周二尖瓣口面积(MVA)分别为(1.16±0.30)cm2与(2.21±0.52)cm2,术后MVA明显增加P＜0.001;术后5年MVA(2.07±0.43)cm2,较术后一周MVA减少,仍比术前大,P＜0.001;PBMV前、后左心室舒张末期内径为(4.26±0.50)cm,(4.58±0.44)cm,术后5年为(4.85±0.47)cm2,术后及5年随访与术前分别比较无显著性差异,P均大于0.05;PBMV术前后及5年随访主动脉瓣返流峰值压差分别为(60.00±35.54)mmHg,(58.51±38.71)mmHg,(62.44±34.67)mmHg,术后一周及5年与术前比较无显著性差异。术前后心胸比率分别为(0.56±0.06)、(0.55±0.05)与(0.54±0.06),术后心脏无显著扩大。PBMV术后心功能改善一个级别以上占91.2%,能维持Ⅰ～Ⅱ级心功能5年者占83.8%,5年总生存率98.5%。4例二尖瓣钙化,瓣下结构粘连纤维化严重的患者和3例合并中重度三尖瓣关闭不全患者,PBMV术后心功能无改善而转外科行瓣膜置换术,或加做三尖瓣环缩术,1例青年患者在随访过程中出现二尖瓣再狭窄而再次PBMV,1例心功能Ⅳ级患者PBMV术后出现重度二尖瓣关闭不全,行瓣膜置换术后死于难以纠正的心力衰竭。结论PBMV对二尖瓣狭窄合并轻度主动脉瓣关闭不全患者是可行的,术后并不加重主动脉瓣返流,也不使左室扩大。瓣膜钙化、瓣下粘连、纤维化严重或伴有中重度三尖瓣关闭不全、心胸比率大于0.60患者,是PBMV反指征。     

一步法经皮球囊扩张术治疗二尖瓣狭窄及瓣膜分离术后再狭窄

目的:旨在研究一步法经皮球囊扩张术(PBMV)治疗风湿性心脏病二尖瓣狭窄和瓣膜分离术后二尖瓣再狭窄15年经验及长期随访。方法:摒弃传统的三步法,采用一步法经皮经房间隔穿刺球囊扩张治疗二尖瓣狭窄。结果:492例二尖瓣球囊扩张术成功率98·2%(483/492),术后二尖瓣口面积明显增加从(0·89±0·18)cm2至(2·21±0·41)cm2。211例随访8个月至9年2个月,二尖瓣再狭窄率为11·14%(24/211),病死率为(4·2/211),二尖瓣再置换术为5·2%(11/211)。46例二尖瓣闭式分离术后再狭窄。球囊扩张治疗后临床症状明显改善,二尖瓣外科术后再狭窄患者瓣口面积(MVA)由(1·03±0·28)cm2增至(1·94±0·27)cm2(P<0·001),其中28例随访(4·3±2·1)年,MVA为(1·81±0·27)cm2(与术前比较,P<0·001,与术后即刻比较,P>0·05),发生再狭窄3例,已成功第二次PBMV。结论:一步法PBMV治疗严重二尖瓣狭窄成功率高,并发症低;对年龄≥50岁伴轻度二尖瓣(和)主动脉瓣反流者,二尖瓣闭式分离术后再狭窄者,近远期疗效显著,具有创伤小,安全、有效可重复性等特点。     

