超声心动图评价功能性三尖瓣反流术后中期疗效及影响因素

Determinants of mid-term outcomes of tricuspid annuloplasty for functional tricuspid regurgitation:an echocardiography study

目的应用二维超声心动图评价三尖瓣成形术(TVP)的中期结果 ,比较不同成形方法的疗效,并分析影响术后残余反流(PRTR)的危险因素。方法 2005年8月—2007年2月复旦大学附属中山医院心脏外科行TVP治疗功能性三尖瓣反流(FTR)患者222例,其中男性89例(40.1%)、女性133例(59.9%),平均年龄(50.0±12.0)岁(16～77岁)。根据成形方法分为两组:不使用人工环成形环组136例(61.3%)和使用人工环成形环组86例(38.7%)。术后随访超声心动图和心功能变化,总结TVP的中期疗效,比较两组三尖瓣反流(TR)程度的变化,并分析PRTR的影响因素。结果围手术期死亡2例(0.9%),两组差异无统计学意义(P=0.5 8 8)。术后平均(24.4±10.9)个月(15 d～42月)随访超声心动图和临床结果 ,失访20例(9.0%)。术前平均TR级别(2.5±1.1)+,术后平均TR级别(0.7±0.8)+(P<0.01);术前平均纽约心脏病协会(NYHA)分级为(3.1±0.5)级,术后平均NYHA分级为(1.4±0.5)级(P<0.01)。PRTR 27例(13.5%)。无三尖瓣再次手术者,生存率97.5%。成形环组术前TR程度高于非成形环组(P<0.01),术后TR程度两组差异无统计学意义(P=0.269);术前TR为3+～4+时,术后成形环组TR程度低于非成形环组(P=0.044)。成形环组TR改善程度显著高于非成形环组(P=0.021);术前存在房颤心律(P=0.001)、LA>60 mm(P=0.011)、肺动脉收缩压(sPAP)>65 mmHg(P=0.036)、TR程度3+～4+(P=0.047)时,成形环组TR改善程度显著高于非成形环组。多因素分析PRTR独立危险因素,有风湿性病变(P=0.02 6,OR=9.9)、术后右房(RA)大小(P=0.003,OR=2.9)、术后LVEF较术前减小(P=0.025,OR=4.4)、术后sPAP>50 mmHg(P=0.02 9,OR=4.2)及术后sPAP较术前增加(P=0.020,OR=4.9)。结论 TVP是治疗FTR的有效方法。术前TR为3+～4+,术前存在房颤心律、巨大LA、肺动脉高压时,成形环的效果优于非成形环,可作为使用成形环TVP适应证的参考。风湿性病变、术后RA大、术后LVEF较术前减小、术后肺动脉高压或术后sPAP较术前增加是PRTR的独立危险因素。

Objectives To evaluate the mid-term clinical and echocardiographic：outcomes of tricuspid valve plasty（TVP）, to compare the curative effect of different tricuspid annuloplasty techniques,and to identify the risk factors of postoperative residual tricuspid regurgitation（PRTR）.Methods From August 2005 to February 2007,222 patients underwent tricuspid annuloplasty for functional tricuspid regurgitation（FTR） in the Department of Cardiac Surgery of Zhongshan Hospital,Fudan University. Male 89 cases（40.1%）,female 133 cases（59.9%）,aged（50.0±12.0） years,using 2 main techniques：non-ring procedure in 136 patients（61.3%）,and ring procedure in 86 patients（38.7%）.Postoperative follow-ups were performed using echocardiography and New York Heart Association（NYHA） classification.Mid-term outcomes of TVP was analyzed.The determinants of PRTR were identified,and the curative effect of different tricuspid annuloplasty techniques was compared,by means of clinical and echocardiographic follow-ups.Results There were 2 perioperative death（0.9%）,with no diffrerence between two groups（P= 0.588）. Mean follow-up time was（24.4±10.9） months（15 days to 42 months）,and 20 cases（9.0%） lost to follow-up.Mean preoperative TR grade was（2.5±1.1） ＋,and mean postoperative TR grade was（0.7±0.8） ＋（P〈 0.01）.Mean preoperative NYHA was 3.1±0.5,and mean postoperative NYHA was 1.4±0.5（P〈 0.01）.PRTR occurred in 27 cases（13.5%）.Tricuspid reoperation rate was 0%,and survival rate was 97.5%.The severity of preoperative TR was higher in ring group（P〈 0.01）,and the severity of postoperative TR was similar（P=0.269）.In patients with preoperative TR 3＋ to 4＋,the severity of postoperative TR in ring group was lower than non-ring group（P=0.044）. The change rate of TR was higher in ring group（P=0.021）.When preoperative atrial fibrillation（P=0.001）,leftatrium（LA） 〉 60 mm（P=0.011）, systolic pulmonary artery pressure（sPAP） 〉 65 mmHg（P=0.036） or TR 3＋ to 4＋（P=0.047）,ring group shared higher change rate of TR than non-ring group.In multivariate analysis,rheumatic etiology（P=0.026,OR = 9.9）,postoperative right atrium size（P=0.003,OR =2.9）,less postoperative left ventri cular ejection fraction（LVEF）（P=0.025,OR= 4.4）,postoperative sPAP〉50 mmHg（P=0.029,OR =4.2）,and higher postoperative sPAP（P=0.020,OR= 4.9） were independent risk factors of PRTR.Conclusions TVP is an effective procedure treating FTR.The echocardiographic mid-term outcome in ring group is better than that in non-ring group,especially when preoperative TR 3＋ to 4＋,or when preoperative atrial fibrillation,huge LA or pulmonary artery hypertension.Rheumatic etiology,postoperative right atrium size,less postoperative LVEF,postoperative pulmonary artery hypertension and higher postoperative sPAP show independent association with PRTR.