经皮二尖瓣球囊扩张术后疗效及血小板指数的变化分析

目的研究风湿性二尖瓣狭窄(RMS)经皮二尖瓣球囊扩张术(PBMV)后疗效及血小板指数的变化,初步探讨PBMV在降低血栓形成风险中的作用。方法选择69例风湿性二尖瓣狭窄的患者[平均年龄(46.3±9.2)岁]及27例健康体检者[平均年龄(42.1±6.7)岁]为研究对象。所有研究对象于入院时、病例组术后4周采集患者外周静脉全血,测定血小板计数(PLT)、平均血小板体积(MPV)、血小板压积(PCT)、血小板体积分布宽度(PDW)等指标的变化。经超声心动图检查,记录术前及术后4周二尖瓣口面积(MVA)、左心室舒张末期内径(LVEDd)、左心室收缩末期内径(LVEDs)、左心房内径(LAD)、右心室舒张末期内径(RVEDd)、右心房内径(RAD)等数据。统计分析结果,比较手术前后各指标的变化。结果 (1)风湿性二尖瓣狭窄患者MPV、PDW较正常对照组明显升高,差别有统计学意义(P<0.05,P<0.01);(2)病例组PBMV术后MPV较术前下降,差别有统计学意义(P<0.05);(3)MVA在术后明显增大,LVEDd、LAD术后明显回缩,差别均有统计学意义(P<0.05);(4)MPV与MVA成负相关,相关系数r=-0.45,相关系数检验有统计学意义(P<0.05);与其余指标无明显相关性。结论 PBMV可明显增大二尖瓣口面积,改善风湿性二尖瓣狭窄血流动力学指标;PBMV可降低MPV水平,对降低血栓形成的风险可能有益。     

风湿性二尖瓣狭窄经皮二尖瓣球囊扩张术后疗效及左心房自发性超声显影的变化

目的观察风湿性二尖瓣狭窄(RMS)经皮二尖瓣球囊扩张术(PBMV)后疗效及左心房自发性超声显影(LASEC)的变化,初步探讨PBMV对血栓前状态的影响。方法选择临沂市沂水中心医院2009年1月至2015年5月因风湿性二尖瓣狭窄行PBMV的患者43例[平均年龄(53.3±10.6)岁],且经超声心动图提示有LASEC,纳入病例组,并应用背向散射积分技术(IBS)对LASEC进行定量测定,将左心房及右心房平均IBS值相比得到左心房标化IBS值(IBS%)。术后2周复查超声心动图,记录术前及术后2周的IBS%,同时记录二尖瓣口面积(MVA)、左心室舒张末期内径(LVEDd)、左心室收缩末期内径(LVEDs)、左心房内径(LAD)、右心室舒张末期内径(RVEDd)、右心房内径(RAD)、左心房压(LAP)、跨瓣压差(△P)。选择同期住院未行PBMV且存在LASEC的风湿性二尖瓣狭窄患者[平均年龄(52.1±9.7)岁]17例纳入对照组,经十二导联心电图证实所有研究对象基础心律均为房颤心律,所有研究对象均给予华法林抗凝,INR控制在2~3之间。结果 (1)病例组PBMV术后,MVA明显增大,LVEDd、LAD明显缩小,LAP、△P下降,差别均有统计学意义(P均<0.05),且无一例栓塞并发症出现。(2)病例组PBMV术后IBS%值明显减小,差别有统计学意义(P<0.05),对照组单独华法林治疗2周后IBS%值较治疗前有减小趋势,但差别无统计学意义(P>0.05)。(3)IBS%与MVA呈负相关,相关系数r=-0.55,相关系数检验有统计学意义(P<0.05);与其余指标均无明显相关性。结论 PBMV可明显增大二尖瓣口面积,改善风湿性二尖瓣狭窄患者的血流动力学指标;LASEC并非PBMV的禁忌证,PBMV可降低LASEC的IBS%值,对改善血栓前状态可能有益。     

