Role of three dimensional transesophageal echocardiography in predicting mitral regurgitation after percutaneous balloon mitral valvuloplasty

BackgroundPercutaneous balloon mitral valvuloplasty (PBMV) can be complicated with significant mitral regurgitation (MR). We performed a pilot, prospective study to evaluate the role of three dimensional transesophageal echocardiography (3D-TEE) in the prediction of MR after PBMV through mitral valve quantification (MVQ).MethodsBetween October 2014 and October 2016, 37 patients with rheumatic, moderate-to-severe mitral stenosis, referred to the Cath lab of Bab Alshearia University hospitals for PBMV, were divided into two age and sex matched groups. Group I included 25 patients without significant MR following PBMV [vena contract area (VCA) <0.4 cm²], while group II included 12 patients with significant MR after PBMV [VCA ≥0.4 cm²]. Both groups were comparable in terms of TEE data, Wilkins score for favorability of PBMV and baseline hemodynamics.ResultsData from MVQ showed that both groups were comparable (p > 0.05) in terms of MV annulus quantification (Anteroposterior diameter, annular sphericity, 3D area and height), MV scallops (A1, A2, A3, P1, P2 and P3) areas, as well as A1 and A2 tenting volumes. However, we recorded significant differences between the two groups as regard total MV, A2, P2 and P3 tenting volumes (p < 0.05) and tenting height (p = 0.03), as well as A2, A3 and P2 prolapse volumes (p < 0.05). Moreover, our data showed a significant difference between both groups in terms of MV coaptation heights (p = 0.01), but not in anterior coaptation length (p = 0.13).ConclusionMitral valve quantification through 3D-TEE is a simple automated method, easily applicable to patients before PBMV. Moreover, MVQ-derived data, such as MV scallops' tenting and prolapse volumes, coaptation heights, and exposed and total A2 lengths may predict the possibility of significant MR after PBMV.     

The use of transesophageal echocardiography to avoid left atrial thrombus during percutaneous mitral valvuloplasty

During mitral balloon valvuloplasty, transesophageal echocardiography (TEE) has been employed for the accurate placement of the transseptal needle, guide wires, and balloon catheters and to provide an immediate evaluation of the results of the procedure. We describe a case demonstrating that TEE can be used to avoid a left atrial appendage thrombus during the placement of wires and catheters. With TEE guidance, we feel left atrial appendage thrombi are no longer an absolute contraindication to percutaneous mitral valvuloplasty. © 1993 Wiley-Liss, Inc.     

经皮球囊二尖瓣扩张术并发症的外科治疗

本院自１９８７年１０月至１９９５年９月，３５０例行经皮球囊二尖瓣成形术后发生并发症需要外科治疗的８例患者，其中心脏穿破致急性心包填塞３例、脑栓塞１例、创伤性重度二尖瓣关闭不全２例、创伤性房间隔缺损５例。外科采用紧急开胸止血、左心房血栓清除、修补创伤性房间隔缺损、二尖瓣置换、左径二尖瓣扩张术等治疗方法。作者认为：经皮球囊二尖瓣成形术后发生并发症，应及时采用适当的外科治疗措施，切勿延误治疗时机；经皮球囊二尖瓣成形术需有一定的适应证，不能完全替代二尖瓣置换术或直视二尖瓣成形术。     

Neuro-embolic protection during percutaneous balloon mitral valvuloplasty.

This report describes the management of a patient with severe symptomatic mitral stenosis and a large mobile thrombus extending from the left atrial appendage that was resistant to warfarin therapy. Percutaneous balloon mitral valvuloplasty was performed with cerebral protection using bilateral internal carotid artery filters to minimize the risk of embolic stroke.     

Unsuccessful deflation of a bifoil balloon during percutaneous mitral valvuloplasty

A middle-aged woman was subjected to balloon mitral valvuloplasty using a bifoil balloon catheter. After inflation the balloon failed to deflate inspite of negative suction, probably due to a kink. The balloon was perforated with a transseptal puncture needle in order to deflate it and save open heart surgery. © 1996 Wiley-Liss, Inc.     

