Chrissoheris Michael P, Kourkoveli Panagiota, Aravantinos Dionysios, Spargias Konstantinos
Department of Transcatheter Heart Valves, Hygeia Hospital, 9 Erythrou Stavrou Street, Marousi, TK 15123 Attiki, Greece.
Eur Heart J Case Rep. 2024 Jan 30;8(2):ytae041. doi: 10.1093/ehjcr/ytae041. eCollection 2024 Feb.
Mitral regurgitation (MR) in the context of left ventricular systolic dysfunction is often designated as functional, with emphasis on the underlying cardiomyopathy leading to malcoaptation of the 'otherwise normal valve'.
A 63-year-old male with ischaemic cardiomyopathy (left ventricular ejection fraction 20%) presented with intractable heart failure in need of inotropic support and could not be stepped down from an ICU hospital setting. Functional MR, graded as moderate on transthoracic echocardiography, was initially not considered as pertinent to the clinical condition and options discussed included initiation of dialysis for volume management, chronic inotropic support, and palliative measures. However, a re-examination of the mitral valve by transoesophageal echo revealed severe regurgitation from annular dilatation and restricted mobility during systole. Transcatheter edge to edge repair utilizing the PASCAL device resulted in marked reduction of MR followed by an abrupt clinical improvement, weaning off inotropes and discharge home 4 days later. At four-year follow-up, the patient is stable on optimal heart failure therapy.
For many patients with heart failure and underlying cardiomyopathy, the presence of significant functional MR, instead of a 'bystander' disease, actually becomes the dominant driver of symptoms and compounds the low cardiac output state. In these patients, the term 'functional' MR becomes a misnomer, as in fact the so called 'otherwise normal' mitral valve is actually a severely dysfunctional valve with a wide malcoaptation zone. Transcatheter edge to edge repair is an effective bailout procedure for patients with low cardiac output and disproportionate severe functional MR.
左心室收缩功能不全情况下的二尖瓣反流（MR）通常被认为是功能性的，重点在于潜在的心肌病导致“原本正常的瓣膜”无法良好对合。
一名63岁男性，患有缺血性心肌病（左心室射血分数20%），因顽固性心力衰竭需要使用正性肌力药物支持，且无法从重症监护病房转出。经胸超声心动图显示功能性MR为中度，最初未被认为与临床情况相关，讨论的治疗方案包括启动透析进行容量管理、长期使用正性肌力药物支持以及采取姑息措施。然而，经食管超声心动图对二尖瓣进行再次检查发现，由于瓣环扩张和收缩期活动受限，存在严重反流。使用PASCAL装置进行经导管缘对缘修复后，MR显著减轻，随后临床症状突然改善，停用正性肌力药物，4天后出院回家。在四年的随访中，患者在优化的心力衰竭治疗方案下病情稳定。
对于许多患有心力衰竭和潜在心肌病的患者，显著功能性MR的存在实际上成为症状的主要驱动因素，而非“旁观者”疾病，它加剧了低心输出量状态。在这些患者中，“功能性”MR这一术语成为了不恰当的称呼，因为实际上所谓“原本正常”的二尖瓣实际上是一个严重功能失调的瓣膜，存在广泛的对合不良区域。经导管缘对缘修复是低心输出量且伴有不成比例的严重功能性MR患者的一种有效补救措施。
