Percutaneous transhepatic mitral commissurotomy

A novel, transhepatic approach to mitral valvuloplasty is described in a patient with an inferior vena caval filter. After transhepatic transseptal puncture, an Inoue dilatation catheter was passed through the hepatic parenchyma and across the atrial septum. Balloon mitral valvuloplasty was performed without complications. This approach should be considered when femoral venous access is restricted or is not feasible. © 1996 Wiley-Liss, Inc.     

分级次二尖瓣球囊扩张预防二尖瓣反流的初步研究

目的为探讨经皮穿刺球囊导管二尖瓣扩张术（ＰＢＭＶ）引起二尖瓣反流（ＭＲ）的原因及其预防方法。方法我们采用分级次扩张法和改良Ｉｎｏｎｅ法对人体病变二尖瓣和硅胶二尖瓣模型进行体外球囊导管扩张实验，并对１３２例风湿性心脏病重度二尖瓣狭窄患者，其中分别以分级次扩张法９６例，Ｉｎｏｎｅ法３６例进行ＰＢＭＶ的前瞻性对比研究。结果（１）ＰＢＭＶ引起二尖瓣反流的原因除与瓣膜钙化程度重、瓣下结构紊乱有关以外，瓣口面积小、交界粘连处夹角小是一个重要原因。（２）分级次扩张可使交界粘合处夹角呈渐进性扩大，扩张时不易引起瓣膜撕裂和二尖瓣反流。两组比较Ｉｎｏｎｅ法扩张组二尖瓣反流发生率为１６．７％，分级次扩张组无二尖瓣反流病例，并且术中其他并发症及术后再狭窄发生率后者也明显低于前者。结论球囊导管分级次扩张可有效地预防二尖瓣反流，是治疗二尖瓣狭窄较理想的方法。     

The echocardiographic association of mitral valve prolapse and mitral anulus calcification

Mitral anulus calcification (MAC) and mitral valve prolapse (MVP) are frequently diagnosed conditions. We studied two patients with mild or moderate mitral regurgitation who demonstrated both MAC and MVP on angiography and echocardiography. M-mode echocardiography is probably the definitive test for confirming the presence of MVP. Echocardiography is moderately sensitive in the diagnosis of cardiac calcification, such as MAC, but M-mode echocardiography may not detect the MAC in the majority of patients with both MVP and MAC demonstrated by angiography.     

外科二尖瓣交界分离术后再狭窄二尖瓣球囊成形术

将６６例二尖瓣狭窄患者首次行ＰＢＭＶ和１８例外科分离术后再狭窄患者行ＰＢＭＶ进行比较，结果表明两者扩瓣治疗前、后的血流动力学指数有明显差异（Ｐ＜０．００１），但将两者术后相应的血流动力学指数进行比较差异无显著性（Ｐ＞０．０５）。说明外科二狭分离术后再狭窄患者成功地进行ＰＢＭＶ可显著改善临床症状，仍是一种有效的方法。     

Parachute mitral valve with severe mitral regurgitation in an adult patient

Parachute mitral valve (PMV) is rarely seen in the adult population, in isolation or in association with other congenital heart defects, since most patients may have had milder lesions previously that were asymptomatic early in life, or were not detected due to lack of a comprehensive examination. We report a case of an 18-year-old woman with a history of exertional dyspnea, atypical chest pain, and cough for about 1 year. The echocardiographic examination identified a PMV with severe mitral regurgitation associated with bicuspid aortic valve and coarctation of the aorta. Most patients present with mitral stenosis of varying degree of severity, and rarely present with severe mitral regurgitation as seen in our patient.     

Pathology of mitral valve stenosis and pure mitral regurgitation—Part II

This two-part article examines the histologic and morphologic basis for stenotic and purely regurgitant mitral valves. in Part I, conditions producing mitral valve stenosis were reviewed. in over 99% of stenotic mitral valves, the etiology is rheumatic disease. Other rare causes of mitral stenosis include congenitally malformed valves, active infective endocarditis, massive annular calcium, and metabolic or enzymatic abnormalities. in Part II, conditions producing pure mitral regurgitation are discussed. in contrast to the few causes of mitral stenosis, the causes of pure (no element of stenosis) mitral regurgitation are multiple. Some of the conditions producing pure regurgitation include floppy mitral valves, infective endocarditis, papillary muscle dysfunction, rheumatic disease, and ruptured chordae tendineae.     

