International Circulation: I am here today with Dr. Steven Bolling from Michigan. He is at the University of Michigan in the Cardiovascular Center there doing surgeries. He is offered to spend some time with us today and we welcome you.

　　《国际循环》：我们今天对Steven Bolling教授进行采访。Bolling教授来自密歇根大学心血管中心，主要开展外科手术。今天，我们有幸邀请到Bolling教授拨冗接受本次采访。

　　Dr. Bolling: Thank you for having us here.

　　Bolling教授：非常高兴与大家在此进行交流。

　　International Circulation: Comparing the guidelines that were released in 2008， what are the major updates to the latest AHA/ACC guidelines for patients when you are managing mitral valve and tricuspid valve disease?

　　《国际循环》：与2008年指南相比，最新AHA/ACC指南对二尖瓣及三尖瓣病变管理的更新主要有哪些？

　　Dr. Bolling: That is a good question. As you know， the 2008 guidelines were really a rewrite of guidelines 2 times ago. Those guidelines were almost 20 years old， so they have been very much updated. In the mitral and tricuspid world， it is very interesting how it has changed. First of all， most importantly， mitral valve indications have been divided between primary mitral regurgitation and secondary. Valvular related disease such as degenerative mitral regurgitation and rheumatic mitral regurgitation， and those related to the ventricle like ischemic mitral regurgitation， functional regurgitation. We were really confused for a long time， because mitral regurgitation appeared in both diseases， however， they are very different. Now， for the first time we have different indications， most importantly and primarily is we have become a little more aggressive about when to send the patient to surgery if you can guarantee a 95% repair rate， and I think that is very important， because as we know when we fix a degenerative mitral valve， it almost is as though we cure the patient completely of that disease. In secondary disease， functional mitral regurgitation really has been given its own spotlight for the first time ever. Of course， it is far more controversial about whether we should repair or replace or do surgery， and even there’s indications about percutaneous therapy， but probably the most important thing in secondary or functional mitral regurgitation is that the amount of mitral regurgitation， going backwards， is far less in terms of significance. If you think of primary， it really is 60cc of regurgitant volume going backwards or an orifice area of 0.4; whereas now in functional or secondary， it is cut in half， it is 30cc going backwards and an orifice area of 0.2. Really， that shows that the impact of even small amounts of mitral regurgitation in secondary patients is very high.

　　Secondly， tricuspid regurgitation which was sort of just a ‘by the way’ indication in the old guidelines now has its own indications and they are very aggressive， because the data is there. Tricuspid regurgitation is very undertreated. If you think about 3 quarters of the patients in the United States who have mitral surgery probably should have tricuspid surgery. 60，000 patients have mitral surgery， 45，000 should have tricuspid surgery， and last year it was about 5，000. So we undertreat tricuspid disease by a factor of 10. There are very aggressive guidelines in place even to the point of if the tricuspid annulus is just dilated to 4 centimeters with almost no tricuspid regurgitation， the data is there and the guidelines say support and put a ring on that tricuspid valve. I think these are very good updates since 2008.

　　Bolling教授：这是非常好的问题。2008年指南实际上是对过去20年的一些指南的重新编写，有很多更新内容。就二尖瓣及三尖瓣而言，疾病时其是如何变化的非常有趣。首先，最为重要的是，二尖瓣病变可分为原发性二尖瓣反流和继发性二尖瓣反流。瓣膜病涉及退行性二尖瓣反流、风湿性二尖瓣反流以及与心室相关的反流如缺血性二尖瓣反流及功能性反流等。实际上，我们困惑了很长时间，因为二尖瓣反流既有原发性的，也有继发性的，但二者非常不同。现在我们首次对其推荐了不同适应证，最重要和最基本的就是对何时应进行外科手术推荐更积极。我认为，只要能保证95%的修复率，外科手术就对患者至关重要，因为修复退行性二尖瓣几乎可达到治愈效果。而在继发性二尖瓣反流时，功能性反流首次备受关注。当然，迄今为止，有关二尖瓣反流应实施修复、置换还是手术治疗尚存争议，尽管目前其已是经皮治疗的适应证，但对继发性或功能性二尖瓣反流而言，可能少量的反流量即有显著临床意义，如原发性二尖瓣反流量≥60 ml或有效反流瓣口面积≥0.4 cm2，功能性或继发性二尖瓣反流量≥30 ml或有效反流瓣口面积≥0.2 cm2时。继发性二尖瓣反流即使少量反流也对患者有很大影响。

　　三尖瓣反流在旧版指南中仅略微提及其应用指征，而鉴于目前已有研究证据，新指南对其适应证推荐非常积极。三尖瓣反流存在治疗不足现象。在美国，行二尖瓣手术治疗的患者中有3/4应该接受三尖瓣手术治疗。目前，美国共有6万例患者接受二尖瓣手术，其中4.5万例应接受三尖瓣手术，但去年实际治疗者仅5千例。指南推荐，若三尖瓣瓣环仅扩大到4 cm而未出现三尖瓣反流，可在三尖瓣上放置一个环。我认为，这些是2008年以来非常好的更新。