老年与中青年二尖瓣狭窄患者经皮球囊二尖瓣成形术治疗效果比较

目的：比较经皮球囊二尖瓣成形术（ PBMV）治疗老年与中青年二尖瓣狭窄的效果。方法二尖瓣狭窄患者491例,按照年龄分为老年组（96例,≥60岁）及中青年组（395例,≤60岁）,两组均行PBMV,观察近期及远期疗效;采用Cox多因素回归分析远期发生心功能Ⅲ级及以上合并不良事件的影响因素。结果老年组最后扩张直径为（24．9±1．12）cm、术后左房压为（16．2±5．2）mmHg、术后即刻二尖瓣口面积（MVA）为（1．91±0．22）cm2,中青年组分别为（25．4±1．35）cm、（15．1±4．1）mmHg、（2．01±0．18）cm2,两组比较,P均＜0．05。老年组及中青年组发生不良事件合并心功能Ⅲ级及以上者分别为29例（34．1％）、77例（21．3％）,两组比较,P＜0．05。老年组MVA、心功能评分分别为（1．61±0．21）cm2、（2．07±0．77）分,中青年组分别为（1．67±0．21）cm2、（1．80±0．77）分,两组比较,P均＜0．05。 Cox多因素回归分析显示房颤、术前心功能、Wilkins积分、即刻MVA、术后平均左房压、术后二尖瓣反流程度为远期不良事件合并心功能Ⅲ级及以上的影响因素。结论与青壮年相比,老年人行PBMV同样安全有效,尽管心功能改善程度不如青壮年,但年龄不是PBMV的限制因素。     

经皮穿刺球囊二尖瓣成形术在老年患者的临床应用

采用经皮穿刺球囊成形术（PBMV）治疗风湿性心脏病二尖瓣狭窄20例．左房平均压（kPa）2．83±1．09下降至1．38±0．51，舒张期跨瓣压力阶差（kPa）3．03±1．37下降至1．17±0．63，二尖瓣面积（cm2）1．04±0．28增大至1．94±0．39（P＜0．001）．近中期院诊无再狭窄发生，心功能持续改善，疗效满意．提示PBMV对风心病二尖瓣狭窄的老年患者是安全、确切有效的减症疗法．     

二尖瓣狭窄伴心房颤动球囊二尖瓣成形术前抗凝及术后复律的临床探讨

对26例二尖瓣狭窄（MS）合并心房颤动（Af）的患者在行经皮球囊二尖瓣成形术（PBMV）前给大剂量肝素短程抗凝，并对其中19例在术后即给予同步直流电复律，探讨短程抗凝后PBMV的可能性及PBMV术后即刻电复律的影响因素。其结果表明：本组26例二尖瓣口面积（MVA）由0．92±0．2cm2扩大至1．95±0．37cm2，左房平均压（LAP）由3．12±1．27kPa降至1．42±0．85kPa，而左房内径（LAD）由52．7±8．1mm缩至42．5±5．9mm，26例均无血栓栓塞并发症及出血并发症；其中19例术后即刻行同步电复律者15例复律成功，成功率为78．9％。认为：MS合并Af患者PBMV术前大剂量肝素短程抗凝可缩短术前准备时间并达到预防血栓栓塞之目的，同时在Af病程较短、无巨大左房、球囊充盈程度良好、LAP下降显著、较好地控制心室率等因素基础上，可在PBMV术后即刻给予同步直流电复律。     

经皮球囊二尖瓣扩张术的并发症及其处理

采用Inoue球囊法进行经皮球囊二尖瓣成形术治疗风湿性二尖瓣狭窄病人共300例，术后左房平均压由3．26±1．14kPa（1kPa＝7．5mmHg）降至1．33±0．89kPa，跨瓣压差由2．41±0．93kPa降至0．44±0．39kPa，二尖瓣口面积由1．03±0．23cm2增至2．09±0．38cm2；无一例死亡，53例出现不同的并发症，包括急性心包填塞5例（1．7％），二尖瓣反流（≥2级）9例（3％），肢体动脉栓塞1例（0．3％），房间隔水平分流14例（4．7％），并发症中仅6例因病情严重而需外科手术处理。本文对各种并发症的发生，预防和应急处理措施进行了讨论。     

