內容目錄
Source: Shuangyashan Scientific Research Little Black House
Following the completion of the first mitraclip mitral valve clamp in Guangzhou by our heart valve intervention team of the First Affiliated Hospital of Sun Yat-sen University last year, I recently The hospital completed another 90-year-old patient with mitral valve mitraclip clamp.
This is the oldest patient who received this operation in South China. The elderly patient was discharged from the hospital three days after the operation and regained a new life. This is the implementation of transcatheter mitral valve edge-to-edge clamping in super-elderly patients in my country. Accumulated valuable clinical experience.
As one of the witnesses of this new technology, the editor will share with you today about the cause of recurrent heart failure in patients The real culprit behind: mitral regurgitation.
Mitral regurgitation (MR) is the most common valvular heart disease, with an incidence of 1.7% in the general population and increases with age, reaching 10% in people over 75 years of age. %. The structure of the mitral valve includes four parts: leaflets, annulus, chordae tendineae, and papillary muscles. Damage to any one or more of these structures can lead to mitral regurgitation.
The primary diagnostic tool for MR relies on echocardiography. Quantitative diagnostic criteria are divided into three grades: mild, moderate and severe. In mild mitral regurgitation, the jet area is less than 4 cm², the regurgitation flow per beat is less than 30 ml, and the regurgitation fraction is less than 30%.
The degree of moderate regurgitation was 4-8cm² in jet area, 30-59ml in regurgitation volume per stroke, and 30-49% in regurgitation fraction. The degree of severe regurgitation, the jet area is greater than 8cm², the reflux flow per beat is greater than 60ml, and the reflux fraction is greater than 50%.
Although echocardiography brings a great deal of information to doctors, cardiac CT examination is essential for patients who need surgical/interventional intervention. High-definition CT can accurately determine the geometry of the mitral valve. The condition of mitral valve calcification, etc., will help the doctor’s preoperative evaluation.
MR is divided into two categories, primary and functional, according to valve structure. Primary MR mainly includes valve leaflet prolapse, rheumatic heart disease, endocarditis, etc., and secondary MR mainly includes left ventricular structural changes caused by heart failure such as ischemic cardiomyopathy and atrial fibrillation.
MR and heart failure are closely related, and they are mutually causal. Left ventricular remodeling and dysfunction due to myocardial injury leads to structural changes in the mitral valve, which can lead to secondary mitral regurgitation.
Subsequent LV volume overload exacerbates LV dysfunction, resulting in increased LV wall stress and end-diastolic pressure. This vicious cycle triggers arrhythmias, stimulates neurohormonal activation, and promotes the progression of myocardial fibrosis. All of these conditions lead to a further decrease in left ventricular contractility.
In the early stages of primary MR, the hemodynamic changes caused by reflux are not clinically significant, and patients usually Asymptomatic, sinus rhythm, no pulmonary hypertension.
Subsequently, persistent left ventricular volume overload leads to reduced exercise tolerance and the development of exertional dyspnea. At this stage, atrial fibrillation and/or pulmonary hypertension may be present. In severe secondary MR, the onset of heart failure symptoms is closely related to the degree of left ventricular dysfunction.
The main treatments for primary MR are interventional surgery and surgical repair. According to the 2021 position statement on the management of heart failure complicated with functional mitral regurgitation, the treatment methods for secondary MR mainly include guideline-recommended standardized drug therapy for heart failure, cardiac resynchronization therapy, interventional surgery and surgical repair Valves, whose heart failure drugs are very critical, are the basis of all subsequent treatments.
Existing studies have confirmed that β-blockers, ACEI/ARB, aldosterone receptor antagonists and ARNI are effective in the treatment of secondary MR to varying degrees. Related research on mitral regurgitation is also ongoing.
In addition, the COAPT study and MITRA-FR study found that patients undergoing mitral valve replacement should be fully treated with anti-heart failure drugs before evaluating surgical indications.
MR-induced symptoms persist even after optimal medical therapy and myocardial revascularization. In most cases, whether in severe primary or secondary MR, the onset of symptoms can identify patients who have developed LV dysfunction, and the presence or absence of symptoms is generally used as the criterion for surgical or interventional intervention.
In clinical practice, it is very common for patients to worry about their condition after reading their echocardiography report and finding mild mitral regurgitation.
