30对左心瓣膜置换术后三尖瓣重度关闭不全11例外科治疗

Surgical treatment of severe tricuspid regurgitation after left cardiac valve replacement in 11 casces

目的探讨左心瓣膜置换术后三尖瓣重度关闭不全的机理及外科治疗选择及效果.方法1998年1月～2004年10月,对11例左心瓣膜置换术后三尖瓣重度关闭不全的病人行外科治疗,曾行二尖瓣置换术4例;主动脉瓣置换术1例;主动脉及二尖瓣置换术6例.其中7例病人第1次手术时曾行三尖瓣成形术.术后1～20年发生重度三尖瓣关闭不全,肝大、腹水、右心衰竭,心功能Ⅳ级.11例病人均再次手术,8例行三尖瓣成形术,3例行三尖瓣置换术.结果手术死亡1例,成活10例.术后随访1～4年,2例三尖瓣置换病人恢复良好;5例三尖瓣成形术心功能恢复良好,只有极轻度或轻度三尖瓣关闭不全;2例出现中度三尖瓣关闭不全,1例出现重度三尖瓣关闭不全.结论左心瓣膜置换术后包括部分同期行三尖瓣成形术病人,远期发生三尖瓣关闭不全,可能与以下原因有关:(1)风湿性病变持续发展;(2)左心瓣膜病变未纠正;(3)原三尖瓣成形术失败;(4)持续性肺动脉高压;(5)心房纤颤等因素.对重度三尖瓣关闭不全,发生右心功能衰竭者,应再次外科手术治疗.首选三尖瓣成形术,只有瓣膜严重破坏,成形术无法恢复瓣膜功能时,才考虑作三尖瓣置换术.

Objective To explore the possible pathogenesis,the election and the effect of surgical treatment of severe tricuspid regurgitation(TR) after left cardiac valve replacement(LCVR).Methods Between January 1998 and October 2004,11 patients with severe TR after LCVR accepted reoperation.Four patients underwent mitral valve replacement(MVR),One patient underwent aortic valve replacement(AVR) and six patients underwent mitral and aortic valve replacement(DVR) during initial operation.The surgical treatment of tricuspid valve included tricuspid valve plasty(TVP) in 8 and tricuspid valve replacement(TVR) in 3 at the second operation.Results There was one postoperative death.The ten survivors were followed up for 1-4 years.The heart function improved significantly in 2 after TVR and 5 after TVP.However,echocardiography showed moderate TR in 2 and severe TR in 1 after TVP and medical treatment was needs.Conclusion The development of rheumatic lesion,the reoccur of left cardiac valve lesion,the failure of TVP,sustained pulmonary hypertension and atrial fibrillation may be responsible for the severe TR after left cardiac valve replacement.TYP are firstly elected in these patients.TVR would be performed only when severe tricuspid valve lesion and TVP is unpassible.