Salvatore Tanya, Ricci Fabrizio, Dangas George D, Rana Bushra S, Ceriello Laura, Testa Luca, Khanji Mohammed Y, Caterino Anna Laura, Fiore Corrado, Popolo Rubbio Antonio, Appignani Marianna, Di Fulvio Maria, Bedogni Francesco, Gallina Sabina, Zimarino Marco
Institute of Cardiology, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy.
Department of Cardiology, IRCCS Pol. S. Donato, S. Donato Milanese, Milan, Italy.
Front Cardiovasc Med. 2021 Feb 3;8:585415. doi: 10.3389/fcvm.2021.585415. eCollection 2021.
Secondary mitral regurgitation (MR) occurs despite structurally normal valve apparatus due to an underlying disease of the myocardium leading to disruption of the balance between tethering and closing forces with ensuing failure of leaflet coaptation. In patients with heart failure (HF) and left ventricular dysfunction, secondary MR is independently associated with poor outcome, yet prognostic benefits related to the correction of MR have remained elusive. Surgery is not recommended for the correction of secondary MR outside coronary artery bypass grafting. Percutaneous mitral valve repair (PMVR) with MitraClip implantation has recently evolved as a new transcatheter treatment option of inoperable or high-risk patients with severe MR, with promising results supporting the extension of guideline recommendations. MitraClip is highly effective in reducing secondary MR in HF patients. However, the derived clinical benefit is still controversial as two randomized trials directly comparing PMVR vs. optimal medical therapy in severe secondary MR yielded virtually opposite conclusions. We reviewed current evidence to identify predictors of PMVR-related outcomes in secondary MR useful to improve the timing and the selection of patients who would derive maximal benefit from MitraClip intervention. Beyond mitral valve anatomy, optimal candidate selection should rely on a comprehensive diagnostic workup and a fine-tuned risk stratification process aimed at (i) recognizing the substantial heterogeneity of secondary MR and its complex interaction with the myocardium, (ii) foreseeing hemodynamic consequences of PMVR, (iii) anticipating futility and (iv) improving symptoms, quality of life and overall survival.
继发性二尖瓣反流（MR）尽管瓣膜结构正常，但由于潜在的心肌疾病导致牵拉与关闭力之间的平衡被破坏，进而引起瓣叶对合失败。在心力衰竭（HF）和左心室功能不全的患者中，继发性MR与不良预后独立相关，然而，与纠正MR相关的预后益处仍不明确。除冠状动脉旁路移植术外，不建议通过手术纠正继发性MR。经皮二尖瓣修复术（PMVR）联合MitraClip植入术最近已发展成为一种针对无法手术或高危的严重MR患者的新型经导管治疗选择，其 promising results 支持扩展指南推荐。MitraClip在降低HF患者继发性MR方面非常有效。然而，所获得的临床益处仍存在争议，因为两项直接比较PMVR与最佳药物治疗严重继发性MR的随机试验得出了几乎相反的结论。我们回顾了当前证据，以确定继发性MR中与PMVR相关结果的预测因素，这有助于改善时机选择以及挑选出能从MitraClip干预中获得最大益处的患者。除二尖瓣解剖结构外，最佳候选人选择应依赖于全面的诊断检查和精细调整的风险分层过程，旨在（i）认识到继发性MR的显著异质性及其与心肌的复杂相互作用，（ii）预见PMVR的血流动力学后果，（iii）预测无效性，以及（iv）改善症状、生活质量和总体生存率。 注：原文中“promising results”未翻译，可根据实际情况补充合适的表述，比如“有前景的结果” 。