经皮二尖瓣球囊成形术治疗二尖瓣狭窄伴轻中度二尖瓣关闭不全的疗效评价

目的:探讨风湿性心脏病(RHD)二尖瓣狭窄(MS)伴轻中度二尖瓣关闭不全患者经皮二尖瓣球囊成形术(PBMV)的效果。方法:将33例二尖瓣狭窄伴轻度关闭不全(A组)和30例二尖瓣狭窄伴中度关闭不全(B组)及36例单纯二尖瓣狭窄(C组)的PBMV术后即刻及随访结果作对比研究。结果:A组左房平均压(MLAP)从术前(25.2±5.6)mmHg降至术后(10.2±3.2)mm-Hg,B组左房平均压(MLAP)从术前(26.3±5.2)mmHg降至术后(10.9±4.2)mmHg,C组左房平均压(MLAP)从术前(23.8±7.1)mmHg降至术后(9.5±4.2)mmHg,三组间比较P>0.01,差别无显著性。A组二尖瓣返流术前(14±3.5)％,术后(15±2.6)％,P>0.01,差别无显著性;B组二尖瓣返流术前(30±6.8)％,术后(35±4.5)％,P>0.01,差别无显著性;C组术前0％,术后(2±0.2)％,P>0.01,差别无显著性。A组、B组、C组随访左房内径逐渐缩小。结论:MS合并轻中度二尖瓣返流,PBMV是一种有效和安全的治疗措施,可列入PBMV的手术适应症。     

合并左心房血栓患者的经皮球囊二尖瓣成形术的临床评价

目的评价经皮二尖瓣球囊成形术(PBMV)治疗风湿性心脏病二尖瓣狭窄合并左心房血栓的可行性、安全性和有效性。方法应用华法林抗凝治疗3个月以上的风湿性心脏病二尖瓣狭窄合并左心房血栓患者28例,术前1周再应用小剂量尿激酶溶栓治疗5天,采用改良的Inoue单球囊技术行PBMV。观察PBMV术后血流动力学与超声心动图指标改变,术后随访半年,观察术中及随访期间有无体循环血栓栓塞并发症。结果手术成功率为100%。左心房平均压(LAPm)和跨二尖瓣压力阶差(MVPG)分别由术前的(24.3±4.2)mm Hg(1 mm Hg=0.133kPa)和(17.6±4.9)mm Hg下降至术后的(11.3±4.5)mm Hg(P<0.05)和(7.2±3.9)mm Hg(P<0.05),左心房内径(LAD)由术前(58.2±5.6)mm减小到术后24小时(48.5±5.8)mm(P<0.05)和术后6个月(44.5±5.8)mm(P<0.05),二尖瓣口面积(MVA)由术前(0.80±0.36)cm2增大至术后24小时(1.88±0.34)cm2(P<0.01)和术后6个月(1.76±0.27)cm2(P<0.01),肺动脉压力(PP)由术前的(72.8±15.6)mm Hg下降至术后24小时(43.2±13.2)mm Hg(P<0.01)和术后6个月(39.5±13.6)mm Hg(P<0.05)。术中及随访期间无1例患者发生血栓栓塞并发症。结论对于合并左心房血栓患者经较充分的华法林抗凝治疗,PBMV是安全可行且疗效满意的。     

