Sannino Anna, Grayburn Paul A
Baylor University Medical Center, Baylor Heart and Vascular Hospital, Dallas, Texas, USA.
Heart. 2018 Jan;104(1):16-22. doi: 10.1136/heartjnl-2017-311552. Epub 2017 Sep 13.
Severe aortic stenosis (AS) and mitral regurgitation (MR) frequently coexist. Although some observational studies have reported that moderate or severe MR is associated with higher mortality, the optimal management of such patients is still unclear. Simultaneous replacement of both aortic and mitral valves is linked to significantly higher morbidity and mortality. Recent advances in minimally invasive surgical or transcatheter therapies for MR allow for staged procedures in which surgical or transcatheter aortic valve replacement (SAVR/TAVR) is done first and MR severity re-evaluated afterwards. Current evidence suggests MR severity improves in some patients after SAVR or TAVR, depending on several factors (MR aetiology, type of valve used for TAVR, presence/absence of atrial fibrillation, residual aortic regurgitation, etc). However, as of today, the absence of randomised clinical trials does not allow for evidence-based recommendations about whether or not MR should be addressed at the time of SAVR or TAVR. A careful patient evaluation and clinical judgement are recommended to distinguish patients who might benefit from a double valve intervention from those in which MR should be left alone. The aim of this review is to report and critique the available data on this subject in order to help guide the clinical decision making in this challenging subset of patients.
重度主动脉瓣狭窄（AS）和二尖瓣反流（MR）常同时存在。尽管一些观察性研究报告称中度或重度MR与较高的死亡率相关，但此类患者的最佳治疗方案仍不明确。同时置换主动脉瓣和二尖瓣会导致明显更高的发病率和死亡率。二尖瓣反流的微创外科手术或经导管治疗的最新进展使得可以采用分期手术，即先进行外科或经导管主动脉瓣置换术（SAVR/TAVR），之后再重新评估二尖瓣反流的严重程度。目前的证据表明，在SAVR或TAVR后，部分患者的二尖瓣反流严重程度会有所改善，这取决于多个因素（二尖瓣反流病因、用于TAVR的瓣膜类型、是否存在心房颤动、残余主动脉瓣反流等）。然而，截至目前，由于缺乏随机临床试验，无法就SAVR或TAVR时是否应处理二尖瓣反流给出基于证据的建议。建议进行仔细的患者评估和临床判断，以区分可能从双瓣干预中获益的患者与二尖瓣反流无需处理的患者。本综述的目的是报告和评论关于该主题的现有数据，以帮助指导这一具有挑战性的患者亚组的临床决策。
