左心系统瓣膜置换术后三尖瓣关闭不全的外科治疗

Surgical treatment of tricuspid regurgitation after left cardiac valve replacement

目的总结左心系统瓣膜置换术后三尖瓣关闭不全的外科治疗经验。方法回顾分析2007年1月-2010年11月在我院手术治疗的20例左心系统瓣膜置换术后三尖瓣关闭不全的患者资料。其中二尖瓣置换术后8例,二尖瓣、主动脉瓣置换术后12例。手术均在浅低温跳动下完成,以三尖瓣生物瓣膜置换。结果全组1例死亡(死于严重低心排引起的多脏器功能衰竭),手术死亡率5%;6例有不同程度的低心排血量综合征;2例术后胸腔积液;2例术后出现肾功能不全,行腹膜透析治疗后恢复;1例术后出现心包积液;1例术后频发室速、室颤,经56次体外自动除颤仪除颤及抗心律失常药物治疗后恢复。除死亡病例外,全组病人顺利康复,复查心脏超声提示右房右室明显缩小。结论左心系统瓣膜置换术后远期三尖瓣关闭不全经外科矫治后疗效满意,浅低温心脏不停跳方法可起到满意的心肌保护效果;生物瓣可能是较好的选择。合理掌握手术指征和良好的围术期治疗是手术成功关键。

Objective To summarize our experiences in surgical treatment of tricuspid regurgitation after left valve replacement.Methods Clinical data about 20 patients who developed tricuspid insufficiency after they underwent left valve replacement in our hospital from January 2007 to November 2010 were retrospectively analyzed.Of the 20 patients,8 underwent mitral valve replacement and 12 aortic and mitral double-valve replacement.The surgery was completed on beating heart under hypothermia by implanting biological tricuspid valve.Results Of the 20 patients after operation,1 died of multiple organ failure caused by low cardial output syndrome（LCOS）with a mortality of 5%,6 presented with LCOS,2 had pleural effusion,2 had renal inadequacy which was recovered after peritoneal dialysis,1 had pericardial effusion,1 presented with frequent ventricular tachycardia and ventricular Fibrillation which were recovered after defibrillation and anti-arrhythmia treatment.All the patients were recovered,except for 1 patient who died.Echocardiography revealed that the size of their right atrium and ventricle was much smaller after operation than before operation.Conclusion The effect of surgical treatment on tricuspid regurgitation after left valve replacement is satisfactory.Mild hypothermia for beating heart can effectively protect myocardium.Biological valve is a better choice.Rational indications for surgery and perioperative treatment are the key to successful surgery.