二尖瓣狭窄球囊成形术对瓣口面积和左心房、左心室压力及内径的影响

目的 :观察经皮球囊二尖瓣成形术 (PBMV)前后二尖瓣口面积 (MVA)和左心房左心室压力及内径的关系。方法 :2 8例手术成功二尖瓣狭窄患者分成中度狭窄组 (15例 ,A)和重度狭窄组 (13例 ,B) ,对其术前术后指标进行检验和直线回归统计分析。结果 :1周内A组左心房内径和B组左心室内径变化不明显 (P >0 0 5 ) ,A组的左心房内径缩小值 ,左心房压力下降值 ,MVA扩大值、扩大率均 B组 (P <0 0 1) ,其余指标无差异 (P >0 0 5 ) ;术前MVA与术后MVA扩大率 ,左心房内径变化有显著相关性 (P <0 0 1)影响术后左心房大小的因素主要是术前MVA ,术前左心房内径和术后MVA扩大率。据术前MVA的大小可估计术后MVA、左心房、左心室压力和内径的变化。结论 :PBMV可显著的改善患者的血流动力学指标 ,在重度二尖瓣狭窄患者更明显 ,有适应征者应积极进行此项手术治疗。     

二尖瓣狭窄球囊成形术对瓣口面积和左心房、左心室压力及内径的影响

目的：观察经皮球囊二尖瓣成形术（PBMV）前后二尖瓣口面积（MVA）和左心房左心室压力及内径的关系,方法：28例手术成功二尖瓣狭窄患者分成中度狭窄组（15例,A）和重度狭窄组（13例,B）,对其术前术后指标进行检验和直线回归统计分析。结果：1周内A组左心房内径和B组左心室变化不明显（P＞0．05）,A组的左心房内径缩小值,左心房压力下降值,MVA扩大值、扩大率均＜B组（P＜0．01）,左心室内径扩大值＞B组（P＜0．01）,其科指标无差异（P＞0．05）;术前MVA与术后MVA扩大率,左心房内径变化有显著相关性（P＜0．01）影响术后左心房大小的因素主要是术前MVA,术前左心房内径和术后MVA扩大率。据术前MVA的大小可估计术后MVA、左心房、左心室压力和内径的变化。结论：PBMV可显著的改善患者的血流动力学指标,在重度二尖瓣狭窄患者更明显,有适应征者应积极进行此项手术治疗。     

经皮球囊二尖瓣成形术对风湿性心脏病二尖瓣狭窄伴阵发性房颤患者P波离散度的影响

目的　探讨经皮球囊二尖瓣成形术 (PBMV)对风湿性心脏病二尖瓣狭窄伴阵发性房颤患者P波离散度的影响。方法　风湿性心脏病二尖瓣狭窄患者 90例。依据患者是否伴阵发性房颤分为两组。不伴阵发性房颤 (A组 ) 6 0例 ,伴阵发性房颤 (B组 ) 30例 ,均接受PBMV术 ,分别测量两组患者术前及术后 3个月P波最大时限 (Pmax)和P波离散度 (Pd)。结果　术前B组患者Pmax及Pd显著高于A组 (P <0 .0 1) ,术后 3个月B组患者Pmax及Pd较术前显著减低 (P <0 .0 1)。结论　Pmax及Pd可预测风湿性心脏病二尖瓣狭窄患者伴阵发性房颤的发生 ;PBMV术可改善心房电传导。降低风湿性心脏病二尖瓣狭窄伴阵发性房颤患者的Pmax及Pd。     

超声负荷试验对26例经皮球囊二尖瓣成形术前后综合心功能评价

目的研究静息及不同运动状态下心脏血流动力学及二尖瓣口面积变化,更客观、全面地评价PBMV术疗效.方法静脉滴注异丙肾上腺素提高心率,模拟轻、中、重度体力活动,分别于术前、术后采用超声心动图观察MVA、MVG、Vmax、CO、EF等项指标.结果二尖瓣狭窄患者26例,男性9例,女性17例,年龄34.3±6.8岁.PBMV术前行超声负荷试验时随着心率逐步增快(在基础心率上提高20～60次/min)MVG(14.23±6.44mmHg增至21.84±8.06mmHg P＜0.05)、Vmax (1.65±0.38 m/s增至2.81±0.36 m/sP＜0.05)明显升高;MVA(0.89±0.31 cm2至0.92±0.20 cm2 P＞0.05)、CO(3.98±1.36 L/min至4.70±1.11 L/min P＞0.05)、EF(56.8±6.4%至64.8±8.4%P＞0.05)无显著改变,提示二尖瓣储备、心功能储备几近丧失.PBMV术后静息状态下MVA由0.89±0.31 cm2增至2.03±0.36 cm2,MVG由14.23±6.44mmHg下降至3.63±1.64mmHg(P＜0.05),运动负荷状态下MVA由2.03±0.36cm2增至2.48±0.40 cm2,CO由5.27±0.86 L/min增至10.20±0.93L/min(P＜0.05),提示二尖瓣储备、心功能储备部分恢复.结论PBMV术导致MVA增大同时其储备功能部分恢复.二尖瓣储备较术后静息状态下MVA值对心功能的评价具有更大价值.     