再次经皮球囊二尖瓣成形术治疗成形术后再狭窄的疗效观察

目的　评价再次经皮球囊二尖瓣成形术 (PBMV)治疗二尖瓣狭窄PBMV术后再狭窄的临床疗效。方法　采用Inoue法对 2 9例PBMV术后再狭窄患者进行再次PBMV ,并与 2 5 8例首次接受PBMV的患者进行疗效比较。结果　再次PBMV后二尖瓣口面积由 ( 0 98± 0 13)cm2 增至 ( 1 6 5±0 2 4)cm2 (P <0 0 0 1) ,二尖瓣跨瓣压差由 ( 2 6 5± 1 44 )kPa( 1kPa =7 5mmHg)降至 ( 0 79± 0 2 3)kPa(P<0 0 0 1) ,左房平均压由 ( 3 37± 0 6 2 )kPa降至 ( 1 6 6± 0 93)kPa(P <0 0 0 1) ,左房内径由 ( 4 5 2± 0 5 7)cm降至 ( 4 17± 0 5 0 )cm(P <0 0 5 )。再次PBMV组二尖瓣口面积增加值与左房平均压下降值小于首次PBMV组 [分别为 ( 0 6 7± 0 11)cm2 vs( 0 88± 0 32 )cm2 (P <0 0 5 )与 ( 1 71± 0 88)kPavs( 1 94± 0 5 6 )kPa(P <0 0 5 ) ]。再次PBMV组无心包填塞、死亡发生 ,主要并发症为重度二尖瓣反流 2例。结论只要选择合适病例 ,再次PBMV术仍可取得显著的即刻血流动力学改善 ,是PBMV术后再狭窄患者的一种安全而有效的治疗方法。     

经皮二尖瓣球囊成形术治疗二尖瓣狭窄伴瓣膜明显畸形的临床疗效观察

分析经皮二尖瓣球囊扩张术（PBMV）治疗二尖瓣狭窄伴严重瓣膜畸形（超声评分≥10分）的临床疗效和安全性。本组共32例，男12例，女20例，平均48岁。手术成功率100％。术后二尖瓣口面积（MVA）从0．91±0．12cm2增加到1．48±0．21cm2（P＜0．05），平均左房压力从23．1±5．2mmHg降到16．8±4．9mmHg，平均肺动脉压从48．9±12．8降到了31．2±14．0mmHg（P＜0．05）。本组手术前后二尖瓣反流程度无明显增加，出院时仅2例发生了明显的二尖瓣反流，无心包填塞、栓塞和死亡，即手术并发症为6．3％。有84％的患者术后心功能改善，心功能恶化者占6．3％。结论：PBMV治疗二尖瓣狭窄伴严重瓣膜畸形的手术成功率高，并发症少，虽对血流动力学的改善不完全，但能改善绝大多数患者的临床症状。     

根据身高、体重和二尖瓣环内径选择球囊直径行经皮球囊二尖瓣成形术的疗效

本研究报告根据身高、体重和二尖瓣环内径 (MAD)选择球囊直径进行经皮球囊二尖瓣成形术 (PBMV) 80例的疗效 ,并与根据身高选择球囊直径行PBMV进行了对比研究。1.资料与方法 :选择 1998年 4月～ 2 0 0 3年 9月适宜行PBMV、且无心房纤颤的风湿性二尖瓣狭窄患者 16 0例 (男6 8例 ,女 92例 ) ,平均年龄 (4 3 2± 14 4 )岁。二尖瓣狭窄病史 4个月～ 2 2年 ,平均 6 1年。心功能Ⅳ级 2 2例 ,Ⅲ级 10 2例 ,Ⅱ级 36例 ;均排除风湿活动、电解质紊乱及感染等因素 ,均经心脏超声除外附壁血栓。随机分为二组 ,综合组 80例 ,根据身高、体重和MAD…     

