Barlow J B
Department of Cardiology, University of the Witwatersrand, Johannesburg, South Africa.
Isr J Med Sci. 1996 Oct;32(10):831-42; 843-4.
The respective roles of cardiologist and cardiac surgeon in the operative management of any specific case of mitral valve disease are variable. The range from the prevalent complete predominance of the surgeon through meaningful interaction between the two, concerning the timing and type of surgery, to predominance of the cardiologist when the surgeon accepts a role of technician. There are a number of scenarios in mitral valve surgery in which a reduced risk of postoperative hospital mortality and morbidity, by performing the simplest and shortest procedure, have to be balanced against enhanced peri-operative problems when other aspects are addressed that improve, sometimes markedly, the long-term prognosis. It is argued that a mildly stenotic aortic valve should often be replaced at the time of mitral valve surgery; that despite technical difficulties and a variable long-term postoperative course, surgeons should continue to repair rather than replace the mitral valves of young patients with severe mitral regurgitation despite the invariable presence of active rheumatic carditis; and that excess leaflet tissue and lax chordae in cases of degenerative mitral regurgitation are casually related to multifocal and potentially fatal ventricular ectopy. The crucial but neglected role of an organically abnormal tricuspid anulus in allowing dilatation and hence tricuspid regurgitation in patients with rheumatic mitral valve disease is considered in some detail. Such dilatation may occur late after mitral valve surgery for rheumatic disease, has generally and incorrectly been regarded as "functional" tricuspid regurgitation, contributes importantly to the postoperative "restriction-dilatation syndrome" and can be effectively prevented, or when once established then surgically managed, by a modified De Vega anuloplasty. Finally it is believed that, unlike mitral balloon valvuloplasty in selected instances, successful tricuspid balloon valvuloplasty can never be accomplished without causing significant tricuspid regurgitation and the procedure should be abandoned.
心脏病专家和心脏外科医生在二尖瓣疾病特定病例的手术管理中各自的角色是可变的。范围从外科医生完全占主导地位，到两者就手术时机和类型进行有意义的互动，再到当外科医生承担技术人员角色时心脏病专家占主导地位。在二尖瓣手术中有多种情况，通过实施最简单、最短的手术来降低术后医院死亡率和发病率的风险，必须与解决其他方面问题时增加的围手术期问题相平衡，而这些问题有时能显著改善长期预后。有人认为，在二尖瓣手术时，轻度狭窄的主动脉瓣通常应予以置换；尽管存在技术困难且术后长期病程多变，但对于患有严重二尖瓣反流的年轻患者，外科医生应继续修复而非置换二尖瓣，尽管这些患者始终存在活动性风湿性心内膜炎；并且在退行性二尖瓣反流病例中，多余的瓣叶组织和松弛的腱索与多灶性且可能致命的室性早搏偶然相关。文中详细探讨了器质性异常的三尖瓣环在风湿性二尖瓣疾病患者中导致扩张进而引起三尖瓣反流方面所起的关键但被忽视的作用。这种扩张可能在风湿性疾病二尖瓣手术后较晚出现，通常被错误地视为“功能性”三尖瓣反流，对术后“限制 - 扩张综合征”有重要影响，通过改良的德维加瓣环成形术可以有效预防，或者一旦形成则可通过手术进行处理。最后，人们认为，与在特定情况下的二尖瓣球囊瓣膜成形术不同，成功的三尖瓣球囊瓣膜成形术在不引起明显三尖瓣反流的情况下永远无法完成，该手术应被放弃。