左心房大小对风湿性二尖瓣狭窄伴心房颤动患者二尖瓣球囊扩张术后电复律成功率的影响

目的：探讨左心房大小对风湿性二尖瓣狭窄伴心房颤动患者行二尖瓣球囊扩张术后电复律成功率的影响。方法：将96例风湿性二尖瓣狭窄伴心房颤动患者按左心房的直径分为A、B两组,A组（左心房直径小于50 mm）47例,B组（左心房直径大于50 mm）49例。两组患者均采用MAT-I型双腔球囊行经皮二尖瓣球囊扩张术（PBMV）,术后即刻给予100～300 J电复律,转复为窦性心律后,给予胺碘酮口服1～3个月,术后给予华法林1.5～2.5 mg/d,口服3周,定期监测国际标准化比值（INR）,INR保持在2～3。随访3个月,观察两组的电复律成功率、左心房内径及LVEF的变化并进行比较。结果：A组PBMV术后三次电复律成功率和3个月成功维持窦性心律比例（97.9%,85.1%）高于B组（77.6%,57.1%）,两组比较差异有统计学意义（P〈0.05）。两组的左心房内径较复律前缩小、LVEF增加（P均〈0.05）,A组的左心房内径及LVEF变化较B组明显（P〈0.05）。两组均无患者发生严重心律失常及栓塞并发症。结论：左心房直径小于50 mm者PBMV术后电复律成功率和心功能改善优于左心房直径小于50mm者。     

实时三维超声心动图评价风湿性心脏病二尖瓣狭窄伴窦性心律患者经皮球囊扩张术左房功能

目的：探讨实时三维超声心动图（RT-3DE）评价风湿性心脏病二尖瓣狭窄（MS）合并窦性心律患者经皮球囊扩张术（PBMV）前后左房功能的价值。方法：采用RT-3DE对30名正常志愿者和30例MS合并窦性心律患者（PBMV术前、术后）测量并计算左心房最大容积指数（LAVmaxI）、左心房最小容积指数（LAVminI）及左心房收缩前容积指数（LAVpreI）,左房总射血容量指数（TASVI）、左房被动射血容量指数（PASVI）、左房主动射血容量指数（AASVI）,左房整体射血分数（LAEF）、左房被动射血分数（LAEFpassive）、左房主动射血分数（LAEFactive）。分析它们与二尖瓣口面积（MVA）、平均跨瓣压差（MMG）的相关性。结果：①MS患者LAVmaxI、LAVminI、LAVpreAI明显高于正常对照组,PBMV术后下降（P<0.05）;MS患者PASVI、TASVI明显低于正常组,而AASVI明显高于正常组（P<0.05）,PBMV术后PASVI增加、AASVI降低（P<0.05）,TASVI接近于正常组（P>0.05）。MS患者术前LAEFpassive、LAEFactive、LAEF低于正常对照组,术后明显增加（P<0.05）。②PBMV术前后左房容积及功能参数改变量与MVA、MMG改变量呈一定相关关系（P>0.05）。结论：RT-3DE可准确定量评价MS合并窦性心律患者PBMV术前、术后左心房功能。     