Pathology of mitral valve stenosis and pure mitral regurgitation—Part I

This two-part article examines the histologic and morphologic basis for stenotic and purely regurgitant mitral valves. In Part I, conditions producing mitral valve stenosis are reviewed. In over 99% of stenotic mitral valves, the etiology is rheumatic disease. Other rare causes of mitral stenosis include congenitally malformed valves, active infective endocarditis, massive annular calcium, and metabolic or enzymatic abnormalities. In Part II, conditions producing pure mitral regurgitation will be discussed. In contrast to the few causes of mitral stenosis, the causes of pure (no element of stenosis) mitral regurgitation are multiple. Some of the conditions producing pure regurgitation include floppy mitral valves, infective endocarditis, papillary muscle dysfunction, rheumatic disease, and ruptured chordae tendineae.     

“Balloon impasse”: A marker for severe mitral subvalvular disease and a predictor of mitral regurgitation in inoue-balloon percutaneous transvenous mitral commissurotomy

In certain instances of percutaneous transvenous mitral commissurotomy, the Inoue catheter balloon, although deflated and properly aligned, becomes held up or checked at the mitral valve. This “balloon impasse,” observed in 13 of 760 patients undergoing the commissurotomy, reflects severe obstructive subvalvular disease even though echocardiographic evidence suggests otherwise. Our experience shows that the sign portends severe mitral regurgitation if the usual balloon sizing method is used. Such a situation occurred with four of the first six patients. In the next seven patients, the use of smaller balloon catheters (PTMC-18 or PTMC-20) for the initial set of stepwise dilatations averted creation of severe mitral regurgitation. When the “balloon impasse” sign is encountered during the commissurotomy procedure, the catheter selection and balloon sizing method should be judiciously altered. © 1995 Wiley-Liss. Inc.     

Percutaneous mitral balloon valvotomy.

Percutaneous mitral balloon valvotomy (PMBV) was introduced in 1984 by Inoue who developed the procedure as a logical extension of surgical closed commissurotomy. Since then, PMBV has emerged as the treatment of choice for severe pliable rheumatic mitral stenosis (MS). With increasing experience and better selection of patient, the immediate results of the procedure have improved and the rate of complications declined. When the reported complications of PMBV are viewed in aggregate, complications occur at approximately the following rates: mortality (0-0.5%), cerebral accident (0.5-1%), mitral regurgitation (MR) requiring surgery (1.6-3%). These complication rates compare favorably to those reported after surgical commissurotomy. Several randomized trials reported similar hemodynamic results with PMBV and surgical commissurotomy. Restenosis after PMBV ranges from 4 to 70% depending on the patient selection, valve morphology, and duration of follow up. Restenosis was encountered in 21% of the author's series at mean follow-up 6 +/- 4.5 years and the 10 and 15 years restenosis-free survival rates were (70 +/- 3)% and (44 +/- 5)%, respectively, and were significantly higher for patients with favorable mitral morphology (85 +/- 3% and 65 +/- 6%), respectively (P < 0.0001). The 10 and 15 years event-free survival rates were (79 +/- 2)% and (43 +/- 9)% and were significantly higher for patients with favorable mitral morphology (88 +/- 2)% and (66 +/- 6)%, respectively (P < 0.0001). The effect of PMBV on severe pulmonary hypertension, concomitant severe tricuspid regurgitation, left ventricular function, left atrial size, and atrial fibrillation are addressed in this review. In addition, the application of PMBV in specific clinical situations such as in children, during pregnancy and for restenosis is discussed.     

Asynchronous movement of mitral annulus: an additional mechanism of ischaemic mitral regurgitation

In-coordinate mitral annulus movement might participate in the pathogenesis of functional mitral regurgitation. We evaluated a relationship between indices of mitral annulus systolic asynchrony and mitral regurgitation in patients after myocardial infarction in order to determine independent determinants of effective regurgitant orifice (ERO) area in a multivariate regression model.Tissue Doppler echocardiographic studies and quantitative analysis of mitral regurgitation were performed in 40 patients (33 men, 7 women, mean age 60.1 +/- 9.2 years) with a history of Q-wave myocardial infarction, with and without significant functional mitral regurgitation.A multivariate regression model showed that mitral annulus movement asynchrony index-difference between the longest and the shortest time from the R wave in the electrocardiogram to the cessation of systolic movement of the four aspects of mitral annulus, is an independent from ejection fraction, sphericity index, tenting, annulus diameter and infarct location, determinant of mitral regurgitation ERO area (r(2) change 0.72, p 相似文献   

