Lawrie Gerald M
Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA.
Methodist Debakey Cardiovasc J. 2010 Jan-Mar;6(1):8-14. doi: 10.14797/mdcj-6-1-8.
The first successful open repair of a mitral valve for mitral insufficiency was performed by Dr. Dwight McGoon in 1958. He employed a triangular plication of the prolapsing portion of the posterior leaflet and no annuloplasty. Other surgeons subsequently introduced a variety of techniques. Of these, the repair techniques developed by Dr. Alain Carpentier, which incorporated both leaflet repair by a quadrangular resection and annuloplasty, soon proved to be the most effective and reproducible method at that time. Because of the limited knowledge of normal and pathological mitral valve function available in the late 1960s, this repair was based on anatomical and pathological studies obtained through autopsies as well as intraoperatively. While the Carpentier technique continues to be used widely, most centers have found it difficult to repair more than 50-60% of insufficient valves. Only a few centers have achieved higher early success rates. Most have done this by modifications of the classical techniques. Recent reports have documented high rates of recurrence of significant mitral regurgitation in the 5- to 10-year follow-up interval. Our own experience with the Carpentier technique began in 1983. By this time, a growing body of knowledge was accumulating that demonstrated the highly dynamic behavior and important interactions of the six elements of the mitral complex: the left atrium, leaflets, mitral annulus, chordae, papillary muscles, and left ventricle. Because the Carpentier technique uses leaflet resection and rigid or semi-rigid annuloplasty rings, it produces a substantial disruption of these important functions. The mitral annulus is flattened and fully immobilized, and the leaflets also are flattened at their annular attachment. The loss of surface area amd distortion of the subvalvular chordae and papillary muscles from the leaflet resection produces diminished or absent leaflet movement. The entire mitral valve is left in a highly stressed state. In order to overcome these problems, we developed a new technique called the American Correction (Figure 1). The mitral leaflets are never resected, regardless of size. Artificial polytetrafluoroethylene (PTFE) chordae are used to correct localized leaflets prolapse. A full, totally flexible annuloplasty ring is utilized. Most importantly, all adjustments of leaflet position and annular sizing are done during inflation of the heart, with pressurized normal saline delivered at 4 liters a minute into the cavity of the left ventricle. In a controllable fashion, the left ventricular intracavitary and aortic root pressure can be elevated to systolic levels. This produces a series of reproducible changes in the leaflets and annulus that can be correlated with the normally functioning mitral valve in the beating heart (Figures 2-5).
1958年，德怀特·麦贡医生首次成功地对二尖瓣关闭不全进行了开放性修复手术。他采用了对后叶脱垂部分进行三角形折叠的方法，未进行瓣环成形术。其他外科医生随后引入了多种技术。其中，阿兰·卡彭蒂埃医生开发的修复技术，包括通过四边形切除进行瓣叶修复和瓣环成形术，很快被证明是当时最有效且可重复的方法。由于20世纪60年代末对正常和病理性二尖瓣功能的了解有限，这种修复是基于通过尸检以及术中获得的解剖学和病理学研究。虽然卡彭蒂埃技术仍被广泛使用，但大多数中心发现，超过50%-60%的关闭不全瓣膜难以修复。只有少数中心取得了更高的早期成功率。大多数中心是通过对经典技术进行改良做到这一点的。最近的报告记录了在5至10年的随访期内，严重二尖瓣反流的复发率很高。我们自己在1983年开始使用卡彭蒂埃技术。到这个时候，越来越多的知识积累表明，二尖瓣复合体的六个要素：左心房、瓣叶、二尖瓣环、腱索、乳头肌和左心室，具有高度动态的行为和重要的相互作用。由于卡彭蒂埃技术使用瓣叶切除和刚性或半刚性瓣环成形环，它对这些重要功能造成了实质性破坏。二尖瓣环变平并完全固定，瓣叶在其与瓣环的附着处也变平。瓣叶切除导致瓣下腱索和乳头肌表面积减少和变形，使瓣叶运动减弱或消失。整个二尖瓣处于高度紧张状态。为了克服这些问题，我们开发了一种名为“美国矫正术”的新技术（图1）。无论瓣叶大小如何，都绝不进行切除。使用人工聚四氟乙烯（PTFE）腱索来纠正局部瓣叶脱垂。使用一个完整的、完全可弯曲的瓣环成形环。最重要的是，所有瓣叶位置和瓣环尺寸的调整都是在心脏充盈时进行的，以每分钟4升的压力将生理盐水注入左心室腔。以可控的方式，左心室内腔和主动脉根部压力可升高至收缩期水平。这会在瓣叶和瓣环中产生一系列可重复的变化，这些变化可以与跳动心脏中正常功能的二尖瓣相关联（图2-5）。
