Division of Cardiovascular Medicine, The Ohio State University, 473 W. 12th Avenue, Suite 200, Columbus, OH, 43210, USA.
Department of Cardiology, Larissa University General Hospital, Larissa, Greece.
Heart Fail Rev. 2023 Sep;28(5):1201-1209. doi: 10.1007/s10741-023-10322-5. Epub 2023 Jul 6.
Acute severe mitral regurgitation (MR) is rare, but often leads to cardiogenic shock, pulmonary edema, or both. Most common causes of acute severe MR are chordae tendineae (CT) rupture, papillary muscle (PM) rupture, and infective endocarditis (IE). Mild to moderate MR is often seen in patients with acute myocardial infarction (AMI). CT rupture in patients with floppy mitral valve/mitral valve prolapse is the most common etiology of acute severe MR today. In IE, native or prosthetic valve damage can occur (leaflet perforation, ring detachment, other), as well as CT or PM rupture. Since the introduction of percutaneous revascularization in AMI, the incidence of PM rupture has substantially declined. In acute severe MR, the hemodynamic effects of the large regurgitant volume into the left atrium (LA) during left ventricular (LV) systole, and in turn back into the LV during diastole, are profound as the LV and LA have not had time to adapt to this additional volume. A rapid, but comprehensive evaluation of the patient with acute severe MR is essential in order to define the underline cause and apply appropriate management. Echocardiography with Doppler provides vital information related to the underlying pathology. Coronary arteriography should be performed in patients with an AMI to define coronary anatomy and need for revascularization. In acute severe MR, medical therapy should be used to stabilize the patient before intervention (surgery, transcatheter); mechanical support is often required. Diagnostic and therapeutic steps should be individualized, and a multi-disciplinary team approach should be utilized.
急性重度二尖瓣反流（MR）较为罕见，但常导致心源性休克、肺水肿，或二者皆有。急性重度 MR 的最常见病因包括腱索（CT）断裂、乳头肌（PM）断裂和感染性心内膜炎（IE）。急性心肌梗死（AMI）患者常出现轻度至中度 MR。目前，在二尖瓣脱垂/二尖瓣脱垂患者中，二尖瓣松弛导致的 CT 断裂是急性重度 MR 的最常见病因。在 IE 中，可能发生原生或人工瓣膜损伤（瓣叶穿孔、瓣环分离等）以及 CT 或 PM 断裂。自从 AMI 中引入经皮血运重建以来，PM 断裂的发生率显著下降。在急性重度 MR 中，由于左心室（LV）收缩时大量反流进入左心房（LA），继而在舒张期反流回 LV，左心房和左心室没有时间适应这种额外的容量，因此对 LV 产生了深刻的血流动力学影响。为了明确潜在病因并采取适当的治疗措施，对急性重度 MR 患者进行快速、全面的评估至关重要。超声心动图结合多普勒可提供与潜在病理相关的重要信息。对于 AMI 患者，应进行冠状动脉造影以明确冠状动脉解剖结构和血运重建的需求。在急性重度 MR 中，应在介入（手术、经导管）前使用药物治疗稳定患者；通常需要机械支持。诊断和治疗步骤应个体化，并采用多学科团队方法。
