三尖瓣置换术及抗凝治疗70例临床分析

Tricuspid valve replacement and anticoagulation therapy： a report of 70 cases

目的探讨三尖瓣置换术（TVR）的手术指征、瓣膜选择及术后抗凝治疗方法。方法1998年5月至2008年1月，共有70例患者接受TVR，其中风湿性心脏病患者59例。手术包括：二尖瓣置换术（MVR）＋TVR37例，MVR＋主动脉瓣置换术（AVR）＋TVR18例，TVR13例，TVR＋AVR2例。全部患者自术后2d开始采用华法林进行抗凝治疗。结果术后3例患者因低心排血量死亡，死亡率4．3％。1例发生Ⅲ度房室传导阻滞，1例发生急性肾功能衰竭，并发症率7．1％。随访59例，随访率88．1％，平均随访（3．6±5．2）年，共243．5人年。1例患者于术后3个月死亡；远期死亡率0．4％人年。5例患者出现一般性出血，出血率2．1％人年。1例发生脑梗死，1例因三尖瓣血栓形成再手术，栓塞率0．8％人年。门诊随访INR均值1．87±0．68。患者术后心功能（NYHA分级）Ⅰ～Ⅱ级52例，Ⅲ级7例。结论风湿性心脏病三尖瓣病变严重者应行TVR；双叶机械瓣膜应用于TvR效果满意；TVR术后抗凝治疗强度尚有待探讨。

Objective To evaluate the operative indication, the choice of valve prostheses, and the method of anticoagulation therapy of tricuspid valve replacement （TVR）. Methods From May 1998 to January 2008, 70 patients underwent TVR. There were 59 cases of rheumatic heart diseases. The operations included mitral and tricuspid valve replacement for 37 cases, triple valve replacement for 18 cases, isolated TVR for 13 cases, and tricuspid and aortic valve replacement for 2 cases. All the patients received oral anticoagulant therapy （warfarin） 2 d after the operations. Results There were 3 in-hospital deaths （4. 3% ） and 1 late death （0.4%）. The follow-up rate was 88. 1%, and the cumulative follow-up was 243.5 patient-years （pty）. The anticoagulation-related event rate was 2. 9% pty, and the mean INR value of 643 out-patient samples was 1.87 ±0. 68. Post-operative heart function NYHA classification： 52 cases in class Ⅰ to Ⅱ, and 7 cases in class Ⅲ. Conclusions TVR should be indicated for severely damaged and deformed tricuspid valve of rheumatic heart diseases. Bileaflet mechanical valve is a suitable prosthesis for TVR. The optimal anticoagulation therapy intensity of TVR needs to be investigated.