Sakaguchi Taichi
Department of Cardiovascular Surgery, Hyogo College of Medicine, Nishinomiya, Japan.
Kyobu Geka. 2020 Jul;73(7):529-537.
Mitral regurgitation (MR) in Barlow's disease is complicated because of its mixed pathophysiology, leaflet billowing with/without organic prolapse, and abnormal annular dynamics that causes functional prolapse. Complex repair techniques, including aggressive leaflet resection and implantation of multiple neochords, are conventionally performed;nevertheless, these are technically demanding, especially when performed using a minimally invasive approach. We aimed to standardize the repair technique for Barlow's disease and developed stepwise repair techniques.
Of 209 patients who underwent isolated minimally invasive mitral valve repair for primary MR, 24 patients were found to have Barlow's disease. Their early and mid-term clinical outcomes were compared with those of the rest of patients( control group, n=185). Our repair technique for Barlow's disease consists of the following 3 steps:1) stabilization of the mitral annulus by placing annuloplasty ring sutures;2) distinction between organic and functional prolapse by a saline injection test;and 3) targeted repair for organic prolapse by leaflet resection or chordal replacement.
Patients in the Barlow group were significantly younger than the control group (49±10 years versus 57±13 years, respectively). In terms of repair technique, leaflet resection or plication was performed in 70.8% and 74.6% of each group, while neochordal replacement was performed in 45.8% and 32.4%, respectively. One patient in the Barlow group underwent ring annuloplasty only. The annuloplasty ring size was larger in the Barlow group than the control group (34±2 mm versus 30±2 mm, respectively). Although the total procedure, cardiopulmonary bypass and cross-clamp times were significantly longer in the Barlow group than the control group, mechanical ventilation time, and duration of intensive care unit stay were similar between groups. The incidence rates of major postoperative complications were low in both groups. The freedom rates from moderate or greater MR at 3 years were 100% in the Barlow group and 87.7% in the control group.
A stepwise repair strategy facilitates mitral valve repair in patients with Barlow's disease and provides excellent outcomes even via a minimally invasive approach.
巴洛氏病中的二尖瓣反流（MR）情况复杂，因为其病理生理机制混合，存在瓣叶膨出伴或不伴器质性脱垂，以及导致功能性脱垂的异常瓣环动力学。传统上采用复杂的修复技术，包括积极的瓣叶切除和多条新腱索植入；然而，这些技术要求很高，尤其是在采用微创方法进行时。我们旨在规范巴洛氏病的修复技术并开发逐步修复技术。
在209例接受原发性MR孤立性微创二尖瓣修复的患者中，发现24例患有巴洛氏病。将他们的早期和中期临床结果与其余患者（对照组，n = 185）进行比较。我们针对巴洛氏病的修复技术包括以下3个步骤：1）通过放置瓣环成形环缝线稳定二尖瓣瓣环；2）通过盐水注射试验区分器质性和功能性脱垂；3）针对器质性脱垂进行瓣叶切除或腱索置换的靶向修复。
巴洛组患者明显比对照组年轻（分别为49±10岁和57±13岁）。在修复技术方面，每组分别有70.8%和74.6%的患者进行了瓣叶切除或折叠，而新腱索置换分别为45.8%和32.4%。巴洛组有1例患者仅进行了瓣环成形术。巴洛组的瓣环成形环尺寸比对照组大（分别为34±2 mm和30±2 mm）。虽然巴洛组的总手术时间、体外循环和阻断时间明显长于对照组，但两组之间的机械通气时间和重症监护病房住院时间相似。两组术后主要并发症的发生率都很低。巴洛组3年时中度或更严重MR的无复发率为100%，对照组为87.7%。
逐步修复策略有助于巴洛氏病患者的二尖瓣修复，即使通过微创方法也能提供出色的结果。
