目的:探讨四维经食管超声心动图(4D-TEE)技术在二尖瓣成形术(MVP)中的应用价值。方法:回顾性分析2019年2—7月安徽医科大学第一附属医院行MVP的25例二尖瓣反流患者的临床资料，其中男15例、女10例，年龄(55.56±14.40)岁。患者MVP术前均行4D-TEE检查，精准评估二尖瓣反流的病因及病变分型、病变位置和反流程度，测量左-右纤维三角间距离、收缩期瓣环前外侧至后内侧直径(DAlPm)、瓣环前后径(DAP)、瓣叶各个分区(将二尖瓣前叶和后叶的外、中、内部分别命名为A1～A3和P1～P3)的高度等参数，依据检测结果制定手术方案。术中探查对术前超声检测结果进行验证，并选择合适的成形环尺寸，完成MVP操作后，利用亚甲蓝染色直视下测量瓣叶对合高度。心脏复跳后再次行TEE检查，测量瓣叶对合高度，即刻评估手术效果。21例MVP患者术后3个月行经胸超声心动图(TTE)检查，再次评估二尖瓣反流程度。(1)观察术前通过4D-TEE诊断的二尖瓣反流的病因和病变分型、病变位置、反流程度，以及与术中探查结果的一致性；(2)比较术前4D-TEE所得的二尖瓣各参数与手术最终使用的成形环尺寸的相关性；(3)比较心脏复跳后利用TEE测得的对合高度与术中术者在直视下利用亚甲蓝染色测量的对合高度的相关性等；(4)分析术后3个月反流程度的影响因素。结果:术前4D-TEE的检查结果与术中探查的结果对比，25例患者病因和病变分型诊断的准确率为96.0%(24/25)。对病变部位发生在瓣叶的单一区域或某两个区域诊断的准确率为14/14，对交界区病变及多个区域联合病变诊断的准确率分别为2/3、4/5。术前4D-TEE评估二尖瓣反流程度2级6例、3级2例、4级17例，与术中探查结果一致。通过术前4D-TEE测得的各指标对术中成形环尺寸的逐步多元线性回归分析显示，DAP(n X1)、左右纤维三角距离(n X2)两个参数进入回归模型，建立多元线性方程：成形环尺寸n ?＝10.506＋0.230n X1＋0.395n X2，模型有统计学意义(n P<0.01)，n R2为0.613，提示模型拟合的效果良好。DAP的标准化偏回归系数为0.486，左-右纤维三角间距离的标准化偏回归系数0.450，提示二者对成形环尺寸的预测均有较大意义。以心脏复跳循环稳定即刻TEE测量的A1-P1、A2-P2、A3-P3的对合高度及三个对合缘的平均对合高度与术中亚甲蓝染色直视下测量的对合高度进行Pearson相关性分析，四组相关系数分别为0.838、0.916、0.951、0.953，均呈正相关(n P值均<0.01)。分析术后3个月反流程度的影响因素，进行逐步logistic回归分析结果显示，平均对合高度≤7 mm为术后反流的危险因素，比值比为30.0(n P<0.05)，提示平均对合高度≤7 mm的患者术后更容易出现反流再次加重。n 结论:4D-TEE不仅可以在MVP术前精准地判定二尖瓣反流的病因和病变分型、病变位置及反流程度，并根据测量的定量参数预测术中实际使用的成形环尺寸，协助外科医生手术方案的决策，而且可以在术中实时评估手术疗效，提高手术的成功率；另外，它提供的参数对术后早期的成形效果也起到了一定的预测价值，具有相当重要的临床应用前景。“,”Objective:To explore the application value of four-dimensional transesophageal echocardiography (4D-TEE) in mitral valvuloplasty (MVP).Methods:Retrospective analysis was performed on the clinical data of 25 patients, including 15 males and 10 females [(55.56±14.40) years old], who were admitted to the First Affiliated Hospital of Anhui Medical University due to mitral regurgitation from February 2019 to July 2019 and planned to undergo MVP. All patients underwent 4D-TEE examination before MVP. The cause of mitral regurgitation, lesion type, lesion location, and degree of regurgitation was accurately evaluated, and the intertrigonal distance, anterolateral to posteromedial diameter(DAlPm) and anterior to posterior diameter(DAP) of systolic mitral annulus, and the length of the outer, middle and inner lobes of the anterior and posterior lobes of the mitral valve which were named as A1-A3 and P1-P3 respectively, etc. were measured. Then, on the basis of the test results, a surgical plan was worked out. Intraoperative exploration verified the preoperative ultrasonic detection results, and the appropriate forming ring size was selected. After the MVP operation, we directly measured the coaptation height of the mitral valve leaflet with methylene blue staining. TEE was performed again after cardiac resuscitation. The coaptation height of the mitral valve leaflet was measured, and the surgical effect was evaluated immediately. A total of 21 patients with MVP underwent TTE 3 months postoperatively to reassess mitral regurgitation. (1) The causes of mitral regurgitation, lesion type, lesion location, and degree of regurgitation diagnosed by 4D-TEE before surgery were observed, and the consistency with the intraoperative exploration results was determined; (2) the correlation between parameters of the mitral valve