三尖瓣替换术及早期结果

Tricuspid replacement and short-term follow-up: summary of 42 cases

目的探讨三尖瓣替换术(TVR)的手术适应证和人工瓣膜的选择。方法1997年3月至2004年6月,共施行TVR 42例,其中20例有心脏手术史。手术适应证:①自然瓣膜损毁无法修复(34例);②进行性三尖瓣病变(2例);③修复后残余的瓣膜功能不全仍严重影响心脏功能(6例)。合并下列情况时,积极选择TVR:肺血管阻力中、重度升高;手术后有残余的左心功能不全;有三尖瓣成形手术史。人工心脏瓣膜替换术包括:单纯TVR 30例,主动脉瓣和二尖瓣加TVR 8例,二尖瓣加TVR 3例,主动脉瓣加TVR 1例。三尖瓣位人工瓣使用双叶型机械瓣28枚,生物瓣14枚。其他合并的心脏手术包括:先天性心脏畸形修复10例,人工瓣周漏修补、黏液瘤切除、冠状动脉搭桥各1例。结果全组手术病死率17%(7/42),手术并发症发生率31%(13/42)。术后心功能(NYHA分级):Ⅰ级21例,Ⅱ级10例,Ⅲ、Ⅳ级各1例。术后晚期死亡2例。结论当三尖瓣的病变程度严重,修复把握不大,特别是伴有肺血管病变、左心功能不良、左心病变未能完全矫治时,应积极行TVR;人工瓣应选择双叶型和机械瓣或生物瓣,特别是后者。

Objective To summarize the experience in tricuspid valve replacement （TVR）. Methods From March 1997 to June 2004, 42 patients underwent isolated or combined TVR. Of the cases, 20 cases had prior cardiac operation （ tricuspid valve had been repaired in 8 ）. Indication of TVR ： （ 1 ） irreparable and/or progressive tricuspid lesions; （2） intolerable tricuspid dysfunction after tricuspid repair. Instead of tricuspid repair, TVR was preferred when one of the following co-existed： moderate to severe increase of pulmonary vascular resistance; residual left heart dysfunction; previously repaired tricuspid. Simultaneous replacement after unsuccessful tricuspid repair had to be done in 14 cases. Valve replacement combinations were isolated TVR in 30 cases, tricuspid and aortic and mitral in 8, tricuspid and mitral in 3, tricuspid and aortic in 1. Fourteen tissue and 28 bi-leaflet mechanical valve prostheses were used in the tricuspid position. Other simultaneous procedures included corrections of congenital anomalies in 10 patients, repair of peri-prosthetic leakage, resection of myxoma and coronary artery bypass grafting in 1 case each. Results The operative mortality was 17%, and mortality 31%. Four patients died of low cardiac output. Massive cerebral thromboembolism, renal failure and dyscrasia was the cause of death in 1 case each. Post-operative heart function NYHA classification： 21 cases in Ⅰ , 10 in Ⅱ , 1 in Ⅲ and 1 in Ⅳ. Late death occurred in 2 cases. Conclusions TVR is preferable for a severely damaged or deformed tricuspid valve if the possibility of successful repairing is small, especially when accompanied pulmonary vascular disease and uncorrected lesions and/or dysfunction of the left heart co-exists.