主动脉瓣、二尖瓣和三尖瓣多瓣膜心脏病的外科治疗

Surgical Treatment of Cardiac Mitral and Aortic Valvular Disease Combined with Tricuspid Lesion

目的探讨主动脉瓣、二尖瓣和三尖瓣联合心脏瓣膜病手术治疗和围手术期处理的经验。方法2002年1月至2007年6月,我科手术治疗85例主动脉瓣、二尖瓣和三尖瓣联合心脏瓣膜病患者,其中男性51例,女性34例;年龄16～69岁。术前心功能Ⅲ级56例,Ⅳ级29例。左心室射血分数(EF)≤40%13例,平均肺动脉压(MPAP)≥60mmHg15例,EF≤40%且MPAP≥60mmHg5例。二尖瓣和主动脉瓣置换加三尖瓣成形术52例,二尖瓣置换加主动脉瓣和三尖瓣成形术4例,主动脉瓣置换加二尖瓣和三尖瓣成行术2例,主动脉瓣、二尖瓣和三尖瓣置换术26例,主动脉瓣、二尖瓣和三尖瓣成形术1例。观察EF和MPAP对术后低心排血量综合征的影响。结果术后早期主要并发症为低心排血量综合征(LOS)、室性心律失常、呼吸衰竭和急性肾功能衰竭。EF≤40%患者并发LOS9例(9/13),高于EF>40%者(4/72),(P<0.01);MPAP≥60mmHg患者并发LOS8例(8/15),高于MPAP<60mmHg者(5/70)(P<0.01);EF≤40%且MPAP≥60mmHg患者全部并发LOS(5/5),高于非具备该条件者(8/80)(P<0.001)。无手术死亡病例,全组存活81例,早期死亡4例,死亡原因为急性肾功能衰竭。存活者随访3～69个月,手术效果良好。结论左心室射血分数和肺动脉压是影响术后低心排血量综合征的重要因素。提高主动脉瓣、二尖瓣和三尖瓣联合心脏瓣膜病外科治疗疗效的方法是注重围术期处理、合理纠正病变和加强术后并发症的防治。

Objective This is to summarize the experience of surgical treatment of cardiac mitral and aortic valvular disease combined with tricuspid lesion and the management during perioperative period. Methods 85 patients with cardiac mitral and aortic valvular disease associated with tricuspid lesion from January, 2002 to June, 2007 underwent vulvular operation. There were 51 male and 34 female, with an age range from 16 to 69 years. Preoperative heart function 56 cases in class Ⅲ and 29 cases in class IV. There were 13 cases with EF≤40%, 15 cases with MPAP^60 mmHg, and 5 cases with EF≤40% and MPAP≥60 mmHg. Mitral and aortic valve replacement associated with tricuspid annuloplasty was performed in 52 cases. Mitral valve replacement and aortic valve, tricuspid annuloplasty was performed in 4 cases. Aorticvalve replacement and mitral valve, tricuspid annuloplasty was performed in 2 cases. Aortic and mitral valve and tricuspid replacement was performed in 26 case. Aortic and mitral valve and tricuspid annuloplasty was performed in 1 case. And the effect of EF and MPAP on the postoperative low cardiac output was observed. Results Low cardiac output syndrome （LOS）, ventricular arrhythmia, respiratory failure and acute renal failure were the most frequent early complications. 9 （（9/13） LOS occurred within the cases with EF≤ 40%, significantly higher than the one with EF〉40% （4/72） （P〈0.01）. 8 （（8/15） LOS occurred within the cases with MPAP≥60 mmHg, significantly higher than the one with MPAP〈60 mmHg （5/70） （P〈0.01）. And LOS occurred in all 5 cases with EF≤40% and MPAP≥60 mmHg （5/5）, significantly higher than the one without these conditions （8/80） （P〈 0.001）. There was no operative death, with 81 survivors and 4 early death, the causes of mortality was acute renal failure. 81 survivors were followed up for 3 to 69 months with a good surgical treatment effect. Conclusion The left ventricular ejection fraction and pulmonary artery pressure were identified as the important predictive factors of postoperative LOS. Surgical treatment for cardiac mitral and aortic valvular disease combined with tricuspid lesion should include following measures： emphasizing the management during perioperative period, correcting pathological changes, strengthening the prevention and the treatment of postoperative complications.