Kaul U A, Singh S, Kalra G S, Nair M, Mohan J C, Nigam M, Arora R
Department of Cardiology and Cardiothoracic Surgery, GB Pant Hospital, New Delhi, India.
J Heart Valve Dis. 2000 Mar;9(2):262-6; discussion 266-8.
Percutaneous transvenous mitral commissurotomy (PTMC) has revolutionized the treatment of patients with symptomatic mitral stenosis and is now established as the procedure of choice. Despite high technical expertise in PTMC using the Inoue balloon, mitral regurgitation (MR) remains a major procedure-related complication. We retrospectively analyzed our data of PTMC using the Inoue balloon with regard to the incidence of MR, its likely causative mechanism, and follow up of these patients.
During the past ten years, PTMC was performed in 3,650 patients (median age 26 years; range: 8-76 years), of whom 910 (24.9%) were juveniles. Preprocedure mitral valve area (MVA) was 0.9 +/- 0.4 cm2 (range: 0.3-1.3 cm2); MR was mild in 1,396 cases (38.2%), moderate in 394 (10.8%) and severe in 22 (0.6%). None of the patients was rejected on the basis of echocardiographic score.
The procedure was successful in 3,276 (89.8%), with post-procedure MVA of 1.7 +/- 0.6 cm2 (range: 1.4-2.6 cm2), and without development of any major complication. Severe MR was seen in 120 patients (3.3%), of whom 66 (1.8%) required urgent mitral valve replacement (MVR). Echocardiography in these latter patients showed leaflet rupture in 48 (72.7%), chordal rupture in 12 (18.2%) and excessive commissural tear in six (9.1%). Fifty-four patients (1.5%) with severe MR post PTMC were followed with medical treatment; echocardiography in these patients revealed chordal rupture in 40 (74.1%) and excessive commissural tear in 14 (25.9%). Follow up data were available in 49 patients (1.3%); 30 (0.8%) required MVR and 19 (0.5%) were in NYHA class II at a median follow up of 24 months. Moderate MR was seen in 188 cases (5.1%), with predominant causative mechanisms of excessive commissural tear in 120 (63.8%) and chordal rupture in 68 (36.2%). Severity of MR worsened in 30 cases (0.8%), of which 20 (0.6%) required elective MVR on follow up. MR decreased in 58 patients (1.6%), in whom excessive commissural tear was the causative mechanism.
Significant MR (moderate or severe) after PTMC was seen in 308 patients (8.4%), of whom 116 (3.2%) required MVR urgently or on follow up. All patients with leaflet rupture during PTMC developed severe MR and required urgent MVR. There was a tendency for the severity of MR to decrease with time in cases where excessive commissural tear was the causative mechanism.
经皮经静脉二尖瓣交界切开术（PTMC）彻底改变了有症状二尖瓣狭窄患者的治疗方式，现已成为首选治疗方法。尽管使用Inoue球囊进行PTMC技术精湛，但二尖瓣反流（MR）仍是主要的手术相关并发症。我们回顾性分析了使用Inoue球囊进行PTMC的患者数据，包括MR的发生率、可能的致病机制以及对这些患者的随访情况。
在过去十年中，对3650例患者（中位年龄26岁；范围：8 - 76岁）进行了PTMC，其中910例（24.9%）为青少年。术前二尖瓣瓣口面积（MVA）为0.9±0.4 cm²（范围：0.3 - 1.3 cm²）；1396例（38.2%）为轻度MR，394例（10.8%）为中度MR，22例（0.6%）为重度MR。没有患者因超声心动图评分而被拒绝手术。
手术成功3276例（89.8%），术后MVA为1.7±0.6 cm²（范围：1.4 - 2.6 cm²），且未发生任何重大并发症。120例患者（3.3%）出现重度MR，其中66例（1.8%）需要紧急二尖瓣置换术（MVR）。对这些患者进行超声心动图检查显示，48例（72.7%）为瓣叶破裂，12例（18.2%）为腱索破裂，6例（9.1%）为交界撕裂过度。54例PTMC术后出现重度MR的患者接受了药物治疗；对这些患者进行超声心动图检查发现，40例（74.1%）为腱索破裂，14例（25.9%）为交界撕裂过度。49例患者（1.3%）有随访数据；中位随访24个月时，30例（0.8%）需要MVR，19例（0.5%）纽约心脏协会（NYHA）心功能分级为Ⅱ级。188例患者（5.1%）出现中度MR，主要致病机制为交界撕裂过度120例（63.8%）和腱索破裂68例（36.2%）。30例患者（0.8%）MR严重程度加重，其中20例（0.6%）随访时需要择期MVR。58例患者（1.6%）MR减轻，其致病机制为交界撕裂过度。
308例患者（8.4%）PTMC术后出现显著MR（中度或重度），其中116例（3.2%）在紧急情况下或随访时需要MVR。PTMC期间所有发生瓣叶破裂的患者均出现重度MR并需要紧急MVR。在交界撕裂过度为致病机制的病例中，MR严重程度有随时间降低的趋势。
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