联合二瓣化和改良Kay成形术处理左心瓣膜手术患者三尖瓣瓣环扩张的初步疗效观察

Preliminary Effect of Tricuspid Annuloplasty for Patients with Dilated Tricuspid Annulus and Left-sided Heart Valve Surgery by Employing Combined Bicuspidization and Modified Kay Annuloplasty

目的观察用联合二瓣化和改良Kay成形术处理左心瓣膜手术患者三尖瓣瓣环扩张的临床结果。方法回顾性分析2010年1月至2011年5月华西医院158例伴有三尖瓣瓣环扩张(三尖瓣瓣环径/体表面积≥21 mm/m2)的左心瓣膜手术患者应用联合二瓣化和改良Kay成形术处理三尖瓣的临床资料,其中男27例,女131例;年龄17～74(45.9±10.4)岁,心房颤动92例,窦性心律66例。三尖瓣反流(TR)程度根据超声心动图评价分为0～5级。结果 158例患者均康复出院。体外循环时间54～273(100.8±30.5)min,升主动脉阻断时间25～162(64.5±22.0)min,阻断期间最低食管温度26.3～34.1(28.5±1.1)℃。术后随访3～19(11.0±5.0)个月。手术前、后三尖瓣反流程度差异有统计学意义(2.2±1.3 vs.0.4±0.8,P<0.05)。与术前相比,患者术后右心房内径、右心室内径及左心房内径明显缩小,手术前、后右心房内径、右心室内径及左心房内径之间的差异有统计学意义[(56.5±11.1)mm vs.(47.5±8.9)mm,P<0.05;(22.4±4.4)mm vs(.20.1±3.3)mm,P<0.05;(62.8±20.1)mm vs(.51.9±14.1)mm,P<0.05]。随访期间有中度以上TR 5例(3.2%,5/158),其中中度TR 4例,中-重度TR 1例。患者手术前、后左心室射血分数的变化不明显(60.4%±7.9%vs.59.6%±8.2%,P>0.05)。结论以三尖瓣瓣环径/体表面积≥21 mm/m2作为左心瓣膜手术患者三尖瓣成形手术指征较为合理。应用联合二瓣化和改良Kay成形术处理三尖瓣防止伴有三尖瓣瓣环扩张的患者术后TR的残留或加重是有效的。

Objective To evaluate the preliminary effect of tricuspid annuloplasty for patients with dilated tricuspid annulus and left-sided heart valve surgery by employing combined bicuspidization and modified Kay annuloplasty. Methods Combined bicuspidization and modified Kay annuloplasty were performed in 158 patients with dilated tricuspid annulus（tricuspid annulus diameter/body surface area≥21 mm/m2） and left-sided heart valve surgery in West China Hospital between January 2010 and May 2011.There were 27 male and 131 female patients whose age ranged from 17 to 74（45.9±10.4） years.A total of 92 patients had atrial fibrillation and 66 patients were in sinus rhythm.The severity of tricuspid regurgitation（TR）was graded 0 through 5 as determined by echocardiography.Results All the patients recovered from surgery and were discharged from hospital.The average cardiopulmonary bypass time was 100.8±30.5（range,54 to 273） min,and the average aortic cross clamping time was 64.5±22.0（range,25 to 162）min.The average lowest esophageal temperature during aortic cross clamping was 28.5±1.1（range,26.3 to 34.1） ℃.The average postoperative follow-up was 11.0±5.0（range,3 to 19） months.The postoperative TR severity was significantly lower than preoperative TR severity（2.2±1.3 versus 0.4±0.8,P0.05）.The postoperative right atrium diameter,right ventricle diameter and left atrium diameter were significantly lower than preoperative measurements（56.5±11.1 mm versus 47.5±8.9 mm,P 0.05;22.4±4.4 mm versus 20.1±3.3 mm,P0.05;62.8±20.1 mm versus 51.9±14.1 mm,P0.05）.During follow-up,5 patients had moderate or severe TR（3.2%,5/158,moderate in 4 patients,moderate to severe in 1 patient）.There was no significant difference between preoperative and postoperative left ventricle ejection fraction（60.4%±7.9% vervsus 59.6%±8.2%,P0.05）.Conclusion It is reasonable to perform tricuspid annuloplasty for patients with dilated tricuspid annulus and left-sided heart valve surgery according to their index of tricuspid annulus diameter/body surface area（≥21 mm/m2）.To prevent postoperative residue or progression of TR in patients with dilated tricuspid annulus, it is effective to employ combined bicuspidization and modified Kay annuloplasty.