老年二尖瓣狭窄患者经皮气囊二尖瓣成形术

目的　观察老年风湿性心脏病二尖瓣狭窄患者经皮气囊二尖瓣成形术 (PBMV)的效果。方法　 34名患者 ,其中男 1 4例 ,女 2 0例 ,年龄 55～ 71 (61 5± 9 4)岁。采用Inoue管或国产导管进行PBMV并观察手术前后心功能 ,血流动力学和瓣膜超声形态变化及并发症。结果　二尖瓣面积由 (0 92± 0 2 3)cm2 增至 (1 97± 0 52 )cm2 (P <0 0 1 ) ;二尖瓣跨瓣压由 (2 54± 1 1 3)kPa下降至 (0 63± 0 52 )kPa(P <0 0 1 ) ;左心房压从 (3 0 2± 1 34)kPa降至 (1 67± 1 0 2 )kPa(P <0 0 1 ) ;术后新出现二尖瓣返流 7例 ,返流加重 6例 ,但不影响疗效。 3例术中发生脑栓塞。 1 5例在 0 5～ 3年内复诊的患者中有 3例因二尖瓣再狭窄伴心功能恶化而住院。结论　PBMV对老年二尖瓣狭窄亦能取得较好的效果 ,但病例选择、手术操作有其特殊性     

经皮球囊导管二尖瓣扩张术治疗风心病二尖瓣狭窄102例

对102例风湿性心脏辩膜病二尖瓣狭窄患者进行了经皮球囊导管二尖辩成形术。结果成功101例，二尖辩口面积由0．79±0．34cm2增至1．88±0．32cm2，跨瓣压差由259±077kPa降至0．83±0．42kPa，左房平均压由3．84±1．15kPa降至1．86±0．59kPa。1例发生脑梗塞，其他患者未出现严重合并症。本文对该术疗效、技术操作及严重合并症的预防进行了探讨。     

二尖瓣狭窄伴房颤球囊扩张术术前抗凝及术后复律探讨

对 2 6例二尖瓣狭窄 (MS)合并心房颤动 (Af)患者 ,在行经皮球囊二尖瓣扩张术 (PBMV)前给大剂量肝素短程抗凝 ,并对其中 1 9例在术后即给予同步直流电复律。结果　二尖瓣口面积 (MVA)由 0 92± 0 2cm2 扩大至 1 95± 0 3 7cm2 ,左房平均压 (LAP)由 3 1 2± 1 2 7kPa降至 1 4 2± 0 85kPa,而左房内径 (LAD)由 52 7± 8 1mm缩小至 4 2 5± 5 9mm。 2 6例均无血栓栓塞并发症及出血并发症 ;1 9例术后即刻行同步电复律者 1 5例 ( 78 9% )复律成功。     

Mitral Regurgitation After Percutaneous Mitral Valvotomy

Mitral regurgitation (MR) after percutaneous mitral balloon valvotomy (PMV) is commonly an end point and may be a significant complication. Some increase in MR occurs in more than half of patients undergoing PMV. An increase > 2 grades occurs in 3%–1.5% of patients, and < 5% have severe MR as a complication. MR is a significant predictor for late cardiac events and preexisting MR before PMV is also associated with poor late outcome. Mild increases in MR are due to stretching of the annulus, excess commissural tearing, or papillary muscle trauma. Mild MR frequently disappears at follow-up and rarely increases. Risk factors for development of MR have varied among multiple studies. Balloon oversizing and entrapment/tearing of chordae by the balloon(s) are mechanical factors. Most predictors are related to the pathologic anatomy of the mitral valve. Older age, a larger end-systolic volume index, and lower ejection fraction may be independent predictors of progression of MR. Subvalvular disease and valve thickening have also been identified as predictors. A recently described "scoring" system for predicting MR considers the distribution of anterior and posterior leaflet thickening, extent of commissural calcification/fibrosis, and degree of subvalvular disease. "Even" calcification/thickening produces a "lower" or "better" score than "uneven" distribution. Bicommissural calcification and thickening and shortening of chordae all predict bad outcome. Thus careful echocardio-graphic evaluation of mitral valve pathoanatomy pre-PMV can identify most predictors of the development of MR.     

