人工瓣环成形术与其联合“缘对缘”瓣膜成形术治疗重度三尖瓣关闭不全

Association of edge-to-edge valve repair to artificial ring annuloplasty for severe tricuspid insufficiency

目的总结人工瓣环成形术与人工瓣环联合“缘对缘”瓣膜成形术的治疗重度三尖瓣反流（TR）的治疗效果。方法2001年4月至2010年5月间因重度TR行三尖瓣成形术41例，其中单纯人工瓣环成形（R组）21例，人工瓣环联合“缘对缘”瓣膜成形（E组）20例。所有病人均经术前、术后早期（出院时）及术后中长期经胸超声心动图检查，观察三尖瓣瓣叶对合情况，以三尖瓣反流束面积（TRA）／右房面积（RAA）定量测定反流程度，三尖瓣口面积、肺动脉压及心功能测定。结果出院时R组7例无或微量TR，12例轻度TR，2例中度TR，轻、中度者均有前、隔叶对合不良；E组13例无或微量TR，7例轻度TR。随访6—100个月，平均（54．8±26．7）个月，R组5例无或微量TR，11例轻度TR，4例中度TR、1例重度TR，轻至重度者均有前、隔叶对合不良，1例重度者再次实施“缘对缘”瓣膜成形术；E组无三尖瓣狭窄，10例无或微量TR，9例轻度TR，1例中度TR。人工瓣环成形联合“缘对缘”瓣膜成形术中长期TRA／RAA比值显著低于单纯人工瓣环成形术者（P〈0．01）。结论对于三尖瓣瓣缘对合不良及其瓣环扩张引起的重度TR者，人工瓣环成形联合“缘对缘”瓣膜成形技术能够更有效地减少术后三尖瓣残余反流以及TR的复发。

Objective To analyze whether association of edge to edge valve repair to artificial ring annuloplasty would result in better results in patients with severe tricuspid regurgitation （TR）. Methods From April, 2001 to May, 2010, 41 patients underwent tricuspid valve repair to treat severe TR were studied. Twenty-one patients were done artificial ring annuloplasty alone （group R） and twenty patients were done artificial ring annuloplasty associated with edge to edge valve repair （group E）. All the patients received eehoeardiography before surgery, before discharge and in mid and long-term follow-up. The ratio between TR jet area （TRA） and right atrial area （RAA） was used to quantitatively evaluate the seriousness of TR. Movement of tricuspid valve leaflets, tricuspid valve orifice area, pulmonary artery pressure （ PAP）, left ventricular ejection fraction （LVEF） were obserbed to evaluate heart function. Results At discharge in group R, no or trivial TR was presented in 7 patients, mild TR in 12 patients and moderate TR in 2 patient. Bad apposition of the free edges of anterior and septal leaflets was observed in paients with mild and moderate TR. While in group E, no or trivial TR was presented in 13 patients and mild TR in 7 patients. The follow-up ranged from 6 months to 100 months [ average （54.8 ±26.7） months]. In group R, no or trivial TR was present in 5 patients, mild TR in 11 patients, moderate TR in 4 patients and severe in 1 patient. Bad apposition of the free edges of anterior and septal leaflets was observed in paients with mild to severe TR. Redo tricuspid valve repair was done in one.patient in group R for recurrent severe TR and the edge-to-edge valve repair was utilized. In group E, no tricuspid stenosis was found. No or trivial TR was presented in 10 patients, mild TR in 9 patients and moderate TR in 1 patient. The ratio of TRA/RAA of group R was significantly higher than that of group E （0.25 ± 0.16 vs. 0.13 ± 0.10, P 〈 0.01 ）. Conclusion Association of edge-to-edge valve technique to artificial ring annuloplasty was safe and effective for treatment of severe tricuspid regurgitation due to bad apposition of free edges of tricuspid leaflets and dilatation of tricuspid annulus,. It could decrease the incidence of residual tricuspid regurgitation and prevent the recurrence of severe tricuspid regurgitation.