obtained by 4D-TEE before surgery and the final size of the forming ring used during surgery was compared; (3) the correlation between the coaptation height measured by TEE after cardiac resuscitation and that measured by methylene blue staining were compared under direct vision by the operator; (4) the influencing factors of the degree of mitral regurgitation 3 months postoperatively were analyzed.Results:The accuracy of etiology and lesion type in 25 patients was 96.0% (24/25) compared with the results of preoperative 4D-TEE and intraoperative exploration. The accuracy of lesion diagnosis occurring in a single or two regions of the mitral valve was 14/14, and the accuracy of the diagnosis of mitral commissure region and multiple regions with combined lesions were 2/3 and 4/5, respectively. The findings of preoperative 4D-TEE evaluation of mitral regurgitation degree in 6, 2, and 17 cases with grades 2, 3, and 4, respectively were consistent with the results of intraoperative exploration. In the stepwise multiple linear regression analysis of the intraoperative ring size with each index measured by preoperative 4D-TEE, the DAP (n X1) and intertrigonal distance (n X2) were entered into the regression model. The multivariate linear equation of the forming ring size, that is, ^,n Y)=10.506+ 0.230n X1+ 0.395n X2 was established, and the model was determined as statistically significant (n P<0.01). Then R2 value of the determination coefficient was 0.613, indicating a good model fitting effect. The standardized partial regression coefficient of DAP was 0.486, and the standardized partial regression coefficient of the intertrigonal distance was 0.450, suggesting that both were significant for the prediction of the forming ring size. Pearson correlation analysis was conducted between the coaptation height of A1-P1, A2-P2, and A3-P3, and the average coaptation height of the three coaptation edges and the coaptation height were measured under the direct view of methylene blue staining during the operation. The correlation coefficients of the four groups were 0.838, 0.916, 0.951, and 0.953 and were positively correlated (all n P values<0.01). The factors influencing the degree of mitral regurgitation at 3 months after surgery were analyzed. Stepwise logistic regression analysis showed that the average coaptation height ≤7 mm was a risk factor of postoperative mitral regurgitation, with an odds ratio value of 30.0 (n P<0.05), suggesting that the patients whose average coaptation height was ≤7 mm were more likely to have recurrent regurgitation.n Conclusions:4D-TEE cannot only accurately determine the cause of mitral regurgitation, lesion type, lesion location, and degree of regurgitation before MVP but also predict the actual size of the forming ring used in the operation in accordance with the measured quantitative parameters to assist surgeons in deciding the operation plan. Moreover, the efficacy of the operation can be evaluated in real time, thus improving its success rate. In addition, the parameters provided by 4D-TEE have a certain predictive value for the early postoperative forming effect. Thus, 4D-TEE has an important clinical application prospect.