Sparano Dina M, Ward R Parker
The University of Chicago Medicine, 5841 S. Maryland Ave, MC6080, Chicago, IL, 60637, USA,
Curr Treat Options Cardiovasc Med. 2012 Dec;14(6):575-83. doi: 10.1007/s11936-012-0207-4.
In chronic, severe mitral regurgitation (MR), cardiac function can remain well compensated and patients can remain asymptomatic for many years. Eventually, in most patients, the originally favorable loading conditions give way to unfavorable remodeling, which results in left ventricular (LV) dysfunction and dilation, and ultimately symptoms of pulmonary congestion. Symptomatic, chronic severe MR is a clear indication for surgical correction. However, the optimal management of asymptomatic patients is less clear. While asymptomatic severe MR patients who have developed LV dysfunction or LV dilation warrant surgery, the decision to operate without these findings hinges on the presence of other clinical sequelae, such as atrial arrhythmias and pulmonary hypertension, and on the likelihood of successful mitral valve repair. Controversy exists as to the optimal approach to patients without any of these objective triggers, with some evidence supporting earlier prophylactic surgery and other evidence supporting a "watch and wait" approach. It is our conviction that in absence of an established guideline-based indication for surgical correction, for most asymptomatic patients with chronic severe MR, the preferred approach is close monitoring with serial echocardiography for development of symptoms or other clinical sequelae. However, it is reasonable to consider earlier surgical correction in select asymptomatic patients in whom there is a high likelihood of successful mitral valve repair. In this paper, we comprehensively review all guideline-based management of asymptomatic chronic severe MR, and discuss new evidence that impacts clinical decision-making in these patients.
在慢性重度二尖瓣反流（MR）中，心脏功能可保持良好代偿，患者多年可无症状。最终，在大多数患者中，最初有利的负荷条件会让位于不利的重塑，这会导致左心室（LV）功能障碍和扩张，最终出现肺充血症状。有症状的慢性重度MR是手术矫正的明确指征。然而，无症状患者的最佳管理尚不明确。虽然已出现LV功能障碍或LV扩张的无症状重度MR患者需要手术，但在没有这些表现的情况下决定手术取决于其他临床后遗症的存在，如房性心律失常和肺动脉高压，以及二尖瓣修复成功的可能性。对于没有任何这些客观触发因素的患者的最佳治疗方法存在争议，一些证据支持早期预防性手术，而其他证据支持“观察等待”方法。我们坚信，在没有基于指南的手术矫正指征的情况下，对于大多数无症状的慢性重度MR患者，首选方法是通过连续超声心动图密切监测症状或其他临床后遗症的发展。然而，对于二尖瓣修复成功可能性高的特定无症状患者，考虑早期手术矫正也是合理的。在本文中，我们全面回顾了基于指南的无症状慢性重度MR的所有管理方法，并讨论了影响这些患者临床决策的新证据。
