三尖瓣置换术围术期及中长期临床效果分析

The Early and Middle-long-term Clinical Results of Tricuspid Valve Replacement

目的评价三尖瓣置换术围术期及中长期疗效,并比较在三尖瓣位置生物瓣和机械瓣置换的相对优缺点和适应证,以提高该类手术的疗效。方法回顾性分析1992年4月至2008年2月收治的128例行三尖瓣置换术患者的围术期疗效及中长期随访结果,并按首次三尖瓣置换所采用的瓣膜种类不同分为机械瓣组(89例)和生物瓣组(39例)。采用Kaplan-Meier曲线计算该类患者的中长期生存率和中长期人工瓣膜相关事件(包括血栓栓塞和人工瓣膜血栓形成、抗凝相关性出血、人工瓣膜毁损事件)的发生率。用Binary logistic回归对三尖瓣置换患者早期、晚期死亡的危险因素进行多因素分析。结果围术期死亡19例(14.84%)。随访103例(94.5%),6例失访,随访时间4.93±2.92年,随访期间死亡11例(10.7%)。生物瓣组10年生存率为65.6%±17.4%,机械瓣组为68.7%±10.8%(Log-rank检验,χ2=0.74,P=0.390)。生物瓣组5年无血栓栓塞事件率为92.3%±7.4%,机械瓣组为87.1%±4.6%(Log-rank检验,χ2=0.962,P=0.327)。生物瓣组和机械瓣组10年无出血事件发生率分别为100%和79.7%±9.7%(Log-rank检验,χ2=1.483,P=0.223)。9例患者行再次三尖瓣置换术,生物瓣组7年无再次手术率为71.1%±18.0%,机械瓣组10年无再次手术率为78.8%±10.2%(Log-rank检验,χ2=2.76,P=0.096)。Binary logistic多因素分析结果显示:三尖瓣置换术前有心脏手术史、腹水是早期死亡的危险因素,而术前有腹水、术前心功能分级(NYHA)Ⅲ/Ⅳ级、置换多个瓣膜为晚期死亡的危险因素。结论对重度三尖瓣反流,应该较早或较积极地施行三尖瓣手术,以防止右心功能进行性衰竭,而影响三尖瓣置换术的近期及中长期生存率和生活质量。在三尖瓣置换术中,机械瓣和生物瓣有相似的中长期效果。

Objective To evaluate the early and middle-long-term clinical results of tricuspid valve replacement （TVR） and compare the relative merit between bioprothesis and mechanical valve in tricuspid position, so as to elevate the operative effect. Methods The data of 128 TVR from April 1992 to February 2008 in An Zhen Hospital were retrospectively reviewed, and classified into mechanical prosthesis group （n=89）and bioprothesis group （n=39） according to the prosthesis used in the first procedure. Kaplan-Meier curve were estimated to evaluate the mid-long term survival rate and events incidence related to prosthesis （including thrombosis, embolism and bleeding related to prosthesis and the prosthesis deterioration）. Multivariate binary logistic regressions were used to evaluate the independent risk factor for early and late death. Results There were 19 early deaths（14.84%）. With the follow-up of 4. 93!2. 92 years, there were 11 late deaths（10. 7%）. According to the Kaplan-Meier curve, the 10-year actuarial survival rate for the bioprothesis group and mechanical prosthesis group were 65.6%±17.4% and 68.7%±10.8% respectively（Log-rank test, X^2=0.74,P=0.390）. Freedom from prosthesis-related embolism at 5 years for the bioprothesis group and mechanical prosthesis group were 92.3%±7.4% and 87.1±4.6% respectively（Log- rank test, X^2=0. 962,P=0.327）. Freedom from anticoagulation-related bleeding at 10 years for the bioprothesis group and mechanical prosthesis group were 100% and 79.7%~9.7% respectively（Log-rank test, X^2= 1.483,P= 0.223）. There were 9 TVR reoperation, freedom from reoperation at 7 years for the bioprothesis group was 71.1%±18.0%, and freedom from reoperation at 10 years for the mechanical prosthesis group was 78.8%±10.2% （Log-rank test, X^2=2.76,P=0. 096）. Binary logistic regression revealed that the redo procedure and ascites were independent risk factors for early death, whereas ascites, heart function of New York Heart Association class Ⅲ/Ⅳ and multi valve replacement were independent risk factors for late death. Conclusion To lower the operative mortality and late mortality and morbidity, TVR should be adopted prior to the deterioration of right heart function, and bioprothesis valve has similar early and middle-long term clinical effect with mechanical valve in tricuspid position.