二尖瓣球囊扩张术和机械分离术的临床评价

目的探讨二尖瓣球囊扩张术和机械扩张术治疗二尖瓣狭窄的特点和治疗效果。方法2001年2月～2002年8月,采用二尖瓣球囊扩张术(percutaneous balloon mitral valvuloplasty,PBMV)治疗二尖瓣狭窄52例,评分(7±1);采用机械扩张术(percutaneous mechanical mitral commissurotomy,PMMC)治疗二尖瓣狭窄36例,评分(10±2)。对术后24h、1年的心脏超声检查随访结果进行对比分析。结果PBMV成功率94%(49/52);PMMC成功率92%(33/36)。PBMV后二尖瓣面积(mitral valve area,MVA)(1.7±0.2)cm2,PMMC后MVA(2.1±0.5)cm2,差异有统计学意义(P<0.01)。心包填塞并发症:PBMV发生率5.7%;PMMC5.5%。PBMV和PMMC增加二尖瓣反流面积大于3cm2例数分别占14%(7/52)和10%(3/33),差异有统计学意义(P<0.01)。术后1年,PBMV组需外科换瓣手术3例,PMMC组无手术换瓣病例。结论PBMV和PMMC都是治疗二尖瓣狭窄有效的方法,P...     

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。     

Percutaneous balloon mitral valvuloplasty in a pregnant woman with mitral stenosis

A 39-year-old woman with symptomatic mitral stenosis underwent percutaneous mitral valvuloplasty at the end of her first trimester of pregnancy. Balloon dilatation utilizing a double 18–20 mm balloon technique resulted in improvement in mean mitral gradient (16 to 7 mmHg) and in calculated mitral valve area (1.4 to 2.4 cm²), without significant complications and with an estimated radiation exposure to the fetus of less than 0.2 rads. The procedure resulted in disappearance of symptoms of congestive heart failure and allowed for discontinuation of diuretics. The subsequent course of gestation was uncomplicated and a normal baby boy was delivered in the 36th wk. We conclude that percutaneous mitral valvuloplasty may produce successful palliation of symptoms in patients with mitral stenosis during pregnancy.     

风湿性二尖瓣狭窄伴心房纤颤球囊二尖瓣成形术后心房纤颤的复律治疗

报道９０例风湿性二尖瓣狭窄伴心房纤颤（简称二狭房颤）球囊二尖瓣成形术（ＰＢＭＶ）后复律治疗的结果。８９例患者在ＰＢＭＶ后２周内接受复律治疗，１５例服用奎尼丁后恢复窦性心律，７４例经体表电复律转为窦性心律。随访２３．５±１１．７个月，２４例（２７％）患者心房纤颤复发。我们认为心房纤颤病程长，ＰＢＭＶ后瓣口面积小和左房回缩差是心房纤颤复发的可能原因。     

Use of three‐dimensional transesophageal echocardiography to evaluate mitral valve morphology for risk stratification prior to mitral valvuloplasty

Mitral stenosis is often managed percutaneously with an interventional procedure such as balloon commissurotomy. Although this often results in an increased mitral valve area and improved clinical symptoms, this procedure is not benign and may have serious complications including the development of hemodynamically significant mitral valve regurgitation. Multiple scoring systems have been developed to attempt to risk stratify these patients prior to their procedure. Case: A 64‐year‐old patient underwent an emergent mitral valve replacement after having percutaneous mitral balloon commissurotomy complicated by development of severe mitral regurgitation. Prior to valvuloplasty, her mitral valve was evaluated by traditional methods including calculation of a Wilkins score. Her mitral valve was evaluated after valvuloplasty and preoperatively with three‐dimensional transesophageal echocardiography. This examination demonstrated heterogeneous distribution of calcification affecting the mitral valve commissures more than the leaflets, which is consistent with the noncommissural leaflet tearing that occurred during her procedure, causing severe mitral regurgitation. In the future, careful 3D evaluation of mitral valve morphology including leaflets, annular calcification, and subvalvular apparatus may help risk stratify patients prior to intervention.     

