Sai-Sudhakar Chittoor B, Vandse Rashmi, Armen Todd A, Bickle Katherine M, Nathan Nadia S
Department of Anesthesiology, Ohio State University Medical Center, N-416 Doan Hall, 410 W 10th Avenue, Columbus, OH 43210, USA.
J Cardiothorac Surg. 2007 Sep 25;2:39. doi: 10.1186/1749-8090-2-39.
Ischemic mitral regurgitation often complicates severe ischemic heart disease and adversely affects the prognosis in these patients. There is wide variation in the clinical spectrum of ischemic mitral regurgitation due to varying location and chronicity of ischemia and anomalies in annular and ventricular remodeling. As a result, there is lack of consensus in treating these patients. Treatment has to be individualized for each patient. Most of the available surgical options do not consistently correct this condition in all the patients. Chordal cutting is one of the newer surgical approaches in which cutting a limited number of critically positioned basal chordae have found success by relieving the leaflet tethering and thereby improving the coaptation of leaflets. Three-dimensional echocardiography is a potentially valuable tool in identifying the specific pattern of tethering and thus the suitability of this procedure in a given clinical scenario.
A 66-year-old man with cardiomyopathy and ischemic mitral regurgitation presented to us with the features of congestive heart failure. The three-dimensional echocardiography revealed severe mitral regurgitation associated with the tethering of the lateral (P1) and medial (P3) scallops of the posterior leaflet of the mitral valve due to secondary chordal attachments. The ejection fraction was only 15% with severe global systolic and diastolic dysfunction. Mitral regurgitation was successfully corrected with mitral annuloplasty and resection of the secondary chordae tethering the medial and lateral scallops of the posterior leaflet of the mitral valve.
Cutting the second order chordae along with mitral annuloplasty could be a novel method to remedy Ischemic mitral regurgitation by relieving the tethering of the valve leaflets. The preoperative three-dimensional echocardiography should be considered in all patients with Ischemic mitral regurgitation to assess the complex three-dimensional interactions between the mitral valve apparatus and the left ventricle. This aids in timely surgical planning.
缺血性二尖瓣反流常使严重缺血性心脏病复杂化，并对这些患者的预后产生不利影响。由于缺血的部位和慢性程度不同，以及瓣环和心室重塑异常，缺血性二尖瓣反流的临床谱存在很大差异。因此，在治疗这些患者方面缺乏共识。治疗必须针对每个患者进行个体化。大多数现有的手术选择并不能在所有患者中一致地纠正这种情况。腱索切断术是一种较新的手术方法，通过切断有限数量的关键位置的基底腱索，成功地缓解了瓣叶的束缚，从而改善了瓣叶的贴合。三维超声心动图是一种潜在的有价值的工具，可用于识别特定的束缚模式，从而确定该手术在特定临床情况下的适用性。
一名66岁患有心肌病和缺血性二尖瓣反流的男性因充血性心力衰竭症状前来就诊。三维超声心动图显示严重二尖瓣反流，与二尖瓣后叶外侧（P1）和内侧（P3）扇贝形瓣叶因继发腱索附着而受到束缚有关。射血分数仅为15%，伴有严重的全心收缩和舒张功能障碍。通过二尖瓣环成形术和切除束缚二尖瓣后叶内侧和外侧扇贝形瓣叶的继发腱索，成功纠正了二尖瓣反流。
切断二级腱索并结合二尖瓣环成形术可能是一种通过缓解瓣叶束缚来治疗缺血性二尖瓣反流的新方法。所有缺血性二尖瓣反流患者术前均应考虑进行三维超声心动图检查，以评估二尖瓣装置与左心室之间复杂的三维相互作用。这有助于及时进行手术规划。