Floppy mitral valve, mitral valve prolapse, and mitral valvular regurgitation

Opinion statement  

Percutaneous mitral valve repair for mitral regurgitation

Mitral regurgitation (MR) associated with, ischemic, and degenerative (prolapse) disease, contributes to left ventricular (LV) dysfunction due to remodeling, and LV dilation, resulting in worsening of MR. Mitral valve (MV) surgical repair has provided improvement in survival, LV function and symptoms, especially when performed early. Surgical repair is complex, due to diverse etiologies and has significant complications. The Society for Thoracic Surgery database shows that operative mortality for a 1st repair is 2% and for re-do repair is 4 times that. Cardiopulmonary bypass and cardiac arrest are required. The attendant morbidity prolongs hospitalization and recovery. Alfieri simplified mitral repair using an edge-to-edge technique which subsequently has been shown to be effective for multiple etiologies of MR. The MV leaflers are typically brought together by a central suture producing a double orifice MV without stenosis. Umana reported that MR decreased from grade 3.6 +/- 0.5 to 0.8 +/- 0.4 (P < 0.0001) and LV ejection fraction increased from 33 +/- 13% to 45 +/- 11% (P = 0.0156). In 121 patients, Maisano reported freedom from re-operation of 95 +/- 4.8% with up to 6 year follow-up. Oz developed a MV "grasper" that is directly placed via a left ventriculotomy and coapts both leaflets which are then fastened by a graduated spiral screw. An in-vitro model using explanted human valves showed significant reduction in MR and in canine studies, animals followed by serial echo had persistent MV coaptation. At 12 weeks the device was endothelialized. These promising results have paved the way for a percutaneous or minimally invasive-off pump mitral repair. Evalve has developed catheter-based technology, which, by apposing the edges of a regurgitant MV, results in edge-to-edge repair. Release of the device is done after echo and fluoroscopic evaluation under normal loading conditions. If the desired effect is not produced the device can be repositioned or retrieved. Animal studies show excellent healing, with incorporation of the device into the leaflets at 6-10 weeks with persistent coaptation. Another percutaneous approach has been to utilize the proximity of the coronary sinus (CS) to the mitral annulus (MA). Placement of a self-compressing device in the CS along the region of the posterior MA has, in canine models, reduced MR and addresses the issues of MA dilation and its contribution to MR. Ongoing studies are underway for both techniques.     

Non-surgical mitral valvuloplasty for rheumatic mitral stenosis

One hundred and twenty-six patients of rheumatic mitral stenosis (MS), aged 10-30 (mean 19.5 +/- 5.9) years underwent balloon mitral valvuloplasty (BMV). All valvuloplasties were done by the anterograde transvenous, transatrial route. The procedure was successful in 120 (95%) cases. Single balloon was used in 10 patients early in the series and double balloon was used in the other 110 patients. BMV resulted in a significant increase in the mitral valve area (MVA) from 0.96 +/- 0.35 to 2.3 +/- 0.8 cm2 (p less than 0.0001) and a significant fall in the transmitral pressure gradient (TMG) from 28.2 +/- 3.2 to 7.4 +/- 4.8 mmHg (p less than 0.001). The MVA achieved by BMV was found to have a significant positive correlation with the balloon diameter to body surface area ratio (BD/BSA) (r = 0.69, p less than 0.001). New mitral regurgitation (MR) developed in 15 patients--trivial in 11, 2+ in 2 and 3+ in 2. One patient required emergency mitral valve replacement. Procedure induced MR did not have a significant relation to the balloon size, degree of mitral sub-valvular pathology or the severity of mitral stenosis. Iatrogenic atrial septal defect was detected by oximetry in none, by angiography in one patient, and by Doppler color flow imaging in 5 patients. Cardiac tamponade was the most frequent serious complication, occurring in 6 patients, 4 of whom died following emergency surgery. Sixty-five patients have been followed up for at least 6 months (range 6-30, mean 16.3 +/- 6.3 months) following BMV.(ABSTRACT TRUNCATED AT 250 WORDS)     

Inoue-balloon mitral valvuloplasty in double-orifice mitral stenosis

We report 7 symptomatic patients with stenotic double-orifice mitral valve of incomplete bridge type. In each patient, the fibrous bridge tissue between the valve leaflets was successfully split using an Inoue balloon valvuloplasty technique with stepwise dilations applied only to the posteromedial orifice.     

分级次二尖瓣球囊扩张预防二尖瓣反流的初步研究

目的为探讨经皮穿刺球囊导管二尖瓣扩张术（ＰＢＭＶ）引起二尖瓣反流（ＭＲ）的原因及其预防方法。方法我们采用分级次扩张法和改良Ｉｎｏｎｅ法对人体病变二尖瓣和硅胶二尖瓣模型进行体外球囊导管扩张实验，并对１３２例风湿性心脏病重度二尖瓣狭窄患者，其中分别以分级次扩张法９６例，Ｉｎｏｎｅ法３６例进行ＰＢＭＶ的前瞻性对比研究。结果（１）ＰＢＭＶ引起二尖瓣反流的原因除与瓣膜钙化程度重、瓣下结构紊乱有关以外，瓣口面积小、交界粘连处夹角小是一个重要原因。（２）分级次扩张可使交界粘合处夹角呈渐进性扩大，扩张时不易引起瓣膜撕裂和二尖瓣反流。两组比较Ｉｎｏｎｅ法扩张组二尖瓣反流发生率为１６．７％，分级次扩张组无二尖瓣反流病例，并且术中其他并发症及术后再狭窄发生率后者也明显低于前者。结论球囊导管分级次扩张可有效地预防二尖瓣反流，是治疗二尖瓣狭窄较理想的方法。