老年患者二尖瓣狭窄球囊成形术并发症的防治

目的 降低老年患者二尖瓣球囊成形术的并发症.方法 对57例老年二尖瓣狭窄患者进行经皮二尖瓣球囊成形术(PBMV).将患者分为A组27例,男性11例,女性16例,年龄60～72(66±5)岁,采用传统的PBMV技术;B组30例,男性10例,女性20例,年龄60～70(64±5)岁,采用改进的PBMV技术,主要包括4种方法监控定位行房间隔穿刺;根据左心房大小调整二尖瓣导向探条前段的J形弧度;3种方法监控球囊导管是否已进入左心室并判断其未卡在腱索内;微级递增球囊直径扩张二尖瓣口等.结果 A组并发症为26%(7/27),其中中～重度二尖瓣关闭不全4例,缓慢性心律失常及低血压2例,心包填塞1例;B组仅3%(1/30)发生中度二尖瓣关闭不全,两组比较,差异有显著性意义(P＜0.05).超声心动图显示左心房内云雾状改变不是PBMV的禁忌证.结论 PBMV操作技术的改进可显著降低老年患者PBMV手术的并发症.     

经皮球囊二尖瓣成形术前后心功能的分析

作者采用心机图方法检测４５例二尖瓣狭窄患者行经皮球囊二尖瓣成形术前后的心功能变化。结果显示，术后收缩功能有显著改善；舒张功能亦有所进步，但除了全舒张时间及快速充盈波相对振幅比值有显著性差异外，其他指标虽有改善，但均无统计学意义。     

Percutaneous mitral balloon valvuloplasty in pregnant women with mitral stenosis.

Forty-four consecutive pregnant patients with mitral stenosis were submitted to percutaneous mitral valvuloplasty (PMV) over a period of 12 years. The mean age was 28 +/- 6 years and the mean gestational age was 23 +/- 6 weeks. The mean mitral valve area had a significant increase from 1.17 +/- 0.26 to 2.06 +/- 0.41 cm(2) (P = 0.0000). The mean mitral valve gradient decreased from 16.22 +/- 5.55 to 7.94 +/- 3.75 mm Hg (P = 0.0001). The procedure was performed successfully in 95% of the patients and there were no major complications. Concerning labor and delivery, we evaluated 37 patients. Thirty patients (81%) reached term and delivered normal infants. Seven patients (18.9%) delivered prematurely, resulting in two fetal death; one patient delivered a stillborn. We concluded that PMV is a safe procedure for the treatment of mitral stenosis in pregnant patients, providing significant symptomatic relief and better clinical conditions for labor and delivery.     

二尖瓣狭窄并中度反流的经皮二尖瓣球囊扩张术42例及随访观察

目的　探讨二尖瓣狭窄 (MS)并中度反流 (MR)患者经皮二尖瓣球囊扩张术 (PBMV)近远期疗效。方法　采用Inoue单球囊对 42例风心病二尖瓣狭窄并中度反流患者行PAMV治疗。结果　二尖瓣口面积由 (0 92± 0 2 2 )cm2 增至 (1 94± 0 2 5 )cm2 (P <0 0 1) ;二尖瓣跨瓣压差由 (2 7± 1 0 1)kPa降至 (1 0 2± 0 5 6 )kPa(P <0 0 1) ;心功能由 (2 6 1± 0 2 2 )级改善至 (1 42± 0 46 )级 (P <0 0 1) ;左室最大前后径无明显变化 (P >0 0 5 )。 2例患者二尖瓣反流较术前加重。随访 37例患者 (18± 4)个月 ,二尖瓣口面积、左室最大前后径及心功能与术后比较 ,均无明显变化 (P >0 0 5 )。结论　掌握好病例选择 ,严格把握球囊扩张尺度 ,风心病二尖瓣狭窄并中度反流患者PBMV近、远期疗效满意     

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.     

经皮球囊二尖瓣成形术治疗伴巨大左心房的重度二尖瓣狭窄的临床研究

目的:评价经皮球囊二尖瓣成形术(PBMV)治疗风湿性心脏病(风心病)重度二尖瓣狭窄(MS)合并巨大左心房的可行性、安全性和有效性。方法:风心病重度MS合并巨大左心房患者共28例,其中男9例,女19例,年龄20～51(34.9±7.5)岁。采用常规及改良的非常规方法进行PBMV。以手术前后肺动脉平均压、左房平均压、二尖瓣跨瓣压差及左心房直径、二尖瓣口面积等血流动力学指标评估PBMV效果,并观察有无体循环血栓栓塞等并发症。结果:PBMV成功率为100%。与术前相比较,术后肺动脉平均压下降[(42.28±7.58)mmHg(1mmHg=0.133kPa)∶(23.17±5.99)mmHg]、左心房平均压下降[(28.11±6.18)mmHg∶(13.11±4.43)mmHg]、二尖瓣跨瓣压差显著下降[(19.55±6.14)mmHg∶(7.87±3.01)mmHg)],差异均具有统计学意义(P<0.001);同时左心房直径明显减小[(68.61±8.92)cm∶(51.39±7.88)cm]、二尖瓣口面积增大[(0.75±0.17)cm2∶(1.87±0.33)cm2],差异亦均具有统计学意义(P<0.01),心功...     

