Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands.
Department of Cardiac Anaesthesia and Intensive Care, "Mazzini" Hospital, Teramo, Italy.
J Card Surg. 2022 Jun;37(6):1599-1601. doi: 10.1111/jocs.16479. Epub 2022 Apr 1.
Choosing to perform mitral valve (MV) repair or replacement remains a hot and highly debated topic. The current guidelines seem to be conflicting in this specific field and the evidence at our disposal are scarce, only one small randomized trial and few larger retrospective studies. The meta-analysis by Gamal and coworkers tries to summarize the current evidence, concluding that MV replacement for the treatment of ischemic mitral regurgitation (MR) is at least as safe as repair and certainly offers a more stable result over time than the latter. Obviously, the implantation of a prosthesis, especially a mechanical one, brings with it a series of problems, such as anticoagulation and, above all, a possible lack of ventricular remodeling, especially if a chordal sparing replacement is not performed. It must be said, on the other hand, that isolated annuloplasty cannot act as a counterpart to replacement, because ischemic MR cannot be considered only an annular disease. Therefore, wanting to mimic the nature that, after an infarction, enacts a series of changes involving also the mitral leaflets and chordae, the surgeons are called to act also on these two entities and not only to downsize the annulus. In a nutshell, a procedure should not be opposed in a fundamentalist way to another one, but we must accept the concept of armamentarium where both procedures are present and tail on the single patient, and also on the surgeon's expertize, the technique guaranteeing the best possible result.
选择进行二尖瓣（MV）修复或置换仍然是一个热门且极具争议的话题。目前的指南在这一特定领域似乎存在冲突，我们可获得的证据也很少，只有一项小型随机试验和几项较大的回顾性研究。Gamal 及其同事的荟萃分析试图总结目前的证据，得出结论认为，置换术治疗缺血性二尖瓣反流（MR）至少与修复术一样安全，而且随着时间的推移，肯定比后者提供更稳定的结果。显然，植入假体（尤其是机械假体）会带来一系列问题，如抗凝，尤其是如果不进行保留腱索的置换，可能会缺乏心室重构。另一方面，必须指出，单纯的瓣环成形术不能作为置换术的替代品，因为缺血性 MR 不能仅被视为瓣环疾病。因此，为了模仿在梗死发生后会引发一系列涉及二尖瓣叶和腱索的变化的自然机制，外科医生需要对这两个实体进行操作，而不仅仅是缩小瓣环。简而言之，一种手术方法不应以原教旨主义的方式反对另一种手术方法，而是必须接受同时存在两种手术方法的手术工具库的概念，并根据单个患者的情况，以及根据外科医生的专业知识，选择能够保证最佳结果的技术。
