Padial L R, Freitas N, Sagie A, Newell J B, Weyman A E, Levine R A, Palacios I F
Cardiac Unit, Massachusetts General Hospital and Harvard Medical School, Boston, USA.
J Am Coll Cardiol. 1996 Apr;27(5):1225-31. doi: 10.1016/0735-1097(95)00594-3.
Using two-dimensional echocardiography, we sought to identify features that are associated with severe mitral regurgitation after percutaneous mitral valvulotomy and combine them into a predictive score.
Severe mitral regurgitation after percutaneous mitral valvulotomy is a major complication carrying an adverse prognosis that, to date, has not been predictable in advance.
In a consecutive series of 566 patients who underwent percutaneous mitral valvulotomy, 37 (6.5%) developed severe mitral regurgitation (assessed by angiography) after the procedure, 31 of whom had an echocardiogram available before percutaneous mitral valvulotomy. These 31 patients were matched by age, gender, mitral valve area and degree of mitral regurgitation before valvulotomy with 31 randomly selected patients who did not develop severe mitral regurgitation after percutaneous mitral valvulotomy. An echocardiographic score was developed on the basis of the pathologic studies of valves of patients who developed severe regurgitation after percutaneous mitral valvulotomy (leaflet rupture of relatively thin portions of nonhomogeneously thickened leaflets in the presence of commissural and subvalvular calcification) and evaluated uneven distribution of thickness in the anterior and posterior mitral leaflets, degree of commissural disease and subvalvular disease involvement, with each component graded from 0 to 4 (total, 0 to 16). Intraobserver and interobserver variability for score assessment were 6% and 7%, respectively.
The total mitral regurgitation echocardiographic score was significantly greater in the severe mitral regurgitation group (11.7 +/- 1.9 [mean +/- SD] vs. 8.0 +/- 1.2, p < 0.001). In addition, the component grades for the anterior leaflet (3.2 +/- 0.7 vs. 2.3 +/- 0.6, p < 0.001), commissures (2.6 +/- 0.7 vs. 1.6 +/- 0.6, p < 0.001) and subvalvular apparatus (3.2 +/- 0.6 vs. 2.3 +/- 0.7, p < 0.001) were also higher in the mitral regurgitation group. With a total score > or = 10 as a cutoff point for predicting severe mitral regurgitation after percutaneous mitral valvulotomy, a sensitivity of 90 +/- 5% and a specificity of 97 +/- 3% were obtained. Stepwise logistic regression analysis identified the mitral regurgitation echocardiographic score as the only independent predictor for developing severe mitral regurgitation after percutaneous mitral valvulotomy (p < 0.0001).
This new mitral regurgitation echocardiographic score can predict the development of severe mitral regurgitation after percutaneous mitral valvulotomy and can be useful in the selection of patients for this technique.
我们利用二维超声心动图，试图识别经皮二尖瓣球囊成形术后与严重二尖瓣反流相关的特征，并将其组合成一个预测评分。
经皮二尖瓣球囊成形术后严重二尖瓣反流是一种主要并发症，预后不良，迄今为止，尚无法提前预测。
在连续的566例行经皮二尖瓣球囊成形术的患者中，37例（6.5%）术后出现严重二尖瓣反流（通过血管造影评估），其中31例在经皮二尖瓣球囊成形术前有超声心动图检查结果。将这31例患者按年龄、性别、二尖瓣瓣口面积及球囊成形术前二尖瓣反流程度与31例随机选取的经皮二尖瓣球囊成形术后未发生严重二尖瓣反流的患者进行匹配。基于对经皮二尖瓣球囊成形术后发生严重反流患者瓣膜的病理研究（在存在瓣叶联合部及瓣下钙化的情况下，不均匀增厚瓣叶相对薄的部分出现瓣叶破裂）制定超声心动图评分，评估二尖瓣前后叶厚度分布不均、瓣叶联合部病变程度及瓣下病变累及情况，每个成分从0到4分进行分级（总分0到16分）。评分评估的观察者内及观察者间变异分别为6%和7%。
严重二尖瓣反流组二尖瓣反流超声心动图总分显著更高（11.7±1.9[均值±标准差]对8.0±1.2，p<0.001）。此外，二尖瓣反流组前叶（3.2±0.7对2.3±0.6，p<0.001）、瓣叶联合部（2.6±0.7对1.6±0.6，p<0.001）及瓣下结构（3.2±0.6对2.3±0.7，p<0.001）的成分分级也更高以总分≥10分为经皮二尖瓣球囊成形术后预测严重二尖瓣反流的截断点，敏感性为90±5%，特异性为97±3%。逐步逻辑回归分析确定二尖瓣反流超声心动图评分是经皮二尖瓣球囊成形术后发生严重二尖瓣反流的唯一独立预测因素（p<0.0001）。
这种新的二尖瓣反流超声心动图评分可预测经皮二尖瓣球囊成形术后严重二尖瓣反流的发生，有助于该技术患者的选择。
