Guérin P
Unité de cardiologie interventionnelle, l'institut du thorax, CHU Nantes, 44000 Nantes, France.
Ann Cardiol Angeiol (Paris). 2018 Dec;67(6):474-481. doi: 10.1016/j.ancard.2018.10.007. Epub 2018 Oct 30.
Mitral regurgitation (MR) is the second most common form of valvular heart disease. It is classified as either primary (degenerative) or secondary (functional). Secondary MR is the consequence of myocardium disease. Primary MR from degenerative valve disease is due to a primary disruption of the mitral valve apparatus from either prolapsed or flail leaflets. It covers all aetiologies in which intrinsic lesions affect one or several components of the mitral valve apparatus. Gold-standard therapeutic management of severe primary MR is surgery usually to repair but sometime to replace the mitral valve. However patients considered to be at high-risk due to their age or the presence of comorbidities - accounting for 50% of all patients - are not eligible for surgery. Catheter-based interventions have been developed to correct MR percutaneously. The only such intervention which has been evaluated in organic MR is the edge-to-edge procedure using the MitraClip (Abbott Vascular, Menlo Park, CA). MitraClip offers an alternative to open surgical repair or replacement via a minimally invasive route and it was shown in the EVEREST II study that MitraClip was safer than surgery even though it was less effective in reducing MR. A substantial number of patients are ineligible for mitral valve surgery because of prohibitive surgical risk. For those patients, MitraClip may offer an alternative treatment option. Percutaneous edge-to-edge repair is the first percutaneous option accepted in the 2012 ESC guidelines: Percutaneous edge-to-edge procedure may be considered in patients with symptomatic severe primary MR who fulfill the echo criteria of eligibility, are judged inoperable or at high surgical risk by a 'heart team', and have a life expectancy greater than 1 year (recommendation class IIb, level of evidence C). Because of its frailty, MitraClip in the elderly may be a good alternative to mitral surgery when indicated for primary or secondary MD.
二尖瓣反流（MR）是第二常见的心脏瓣膜病形式。它被分类为原发性（退行性）或继发性（功能性）。继发性MR是心肌病的结果。退行性瓣膜病导致的原发性MR是由于二尖瓣装置的原发性破坏，原因是瓣叶脱垂或连枷样瓣叶。它涵盖了所有内在病变影响二尖瓣装置一个或多个组件的病因。重度原发性MR的金标准治疗方法是手术，通常是修复二尖瓣，但有时也会进行置换。然而，由于年龄或合并症而被认为处于高风险的患者——占所有患者的50%——不符合手术条件。基于导管的干预措施已被开发用于经皮纠正MR。在器质性MR中唯一经过评估的此类干预措施是使用MitraClip（雅培血管，加利福尼亚州门洛帕克）的缘对缘手术。MitraClip通过微创途径为开放手术修复或置换提供了一种替代方案，并且在EVEREST II研究中表明，MitraClip比手术更安全，尽管它在减少MR方面效果较差。由于手术风险过高，大量患者不符合二尖瓣手术条件。对于这些患者，MitraClip可能提供一种替代治疗选择。经皮缘对缘修复是2012年欧洲心脏病学会（ESC）指南中接受的首个经皮治疗选择：对于有症状的重度原发性MR患者，若符合超声心动图入选标准、经“心脏团队”判断为无法手术或手术风险高且预期寿命大于1年，可考虑行经皮缘对缘手术（推荐类别IIb，证据水平C）。由于其脆弱性，对于原发性或继发性二尖瓣疾病患者，老年患者使用MitraClip可能是二尖瓣手术的一个良好替代方案。
