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。     

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

Opinion statement  

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.     

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.     

Posterior mitral leaflet motion in mitral stenosis.

A reduced rate of diastolic closure of the anterior mitral leaflet has been shown to occur in mitral stenosis, primary pulmonary hypertension, and in cases with reduced left ventricular compliance. Posterior notion of the posterior mitral leaflet in diastole has been the distinguishing feature to rule out the diagnosis of mitral stenosis. We have analyzed echocardiograms of 167 patients with mitral stenosis and have found 16 cases where the posterior mitral leaflet moved posteriorly, that is, in an opposite direction from the anterior mitral leaflet. Two other features were found that were helpful in establishing the diagnosis of mitral stenosis in these atypical cases, namely, thickening of the mitral leaflets and reduction or absence of the artrial wave.     

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。     

Effect of atrial fibrillation and mitral regurgitation on calculated mitral valve area in mitral stenosis

Forty-nine patients with mitral stenosis (MS) were studied by Doppler echocardiography and 2-dimensional (2-D) echocardiography to assess the ability of Doppler ultrasound to accurately measure mitral valve orifice area and to assess whether atrial fibrillation (AF) or mitral regurgitation (MR) affected the calculation. Twenty-four patients underwent cardiac catheterization. Mitral valve area by Doppler was determined by the pressure half-time method. Mean mitral valve area of all 49 patients by Doppler and 2-D echocardiography correlated well (r = 0.90). There was good correlation between Doppler and 2-D echocardiography in patients with pure MS in sinus rhythm (r = 0.88), in patients with MR (r = 0.93) and in patients with AF (r = 0.96). In the 7 patients with pure MS in sinus rhythm, there was good correlation between Doppler, 2-D echocardiography and cardiac catheterization (r = 0.95). In patients with either MR or AF, cardiac catheterization appeared to underestimate mitral valve orifice compared with both Doppler and 2-D echocardiography (p less than 0.05). Doppler echocardiography can estimate valve area in patients with MS regardless of the presence of MR or AF.     

Ross mitral procedure for massive congenital mitral insufficiency]

The authors report the case of a 4 month old North African baby with massive congenital mitral insufficiency associated with a coarctation of the aorta. The surgical treatment consisted in correction of the coarctation followed, several days later, by a Ross mitral procedure after failure of mitral reconstructive surgery. The postoperative course required circulatory assistance for 4 days and the child returned to his family two months after surgery. Control echocardiography before hospital discharge showed good function of the pulmonary autograft in the mitral position with no regurgitation but slight stenosis with a mean transvalvular pressure gradient of 4 mmHg. This procedure may be used in certain cases as an alternative to mitral valve replacement.     

Analysis of recurrent mitral regurgitation after mitral valve repair

Mitral valve repair was performed in 437 patients with mitral regurgitation from January 1994 to January 2002. The causes of mitral regurgitation were degenerative in 238 (54%), rheumatic in 134 (31%), and others in 65 (15%). The most frequently employed surgical techniques were ring annuloplasty in 417 (95%) cases, new chordae formation in 216 (50%), and quadrangular resection in 117 (27%). The mean follow-up was 29.04 +/- 22.81 months. There were 5 (1.2%) early and 5 (1.2%) late deaths. The reoperation rate was 1.6% with 41 (9%) cases of recurrent mitral regurgitation. Of these 22 were procedure-related: incomplete repair in 13, discordant new chordal length in 7, suture dehiscence and leaflet perforation in 1 case each. There were 19 cases of valve related failures: progression of rheumatic disease in 18 and subacute infective endocarditis in 1. Valve-related failure strongly correlated with progression of rheumatic disease. As initial operative success was the prime determinant of repair durability, intraoperative repair assessment with transesophageal echocardiography was essential.     

Complex arrhythmias in mitral regurgitation with and without mitral valve prolapse: Contrast to arrhythmias in mitral valve prolapse without mitral regurgitation

Atrial and ventricular arrhythmias were characterized by ambulatory electrocardiography in 31 patients with nonischemic mitral regurgitation (MR), 17 of whom had echocardlographic evidence of mitral valve prolapse (MVP) and 14 of whom had other causes of MR. Frequent and complex arrhythmias were common and equally prevalent in each MR subgroup, whether or not MVP was present. Multiform ventricular ectopy was found in 77%% (24 of 31), ventricular couplets in 61 % (19 of 31), and ventricular salvos or ventricular tachycardia in 35% (11 of 31) of patients with MR. Arrhythmias in patients with MR were significantly more prevalent than in 63 patients with MVP who had no evidence of MR. Among patients with MVP, excess arrhythmias associated with MR were most striking with respect to frequent ventricular premature complexes (41 % with MR vs 3 % without MR), multiform ventricular ectopic activity (88% vs 43%), ventricular couplets (65% vs 6%), and ventricular salvos or ventricular tachycardia (35 vs 5 %) (p <0.005 for each comparison). These data demonstrate that complex arrhythmias are common in patients with nonischemic MR irrespective of etiology, and that these arrhythmias are more strongly associated with hemodynamically important MR than with MVP alone.