二尖瓣置换术后远期三尖瓣关闭不全的临床分析

Clinical analysis of tricuspid incompetence late after mitral valve replacement

目的研究二尖瓣置换(mitral valve replacement,MVR)术后远期三尖瓣关闭不全(tricuspid incom-petence,TI)的发生机制及外科治疗对策,更好地掌握在二尖瓣置换术同期对三尖瓣进行手术治疗的指征,提高治疗效果。方法 33例(男12例,女21例)MVR术后中重度TI患者于2003年1月～2010年6月在该院接受单纯三尖瓣手术,同时行三尖瓣成形术(TVP)15例,因三尖瓣无明显病变未作处理者18例。距第1次手术3～11年,平均(4.5±2.2)年,有19例再次行三尖瓣置换(TVR)术,14例行TVP术。结果术后早期死亡3例,死亡率9.7%,随访28例,随访时间6～90个月,平均(33.6±21.2)个月,1例出现中度TI,2例心功能Ⅲ级,余患者症状明显改善。结论三尖瓣瓣环扩大是MVR术后远期TI发生的主要原因,应重视MVR同期对三尖瓣的预防性干预,右心功能尚能代偿前行第2次TVP或TVR,效果均满意。

【Objective】 To study the underlying mechanism and the strategy for surgical treatment of tricuspid incompetence late after mitral valve replacement,and to gain a better understanding of the surgical indication of concomitant tricuspid valve surgery in the first time mitral valve replacement.【Methods】 33 patients（male 12,female 21） who were diagnosed echocardiographically as severe tricuspid incompetence late after mitral valve replacement（MVR） were surgically treated 3 to 11（4.5±2.2） years after their first MVR from Junuary 2003 to June 2010,including 15 concomitant tricuspid valve annuloplasties while 18 patients whose tricuspid valves were left untreated.of the 33 patients,19 had tricuspid valve replacement（TVR） and 14 had tricuspid valve annuloplasty（TVP）.【Results】 There were 3 early postoperative deaths with a motality 9.7% due to low cardiac output syndrome and multiple organ dysfunction syndrome.Among the survivors,28 patients were followed up for 6 to 90（33.6±21.2） months,25 patients showed significant clinical improvement while 1 patient had recurrent moderate tricuspid regurgitation and the other 2 were in New York Heart Association（NYHA） class Ⅲ.【Conclusion】 Tricuspid annular dilatation is the leading etiology for the development of tricuspid valve incompetence late after MVR.A special attention must be paid to the concomitant prophylactic intervention to tricuspid valves in the first MVR.TVR and TVP can achieve good surgical outcome for tricuspid valve disease patients before right heart dysfunction.