Development of mitral stenosis after single mitraclip insertion for severe mitral regurgitation

We report the first case of mitral stenosis following Mitra‐Clip insertion in a patient with symptomatic NYHA IV heart failure, secondary to severe mitral regurgitation (MR). A 79‐year‐old female with a history of prior aortic valve replacement underwent percutaneous mitral valve (MV) repair. A single clip was advanced coaxially down onto the MV under TOE guidance, with the anterior and posterior leaflets clipped together between A2 and P2. TOE confirmed a significant reduction in MR (grade 4 to grade 1). Despite initial symptomatic relief, she represented 3 months later with similar symptoms. Repeat TOE confirmed a well positioned Mitra‐Clip with mild residual MR. However, the possibility of significant mitral stenosis was raised due to the presence of significant turbulence through the bi‐orifice valve, with a peak gradient of 25 mm Hg. In addition there was evidence of severe functional tricuspid valve (TV) regurgitation with elevated pulmonary artery pressures (PAP 90 mm Hg), confirmed on subsequent right heart catheterization. After repeated heart team discussions and a failure of optimal medical therapy, and despite a logistic EuroScore of 35.5, minimally invasive surgical replacement of the MV and simultaneous TV repair was undertaken via a right thoracotomy. Despite procedural success and initial good postoperative response, the patient died subsequently from a combination of hospital‐acquired pneumonia and significant gastrointestinal bleeding (post operative day 35). Mitra‐Clip is a promising novel approach to MV repair. The establishment of further clinical and echocardiographic based selection criteria will help identify the correct patients for this treatment. © 2013 Wiley Periodicals, Inc.     

Severe mitral incompetence following balloon mitral valvuloplasty: Complete resolution during follow-up

Mitral incompetence (MR) is a complication of balloon mitral valvuloplasty. There are few reports of long-term outcome. We beleive this is the first report in the literature of complete resolution during follow-up of severe mitral regurgitation resulting from balloon valvuloplasty.     

Pitfalls and tips in Inoue balloon mitral commissurotomy

Balloon mitral commissurotomy is a safe and effective alternative therapeutic modality in selected patients with significant rheumatic mitral stenosis. Since its introduction in 1984, Inoue balloon mitral commissurotomy has gained wider acceptance over other balloon valvuloplasty techniques because it is technically less demanding and associated with fewer complications. Nevertheless, certain pitfalls which may make the procedure more difficult or create complications are sometimes encountered. In this article, we offer tips to facilitate a safe and expeditious execution of Inoue balloon mitral commissurotomy based on our experience with over 1,000 procedures. © 1996 Wiley-Liss, Inc.     

Predicting mitral regurgitation following percutaneous mitral valvotomy with the Inoue balloon: comparison of two echocardiographic scoring systems.

BACKGROUND: Percutaneous balloon mitral valvotomy (PBMV) has become the procedure of choice for many patients with symptomatic mitral stenosis. However, the development of significant mitral regurgitation (MR) remains an infrequent but very important complication. The echocardiographic scoring system described by Padial et al. has been successful in predicting the development of severe MR following PBMV using the double balloon technique. HYPOTHESIS: We aimed to assess the applicability of this new scoring system in predicting a significant increase in MR with the Inoue balloon and to compare it with the established Wilkins score. METHODS: The echocardiograms of 23 patients who had undergone PBMV for symptomatic mitral stenosis were analyzed retrospectively using both scoring systems, and the severity of MR was determined from pre- and postprocedural studies. RESULTS: Post PBMV, significant MR occurred in four patients (17%) while severe MR occurred in two patients (9%). Padial scores [mean (standard error of the mean)] in the group of patients with and without significant MR were [9.1 (0.8)] and [6.0 (0.3)], respectively (p = 0.002), while the Wilkins score was [7.5 (1.0)] and [6.4 (0.5)], respectively (p = 0.3). Using 8 as a cutoff point, the sensitivity and specificity of the newer scoring system was 83 and 100%, respectively, while the sensitivity and specificity of the Wilkins score was 50 and 50%, respectively. The positive predictive value > 8 was 100% (4/4) for the Padial and 25% (1/4) for the Wilkins system. Accordingly, the negative predictive value < 8 was 89% (17/19) for the Padial and 73% (14/19) for the Wilkins system. CONCLUSION: The newer scoring system is better at reliably identifying patients at risk of developing significant MR from PBMV with the Inoue balloon.