Utility of the posterior to anterior mitral valve leaflets length ratio in prediction of outcome of percutaneous balloon mitral valvuloplasty

Background: Scoring of mitral stenosis (MS) severity is very important for selection of patients for balloon mitral valvuloplasty (BMV). Objective: We propose a novel yet simple, independent parameter of MS severity based on the posterior mitral valve leaflet to anterior mitral valve leaflet length ratio (PMVL/AMVL length ratio). It could be a useful predictor to outcome of BMV. Subjects and methods: A total of 106 patients (mean age 29.1 ± 8.6 years) had MS with mitral valve score of eight or less. The length of anterior mitral valve leaflet and posterior mitral valve leaflet were measured. Patients were classified into group with ratio ≥ 1/2 and group of ratio <1/2. Eighty‐five healthy control subjects were studied. Results: Patients with PMVL/AMVL ratio ≥ 1/2 post‐BMV had lower transmitral gradients (4.5 ± 3.1 mmHg vs. 9.7 ± 2.1 mmHg, P < 0.002) and greater mitral valve area (MVA) (2.09 ± 0.3 cm² vs. 1.5 ± 0.2 cm², P < 0.001), lower pulmonary artery systolic pressure (PASP) (23.8 ± 14.3 mmHg vs. 34.2 ± 12.5 mmHg, P < 0.001), left atrial pressure (10.2 ± 6.7 mmHg vs. 18.9 ± 6.4 mmHg, P < 0.001), and lower incidence of de novo or worsening of mild mitral regurgitation (MR; 1.64% vs. 8.9%, 0% vs. 6.6%, P < 0.001). PMVL/AMVL length ratio was positively correlated with post‐BMV MVA (r = 0.69, P < 0.002), PASP (r = 0.592, P < 0.003), and negatively correlated with incidence of de novo or worsening of mild MR (r =–0.78, –0.93, P < 0.001). The regression analyses revealed that PMVL/AMVL ratio is the best and a reliable predictor of success and outcome of BMV, hazard ratio (95% confidence interval) 0.12 (0.05–52), P < 0.001. Conclusion: Length ratio of PMVL/AMVL assessment with echocardiography is an excellent simple predictor of post‐BMV mitral valve area and the cardiac events. (Echocardiography 2011;28:1068‐1073)     

经皮二尖瓣球囊成形术治疗伴重度钙化的二尖瓣狭窄

目的 :探讨风湿性心脏病 (RHD)伴重度钙化的二尖瓣狭窄 (MS)患者行经皮二尖瓣球囊成形术 (PB MV)的近期疗效及安全性。方法 :对 33例伴重度钙化的MS患者行逐步球囊扩张法PBMV治疗 ,术中监测左房平均压等 ,术前、术后 3个月进行心脏超声心动图检查 ,并对结果进行统计分析。结果 :术后左房压、二尖瓣跨瓣压差显著下降 ;超声心动图示二尖瓣口面积显著扩大 ,心功能显著改善 ,左房内径、二尖瓣跨瓣压差、肺动脉收缩压显著减小 ,左室内径无显著变化。结论 :逐步扩张法PBMV治疗伴重度钙化的MS是一种安全、有效的方法。     

风湿性二尖瓣狭窄伴心房颤动二尖瓣球囊扩张术疗效评价

对26例风湿性二尖瓣狭窄伴心房纤额（房颤二狭）与同期31例风湿性二尖瓣狭窄无房颤（窦律二狭）患者PBMV术后及随访结果进行比较，结果显示：虽然房颤二狭具有血栓发生率高、左房前后径大、瓣膜超声评分高等特殊性，但只要术前抗凝准备充分，操作仔细，房颤二狭接受PBMV治疗与窦律二狭一样具有良好的安全性和临床效果。