Mechanism of Recurrent/Persistent Ischemic/Functional Mitral Regurgitation Following Surgical Annuloplasty : Importance of Augmented Posterior Leaflet Tethering

外科瓣环成形术可能使后瓣环向前抬高，加重后叶(PML)拴系，导致再发的缺血性/功能性二尖瓣返流(MR)。采用超声心动图测量30例缺血性心脏瓣膜成形术患者和20例正常对照患者术前、术后早期和术后晚期心脏前叶(AML)和PML与环连线的夹角、吻合口的后移和尖端移位，以及MR分级。术后早期MR和AML的拴系分级普遍下降(P&lt；0.01)，而PML的拴系显著恶化(P&lt；0.01)。30例患者中有9例术后晚期出现复发/持续性MR表现。与没有晚期MR的患者相比，与早期相比，有MR的患者表现出类似的环状面积减少，接合后移位显著增加，以及术后晚期PML栓系的进行性恶化(p&lt；0.05)。而根尖移位是术前MR的主要决定因素(r^2=0.6，p&lt；0.0001)，PM增加，拴系是晚期MR的主要决定因素(r^2=0.75，p&lt；0.0001)。两叶系留，但主要来自增强和进行性PML系留，与外科瓣环成形术后晚期复发/持续性缺血/功能性MR有关。

Surgical annuloplasty can potentially hoist the posterior annulus anteriorly, exaggerate posterior leaflet (PML) tethering, and lead to recurrent ischemic/functional mitral regurgitation (MR). In 30 patients with surgical annuloplasty for ischemic MR and 20 controls, the anterior leaflet (AML) and PML tethering angles relative to the line connecting annuli, posterior and apical displacement of the coaptation, and the MR grade were measured by echocardiography before, early after, and late after surgery. Early after surgery, grade of MR and AML tethering generally decreased (p<0.01), while PML tethering significantly worsened (p<0.01). Nine of the 30 patients showed recurrent/persistent MR late after surgery. Compared to patients without late MR, those with the MR showed similar reduction in the annular area, significant re-increase in posterior displacement of the coaptation, and progressive worsening in PML tethering (p<0.05) late after surgery in comparison to the early phase. While apical displacement of the coaptation was the primary determinant of pre-operative MR (r^2=0.60, p<0.0001), increased PM., tethering was the primary determinant of late MR (r^2=0.75, p<0.0001). Both leaflets tethering but with predominant contribution from augmented and progressive PML tethering is related to recurrent/persistent ischemic/functional MR late after surgical annuloplasty.