Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
Department of Cardiology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
JAMA Cardiol. 2020 Mar 1;5(3):346-355. doi: 10.1001/jamacardio.2019.5466.
Most patients with severe degenerative mitral regurgitation (DMR) are likely to require surgery, but years can pass until there is a clear indication for it. The timing of mitral valve surgery for asymptomatic patients with severe DMR is controversial, and current guidelines are limited because they are based on nonrandomized studies and expert opinion.
In this narrative review, a decrease in left ventricular ejection fraction and an increase in left ventricular end-systolic diameter are adverse signs in the context of mitral regurgitation. Consequently, serial echocardiography is essential. However, measurements may be imprecise, and the evidence regarding the association with outcome in asymptomatic patients is inconsistent. Mitral valve repair is the preferred surgical approach; however, repair rate, durability, and outcomes vary between centers, rendering decision-making in an asymptomatic patient with DMR even more challenging. The use of natriuretic peptides, stress testing, cardiac magnetic resonance imaging, and myocardial strain imaging can aid in risk stratification and optimization of the timing of mitral valve surgery in an asymptomatic patient.
Management of asymptomatic patients with DMR requires a comprehensive approach that goes beyond the guidelines. Close follow-up and the use of multiple modalities are recommended. Knowledge of surgical options, experience, and outcomes is important when an intervention is considered.
大多数患有严重退行性二尖瓣反流（DMR）的患者可能需要手术，但直到出现明确的手术指征可能需要数年时间。对于无症状的严重 DMR 患者，二尖瓣手术的时机存在争议，目前的指南受到限制，因为它们基于非随机研究和专家意见。
在二尖瓣反流的背景下，左心室射血分数降低和左心室收缩末期直径增加是不利的迹象。因此，连续进行超声心动图检查至关重要。然而，测量可能不够精确，并且关于无症状患者与结局之间关联的证据不一致。二尖瓣修复是首选的手术方法；然而，修复率、耐久性和结果在不同中心之间存在差异，使得对无症状 DMR 患者的决策更加具有挑战性。使用利钠肽、应激测试、心脏磁共振成像和心肌应变成像可以帮助对无症状患者进行风险分层和优化二尖瓣手术时机。
无症状 DMR 患者的管理需要综合方法，而不仅仅是遵循指南。建议密切随访和使用多种方法。在考虑干预措施时，了解手术选择、经验和结果非常重要。