Imaging in mitral stenosis: assessment before,during and after percutaneous balloon mitral valvuloplasty

Detailed assessment of mitral valve morphology is required to select patients for successful percutaneous balloon mitral valvuloplasty (PBMV). The mitral valve is routinely imaged using transthoracic and transesophageal echocardiography, which have more recently been supplemented with magnetic resonance imaging, 3D echocardiography and intracardiac echocardiography. The scope of PBMV is expanding and it is increasingly used for patients previously considered to have unfavorable mitral morphology. Here we review the evidence to support the examination of each component of the mitral valve and its surrounding structures and the advantages of each imaging modality. Appropriate echocardiographic views are recommended and periprocedural and postprocedural imaging techniques are discussed.     

Atrial fibrillation and mitral valve repair

Atrial fibrillation (AF) is present in 30–40% of patients presenting for mitral valve surgery. In patients undergoing mitral valve repair, the presence of AF may be associated with increased mortality and morbidity and this is also the case in patients in whom AF persists postoperatively. Advances in understanding the pathogenesis of AF led to techniques that include both mitral valve repair and ablation of AF. The concomitant surgical treatment of AF during mitral surgery has become a commonly performed procedure, which was shown to be safe and which may improve the outcome for patients. AF after mitral valve replacement is an accepted indication for anticoagulation, but the data supporting anticoagulation in patients after mitral valve repair who convert to sinus rhythm are sparse. This article reviews the available data regarding outcomes of mitral repair and how they are influenced by AF and its therapy.     

经皮二尖瓣球囊成形术在二尖瓣狭窄伴重度心力衰竭时的应用

介绍二尖瓣狭窄伴重度心力衰竭（心衰）患者实施经皮二尖瓣球囊成形术（PBMV）的结果和初步体会。9例患者中男6例，女3例，年龄24～52岁，全部患者心功能均为Ⅳ级（按NYHA分级），术前抗心衰药物治疗效果极不理想。经施行PBMV后，血流动力学明显得已改善：左房平均压由术前4．34±1．02kPa（1kPa=7．5mmHg）降至术后1．64±0．82kPa，二尖瓣跨瓣压差由术前3．26±0．84kPa降至术后0．72±0．56kPa；瓣口面积由术前0．78±0．30cm~2增至术后2．11±0．24cm~2，左房内径术后较术前缩小了约10mm（P值均＜0．001）；在短期内心功能迅速恢复至Ⅰ～Ⅱ级，运动耐量明显增加，心衰症状缓解率达100％。作者认为：二尖瓣狭窄伴重度心衰时，只要排除了加重心衰的其他原因，应尽早施行PBMV，PBMV是一种安全、可靠和行之有效的治疗方法。作者同时对PBMV时球囊方式选择及并发症的防治进行了讨论。     

Ongoing and future directions in percutaneous treatment of mitral regurgitation

Introduction: Mitral regurgitation (MR) is one of the major valvular disease. Although surgical mitral valve (MV) repair is the standard of care for patients with severe MR, an unmet need exists in the management of patients with severe symptomatic MR and high surgical risk. Transcatheter MV therapies are alternative treatment option in such patients with moderate to severe and symptomatic MR.

Areas covered: Literatures to direct the reader to important further reading were searched with relevant websites; www.ncbi.nlm.nih.gov/pubmed using search word ‘transcatheter mitral intervention’.

Expert commentary: A variety of transcatheter techniques have emerged for the percutaneous treatment of MR. We should carefully select one or combination procedure for each patient as an ideal tailor-made transcatheter MV therapy in order to improve the outcomes.     

Concomitant decalcification of the anterior mitral leaflet via the aortic annulus during aortic valve replacement for significant aortic and mitral stenoses

An 82‐year‐old man undergoing regular hemodialysis with substantial aortic and mitral valve stenoses underwent aortic valve replacement with concomitant mitral decalcification via the aortic annulus. Postoperative transthoracic echocardiography showed reduced mitral stenosis. The patient was discharged on the 14th postoperative day uneventfully.     