For those patients with asymptomatic mitral regurgitation, the principles of intervention according to existing guidelines are:
1. Left ventricular systolic dysfunction (LVEF 30–60% and/ or LVESD≥40 mm) (IB)
2. Left ventricular function preservation (LVEF>60% and LVESD<40 mm) with new-onset atrial fibrillation (closely related to prognosis) or pulmonary artery systolic blood pressure>50 mmHg (IIaB)
3. Left ventricular function preservation (LVEF>60% and LVESD<40 mm) combined with all the following conditions: ① Probability of successful repair> 95% ② Expected operative mortality < 1% ③ The valve surgery is performed in a well-known heart valve center (such as the Valve Center of the First Affiliated Hospital of Sun Yat-sen University) (IIaB)
This time, the mitraclip operation performed in our center is an interventional method for the treatment of MR without surgery. .
The small clip shown in the figure below is sent into the heart through the catheter system, and the lesion is clamped to reduce reflux.
There is only mild MR, and no other special symptoms do not need special treatment. Regular physical examination and echocardiography every year can be used to observe the cardiac structure.
It is worth noting that although existing guidelines recommend echocardiography as the gold standard for the diagnosis of MR, most MR severity is determined by echocardiography. But for asymptomatic patients, comprehensive evaluation is especially important.
The evaluation of echocardiography needs to be determined by experienced sonographers through pulmonary systolic blood pressure, left atrium, left ventricular structure, systolic function, etc. When echocardiography cannot determine left ventricular volume and ejection fraction , cardiac MR examination can help to quantify the severity of MR.
Like other chronic diseases, patients may adapt to the physiological changes caused by chronic MR and fail to inform doctors of their symptoms in time. Cardiopulmonary exercise tolerance can objectively assess the exercise capacity of patients, and serum BNP levels can also help identify patients with mild symptoms, helping doctors to identify and intervene in symptomatic MR patients early. The above contents may be included in the guidelines in the future.
To sum up, there are currently clear diagnostic and therapeutic measures for symptomatic MR reflux patients. The timing of intervention remains challenging for asymptomatic MR patients. Whether the intervention is timely or not depends on the patient’s good compliance. Patients need to go to a local heart valve center with strong comprehensive strength for regular follow-up echocardiography, and the doctor of the valve center will formulate follow-up plans and treatment measures.
A study found that the timing of intervention is too late in the treatment process for nearly normal valvular heart disease, and many patients fail to recognize mild symptoms at an early stage. There is still a long way to go for the treatment of heart valves, which requires the joint efforts of both doctors and patients.
References
1. 2021 ESC/EACTS Guidelines for the management of valvular heart disease.
2. Nkomo VT, Gardin JM, Skelton TN, Gottdiener JS, Scott CG, Enriquez-Sarano M. Burden of valvular heart diseases: a population-based study. Lancet. 2006 Sep 16;368(9540 ): 1005-11. doi: 10.1016/S0140-6736(06)69208-8. PMID: 16980116.
3. Del Forno B, De Bonis M, Agricola E, Melillo F , Schiavi D, Castiglioni A, Montorfano M, Alfieri O. Mitral valve regurgitation: a disease with a wide spectrum of therapeutic options. Nat Rev Cardiol. 2020 Dec;17(12):807-827. doi: 10.1038/s41569-020 -0395-7. Epub 2020 Jun 29. PMID: 32601465.
4. Baumgartner H, Iung B, Otto CM. Timing of intervention in asymptomatic patients with valvular heart disease. Eur Heart J. 2020 Dec 1 ;41(45):4349-4356. doi: 10.1093/ eurheartj/ehaa485. PMID: 32901279.
5. Alperi A, Granada JF, Bernier M, Dagenais F, Rodés-Cabau J. Current Status and Future Prospects of Transcatheter Mitral Valve Replacement: JACC State-of- the-Art Review. J Am Coll Cardiol. 2021 Jun 22;77(24):3058-3078. doi: 10.1016/j.jacc.2021.04.051. PMID: 34140110.
6. Coats AJS , Anker SD, Baumbach A, et al. The management of secondary mitral regurgitation in patients with heart failure: a joint position statement from the Heart Failure Association (HFA), European Association of Cardiovascular Imaging (EACVI), European Heart Rhythm Association (EHRA ), and European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC. Eur Heart J. 2021;42(13):1254–69.
7. Stone GW, Lindenfeld J, Abraham WT, et al. al. Transcatheter Mitral-Valve Repair in Patients with Heart Failure. N Engl J Med. 2018;379(24):2307-2318.
8. Obadia JF, Messika-Zeitoun D, Leurent G, et al. al. Percutaneous Repair or Medical Treatment for Secondary Mitral Regurgitation. N Engl J Med. 2018;379(24):2297-2306.
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