二尖瓣成形术中轻度功能性三尖瓣反流的处理

Mild Functional Tricuspid Regurgitation Approach to Mitral Valve Repair

目的探讨中重度粘液样退行性二尖瓣关闭不全合并轻度功能性三尖瓣反流患者,二尖瓣成形术(mitralvalve repair,MVP)同期是否需行三尖瓣成形术(tricuspid valvuloplasty,TVP)。方法根据MVP同期是否行TVP,将1993年1月至2008年3月第二军医大学附属长海医院胸心外科135例中重度粘液样退行性二尖瓣关闭不全合并轻度功能性三尖瓣反流患者分成MVP组(76例)和MVP+TVP组(59例),观察两组患者围术期病死率和三尖瓣反流的变化,比较两组患者术后远期生存率、三尖瓣中重度反流免除率;采用多因素Cox regression分析术后远期三尖瓣中重度反流的危险因素。结果 (1)所有患者围术期均无死亡,术后在院期间复查超声心动图提示两组患者三尖瓣反流程度均为轻度或轻度以下;(2)MVP组患者术后5年、10年生存率分别为98.4%和95.0%;MVP+TVP组患者术后5年、10年生存率分别为100.0%和93.7%,两组患者术后远期生存率差异无统计学意义(P=0.311),但术后远期三尖瓣中重度反流免除率差异有统计学意义(P=0.040)。多因素分析显示:术前存在肺动脉压>30mm Hg(95%CI:1.127,137.487,P=0.040),心房颤动(95%CI:1.177,23.378,P=0.030)是术后远期三尖瓣中重度反流的独立危险因子。结论中重度粘液样退行性二尖瓣关闭不全患者合并轻度功能性三尖瓣反流,特别是术前存在肺动脉压>30mm Hg、心房颤动的患者,MVP同期应积极行TVP。

Objective To explore whether clinically mild iunctional tricuspid regurgitation should be addressed at the time of mitral valve repair （MVP） for moderate or severe mitral regurgitation due to myxomatous degeneration. Methods We retrospectively analyzed the outcomes of 135 patients with moderate or severe mitral regurgitation due to myxomatous degeneration with mild functional tricuspid regurgitation. All patients were treated between January 1993 and March 2008 in the Department of Cardiothoracic Surgery of Changhai Hospital, the Second Military Medical University. We divided the patients into a MVP group （n= 76） and a MVP＋tricuspid valvuloplasty （TVP） group （n： 59） according to whether they underwent combined TVP, and observed the perioperative mortality rate, degree of tricuspid regurgitation, and compared survival rate, and freedom from long-term moderate or severe tricuspid regurgitation after operation. Cox regression was used to analyze the risk factors for long-term moderate or severe tricuspid regurgitation after operations. Results （1） There were no deaths during the perioperative period, and postoperative transthoracic echocardiography of all patients indicated that tricuspid regurgitation was mild or less. （2） Survival rate at 5 years, 10 years after operations in MVP group was 98.4%, 95.0 %, respectively, and survival rate at 5 years, 10 years after operations in MVP＋TVP group was 100.0%, 93. 7%, respectively, and there was no significant difference in the survival rate after operations between the two groups （P = 0. 311）, but there was a significant difference in the freedom from long-term moderate or severe tricuspid regurgitation after operations between the two groups （P= 0. 040）. Multivariate Cox regression showed that preoperative pulmonary artery pressure 〉30 ram Pig （95%CI 1. 127 to 137. 487, P=O. 040 ）and atrial fibrillation （95%CI 1. 177 to 23.37g, P=O. OZO） were independent risk factors for long-term moderate or severe tricuspid regurgitation after operations. Conclusion TVP is necessary for most patients undergoing MVP for moderate or severe mitral regurgitation due to myxomatous degeneration who have coexistent mild functional tricuspid regurgitation, especially those patients with preoperative oulmonary artery pressure 〉30 mm Pig or atrial fibrillation.