Herrmann H C, Lima J A, Feldman T, Chisholm R, Isner J, O'Neill W, Ramaswamy K
Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia 19104.
J Am Coll Cardiol. 1993 Sep;22(3):783-9. doi: 10.1016/0735-1097(93)90191-3.
The purpose of this study was to assess the incidence, mechanism and outcome of severe mitral regurgitation after treatment of mitral stenosis with percutaneous mitral valvuloplasty using the Inoue balloon.
Severe mitral regurgitation occurs in up to 15% of percutaneous balloon valvuloplasty procedures for acquired mitral stenosis. The incidence and mechanism of production of mitral regurgitation with the recently introduced single-balloon Inoue technique have not been characterized.
We examined the incidence, mechanism, predictors and outcome of severe mitral regurgitation after Inoue balloon valvuloplasty in 280 patients in the North American multicenter registry. Twenty-one patients who developed either clinically significant or angiographically severe regurgitation were identified, and their echocardiograms were reviewed to determine the mechanism of regurgitation. These patients were then compared with the remaining patients without severe regurgitation to identify predictors of this outcome.
The incidence of severe regurgitation in this study was 7.5%, and the mean grade of angiographic regurgitation in these patients increased from 0.9 +/- 1.0 to 2.8 +/- 0.7 (p < 0.05). The most common cause of regurgitation (43%) was rupture of chordae tendineae to the anterior or posterior mitral leaflet. Tearing of a leaflet (usually the posterior one) occurred in 30% of patients; and no recognizable structural abnormality, with wide splitting of the commissures and a central regurgitant jet, was present in five patients (26%). All patients with definite posterior leaflet tears had heavily calcified leaflets. Patients who developed severe regurgitation had fewer balloon inflations and a higher grade of preexisting mitral regurgitation but were otherwise similar to the remaining patients without severe regurgitation. During 6-month follow-up, 71% of the patients with severe regurgitation were treated surgically; the grade of regurgitation decreased in four patients (19%), and five patients (24%) have not required mitral valve replacement during 18 +/- 5 months of follow-up.
Severe mitral regurgitation is a relatively infrequent complication of Inoue balloon valvuloplasty and results from disruption of the valve integrity, including chordal rupture and leaflet tearing. Careful balloon positioning may help avoid chordal rupture, and heavily calcified posterior leaflets may be at greater risk of tearing. Most patients who develop severe regurgitation will require nonemergency mitral valve replacement.
本研究旨在评估采用Inoue球囊行经皮二尖瓣成形术治疗二尖瓣狭窄后严重二尖瓣反流的发生率、机制及转归。
在因获得性二尖瓣狭窄而行经皮球囊瓣膜成形术的患者中，严重二尖瓣反流的发生率高达15%。采用最近引入的单球囊Inoue技术导致二尖瓣反流的发生率及机制尚未明确。
我们在北美多中心注册研究中对280例患者行Inoue球囊瓣膜成形术后严重二尖瓣反流的发生率、机制、预测因素及转归进行了研究。确定了21例出现临床显著或血管造影严重反流的患者，并对其超声心动图进行回顾以确定反流机制。然后将这些患者与其余无严重反流的患者进行比较，以确定该结果的预测因素。
本研究中严重反流的发生率为7.5%，这些患者血管造影反流的平均分级从0.9±1.0增加至2.8±0.7（p<0.05）。反流最常见的原因（43%）是二尖瓣前叶或后叶腱索断裂。30%的患者出现瓣叶撕裂（通常为后叶）；5例患者（26%）未发现可识别的结构异常，但瓣叶联合处增宽且有中心反流束。所有明确有后叶撕裂的患者瓣叶均有重度钙化。发生严重反流的患者球囊充盈次数较少且术前二尖瓣反流分级较高，但在其他方面与其余无严重反流的患者相似。在6个月的随访期间，71%有严重反流的患者接受了手术治疗；4例患者（19%）反流分级降低，5例患者（24%）在18±5个月的随访期间未行二尖瓣置换术。
严重二尖瓣反流是Inoue球囊瓣膜成形术相对少见的并发症，是由瓣膜完整性破坏所致，包括腱索断裂和瓣叶撕裂。仔细的球囊定位可能有助于避免腱索断裂，重度钙化的后叶可能有更高的撕裂风险。大多数发生严重反流的患者将需要择期二尖瓣置换术。
