Maigrot Jean-Luc A, Moros David, Blackstone Eugene H, Weiss Aaron J, Desai Milind Y, Gillinov A Marc, Smedira Nicholas G
Department of Thoracic & Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
J Thorac Cardiovasc Surg. 2025 Jun 7. doi: 10.1016/j.jtcvs.2025.06.001.
Even in the absence of significant left ventricular hypertrophy, abnormalities of the mitral valve leaflets and subvalvular apparatus can contribute to left ventricular outflow tract obstruction. We present a toolkit of techniques for mitral valve repair and replacement in this setting.
Our approach to mitral valve repair for left ventricular outflow tract obstruction follows 2 key principles: modification of the abnormal effects of flow vortices that displace the leaflets into the left ventricular outflow tract and restoration of a more posterior leaflet coaptation zone. Selection of surgical techniques is guided by the patient's pathoanatomical abnormalities.
Over the past 3 decades, tailored techniques for mitral valve repair to relieve left ventricular outflow tract obstruction with minimal or no left ventricular hypertrophy have been developed. These include anterior leaflet shortening, posterior leaflet height reduction, reorientation of mobile and anteriorly displaced papillary muscle heads, and relocation and partial resection of excessively hypertrophied papillary muscle heads. When required, often due to leaflet and annular rigidity, mitral valve replacement can be performed using techniques that enable stent-mounted bioprosthetic valve implantation.
Mitral surgery can relieve left ventricular outflow tract obstruction in patients with minimal septal hypertrophy. Repair is often feasible in most cases. When necessary, mitral valve replacement can be performed using techniques that allow for safe and effective stent-mounted bioprosthetic valve implantation, minimizing the risk of stent-induced left ventricular outflow tract obstruction while sparing patients lifelong anticoagulation.
即使在无明显左心室肥厚的情况下，二尖瓣叶和瓣下结构异常也可导致左心室流出道梗阻。我们在此介绍一套针对这种情况的二尖瓣修复和置换技术。
我们针对左心室流出道梗阻的二尖瓣修复方法遵循两个关键原则：改变使瓣叶移位至左心室流出道的血流漩涡的异常影响，以及恢复更靠后的瓣叶贴合区。手术技术的选择以患者的病理解剖异常为指导。
在过去三十年中，已开发出定制的二尖瓣修复技术，以在左心室肥厚轻微或无左心室肥厚的情况下缓解左心室流出道梗阻。这些技术包括前叶缩短、后叶高度降低、活动且向前移位的乳头肌头部重新定向，以及过度肥厚的乳头肌头部重新定位和部分切除。如有需要，通常由于瓣叶和瓣环僵硬，可采用能进行支架置入生物瓣膜植入的技术进行二尖瓣置换。
二尖瓣手术可缓解间隔肥厚轻微患者的左心室流出道梗阻。在大多数情况下修复通常是可行的。必要时，可采用允许安全有效地进行支架置入生物瓣膜植入的技术进行二尖瓣置换，将支架引起的左心室流出道梗阻风险降至最低，同时避免患者终身抗凝。