Predictors of adverse outcomes after transcatheter mitral valve replacement

Introduction: Transcatheter mitral valve replacement (TMVR) is still a recent technology with numerous unknowns but also great promises. The risk of complications reported in observational studies have limited its adoption by interventional cardiology and surgical communities.

Areas covered: Some of the major setbacks of TMVR are complications related to the devices and those related to the pathway. Device-related complications include left ventricle outflow tract (LVOT) obstruction, transcatheter heart valve (THV) dislocation or embolization, thrombosis, and stroke. The transapical approach currently remains the main pathway for TMVR but is associated with high risk of major bleeding and residual apical myocardial scarring. Complication prediction and prevention seem possible. Device-related complication prediction is based on pre-operative imaging including multi-slice computed tomography with 3-dimensional reconstructions and echocardiography which allow LVOT obstruction prediction and appropriate sizing aiming at avoiding dislocation. Industry should aim at the development of transfemoral delivery systems. Nevertheless, several recent feasibility observational studies suggested acceptable safety and efficacy of transcatheter mitral valve replacement.

Expert opinion: TMVR complications and transapical delivery are some of the main setbacks which need to be addressed for TMVR to be adopted for broad clinical use.     

瓣环扩大在功能性二尖瓣返流机制中的作用

目的探讨瓣环扩大在功能性二尖瓣返流机制中的作用。方法应用超声心动图检查房颤组(20例)、返流组(30例)及正常组(20例)的心脏,测量二尖瓣返流比例、左室射血分数(EF)、左室大小、球形度、收缩期瓣环(MA)面积、收缩期后乳头肌与二尖瓣前瓣环的距离(PPMAMA)。结果房颤组左室大小、球形度、EF、PPMAMA和正常组相比没有统计学差异,但收缩期MA面积较正常组明显扩大,并与返流组相似,分别为(5.3±1.1)cm2、(7.4±1.5)cm2、(8.0±2.0)cm2,但房颤组二尖瓣返流量明显小于功能性二尖瓣返流组,分别为(12±7)%和(30±14)%。结论单纯瓣环的扩张似乎并不引起中或重度二尖瓣返流。     

Echocardiographic quantitation of mitral regurgitation

Mitral valve regurgitation is a common valvular problem, particularly in developing nations. It causes significant morbidity and mortality, especially if the severity of valve regurgitation is underestimated. Echocardiography plays a significant role in the diagnoses, serial follow-up and management of patients with valvular heart disease. However, precise quantitation of the severity of mitral regurgitation is a crucial element in the therapeutic decisions for managing mitral regurgitation. An accurate assessment of the severity of mitral regurgitation allows for optimal timing of surgical intervention, culminating in improved patient outcomes. This review provides a systematic approach to the quantitation of mitral regurgitation using the echocardiography and Doppler methodologies that are available in the modern noninvasive imaging and hemodynamic laboratory. Additional, novel and evolving noninvasive imaging modalities are reviewed briefly.     

二尖瓣成形术治疗二尖瓣后瓣脱垂伴重度关闭不全后收缩期前向运动征1例

<正>患者男,48岁,活动后胸痛伴头晕、恶心及心悸等3个月;10余年前因“胆囊结石”接受“单孔腹腔镜胆囊切除术”。查体：脐上缘见长2.5cm横行手术瘢痕,二尖瓣区闻及2/6级收缩期杂音。实验室检查未见明显异常。经胸超声心动图（transthoracic echocardiography,TTE）：左心房前后径44mm,左心室舒张末期内径54mm,室间隔厚度9mm;左心室射血分数66%;二尖瓣后瓣P1收缩期脱向左心房侧,超过瓣环水平,二尖瓣偏向房间隔大量反流;提示二尖瓣后瓣脱垂伴重度关闭不全。