Mitral Stenosis and Mitral Incompetence due to Libman-Sacks Endocarditis with Mitral Valve Replacement

Abstract: A patient is described with recurrent severe left heart failure induced by combined mitral stenosis and incompetence secondary to Libman-Sacks endocarditis. Marked improvement followed mitral valve replacement with a 29 mm St. Jude Medical Bi-Leaflet prosthesis. There was no evidence of rheumatic valve disease either macroscopically at operation or on histological examination of the excised valve .     

Peak Mitral Inflow Velocity Predicts Mitral Regurgitation Severity

Objectives. Mitral regurgitation (MR) is a common echocardiographic finding; however, there is no simple accurate method for quantification. The aim of this study was to develop an easily measured screening variable for hemodynamically significant MR.Background. The added regurgitant volume in MR increases the left atrial to left ventricular gradient, which then increases the peak mitral inflow or the peak E wave velocity. Our hypothesis was that peak E wave velocity and the E/A ratio increase in proportion to MR severity.Methods. We performed a retrospective analysis of 102 consecutive patients with varying grades of MR seen in the Adult Echocardiography Laboratory at the University of California, San Francisco. Peak E wave velocity, peak A wave velocity, E/A ratio and E wave deceleration time were measured in all patients. The reference standard for MR was qualitative echocardiographic evaluation by an expert and quantitation of regurgitant fraction using two-dimensional and Doppler echocardiography.Results. Peak E wave velocity was seen to increase in proportion to MR severity, with a significant difference between the different groups (F = 37, p < 0.0001). Peak E wave velocity correlated with regurgitant fraction (r = 0.52, p < 0.001). Furthermore, an E wave velocity >1.2 m/s identified 24 of 27 patients with severe MR (sensitivity 86%, specificity 86%, positive predictive value 75%). An A wave dominant pattern excluded the presence of severe MR. The E/A ratio also increased in proportion to MR severity. Peak A wave velocity and E wave deceleration time showed no correlation with MR severity.Conclusions. Peak E wave velocity is easy to obtain and is therefore widely applicable in clinical practice as a screening tool for evaluating MR severity.     

Management of Mitral Regurgitation Due to Mitral Prolapse

Opinion statement Notable advances have been made in the treatment of mitral regurgitation, especially the advances resulting from prolapse of the mitral valve with or without a flail leaflet. Prosthetic mitral valve replacement results in a high incidence of postoperative left ventricular systolic dysfunction. Recognition of the importance of the subvalvular apparatus for preserving contractile function has fostered development of new repair techniques that preserve native valve tissue and reduce or eliminate postoperative systolic dysfunction and the need for anticoagulation. Vasoactive medications have a very limited role in the management of patients with primary mitral regurgitation. Better screening tools enable detection of early ventricular decompensation, and appropriate operative interventions continue to significantly reduce the morbidity and mortality associated with mitral regurgitation. Mortality associated with ischemic mitral regurgitation resulting from annular ring dilatation or structural damage associated with rupture of a papillary muscle continues to be high, and the simplest and most expeditious operative intervention is emphasized.     

Mitral Regurgitation

Mitral regurgitation (MR) is increasingly prevalent and poses an important public health problem. There are several mechanisms through which MR can occur. Primary (organic) MR is due to intrinsic valvular disease, whereas secondary (functional) MR is due to disruption of an otherwise normal mitral apparatus because of abnormal ventricular geometry. Identification of the causative mechanism is important as this will dictate management strategy and may influence subsequent outcome. Careful assessment of MR severity is important with the use of quantitative measures. There is currently no effective medical treatment for chronic MR. Careful follow-up is paramount in the management of MR to accomplish timely surgical intervention. Mitral valve repair is preferable to valve replacement. In chronic primary MR, conventional timing of surgery is based upon appearance of symptoms and hemodynamic consequences of chronic volume overload. Optimal timing of surgery for asymptomatic patients with chronic severe MR remains controversial although there is an increasing trend toward earlier surgery. In recent years there have been significant advances in percutaneous valve interventions for MR. Although initial results are promising, longer term evaluation will answer questions concerning efficacy, durability, and safety of these interventions.