Yahini J H, Deutsch V, Miller H I, Shem-Tov A, Atlas P, Neufeld H N
Isr J Med Sci. 1975 Sep;11(9):928-67.
This review clearly indicates that a clinical picture of pure, isolated mitral insufficiency constitutes an interesting diagnostic challenge. In adult patients especially, this common valvular lesion is often nonrheumatic and may be found in a variety of cardiac conditions. The following provides a general orientation for their differential diagnosis. The first clue to the presence of papillary muscle dysfunction, a "spontaneous" chordal rupture, or a congenital or traumatic lesion which may account for the mitral insufficiency, may be derived from the patient's case history. A history suggesting systemic manifestations raises the possibility of atrial myxoma. When a familial incidence is reported, various syndromes or a cardiomyopathy should be considered as the etiology of the mitral incompetence. The auscultatory findings are typical in the mid-late systolic click and murmur syndrome, but recognition of this condition may require careful examination of the patient in different postures. The possibility of obstructive cardiomyopathy may be confirmed by the characteristic carotid pressure tracing. ECG findings of acute or chronic coronary heart disease favor the possibility of papillary muscle dysfunction. In addition, the ECG may support the clinical impression of a cardiomyopathy. Fluoroscopy may show calcification of the coronary arteries and/or dyskinetic left ventricular contractions in papillary muscle dysfunction, intracardiac calcifications in atrial space-occupying lesions, or calcification of a mitral annulus. Chest X-rays may contribute to the diagnosis of acute mitral insufficiency by showing a relatively small left atrium and ventricle in the presence of severe congestive failure. While echocardiography is invaluable as a noninvasive procedure and readily demonstrates the presence of a flail mitral leaflet from chordal rupture, or aids in the recognition of obstructive cardiomyopathy, an atrial space-occupying lesion, or of a billowing mitral leaflet, left ventriculography and coronary angiography constitute the procedure of choice for the fine anatomic diagnosis and functional evaluation of most cases. The accurate diagnosis of the anatomic disruption of the mitral valvular apparatus, as well as of the state of the myocardium and of the coronary arteries, is of particular importance in symptomatic patients, in order to determine the prognosis and to plan the surgical approach.
本综述清楚地表明，单纯性、孤立性二尖瓣关闭不全的临床表现构成了一项有趣的诊断挑战。尤其是在成年患者中，这种常见的瓣膜病变通常是非风湿性的，可能见于多种心脏疾病。以下为其鉴别诊断提供总体指导。乳头肌功能障碍、“自发性”腱索断裂、先天性或创伤性病变（这些情况可能导致二尖瓣关闭不全）存在的首个线索，可能来自患者的病史。提示全身表现的病史增加了心房黏液瘤的可能性。当报告有家族发病率时，应将各种综合征或心肌病视为二尖瓣关闭不全的病因。听诊发现对于中晚期收缩期喀喇音和杂音综合征具有典型性，但识别这种情况可能需要在不同体位下仔细检查患者。梗阻性心肌病的可能性可通过特征性的颈动脉压力描记图得以证实。急性或慢性冠心病的心电图表现支持乳头肌功能障碍的可能性。此外，心电图可能支持心肌病的临床印象。荧光透视检查可能显示乳头肌功能障碍时冠状动脉钙化和/或左心室运动障碍性收缩、心房占位性病变时的心内钙化或二尖瓣环钙化。胸部X线检查在存在严重充血性心力衰竭时显示左心房和心室相对较小，可能有助于急性二尖瓣关闭不全的诊断。虽然超声心动图作为一种非侵入性检查非常宝贵，能轻易显示腱索断裂导致的连枷样二尖瓣叶，或有助于识别梗阻性心肌病、心房占位性病变或二尖瓣叶膨出，但左心室造影和冠状动脉造影是大多数病例进行精细解剖诊断和功能评估的首选检查方法。准确诊断二尖瓣瓣膜装置的解剖破坏以及心肌和冠状动脉的状态，对于有症状的患者确定预后和规划手术方法尤为重要。
