173例三尖瓣置换术长期随访结果分析

Long-term follow-up result of tricuspid valve replacement in 173 patients

目的:通过回顾性研究,总结单一中心三尖瓣置换手术临床和随访资料,评价并比较应用机械瓣和生物瓣行三尖瓣置换术后的远期疗效。方法:自1994年1月至2014年8月,我院完成173例三尖瓣置换手术。按病因学分类,其中风湿性心脏病65例,先天性心脏病(先心病)87例,感染性心内膜炎13例,心脏肿瘤5例,瓣膜退行性变3例。89例患者置换机械瓣,84例患者置换生物瓣。应用单变量Cox比例风险回归分析方法确定住院死亡高危因素。应用Kaplan-Meier方法测算远期生存率和远期免再次手术率。结果:1住院期间病死率是13.4%(23/172),其中16例死于严重心力衰竭,2例死于心室颤动,3例死于多脏器衰竭,2例死于严重感染。术前重度肺动脉高压、腹水、感染性心内膜炎是住院死亡的危险因素,而瓣膜种类与早期死亡无关。2随访137例,随访率91.95%(137/149),平均随访时间(118.5±26.8)个月。应用机械瓣行三尖瓣置换术后10年、15年生存率分别是65.2%、47.8%,而应用生物瓣行三尖瓣置换术后10年、15年生存率分别是87.8%、76.0%。Kaplan-Meier生存回归分析显示应用生物瓣组远期生存率高于机械瓣组,而免再次手术率两组之间无明显差异。结论:三尖瓣置换手术依然是高风险手术,远期疗效尚可接受,置换生物瓣远期生存率可能优于机械瓣。

Objective： To evaluate and compare the long-term outcomes of tricuspid valve replacement（ TVR） with mechanical prostheses and bioprostheses at a single institution through retrospective research.Methods： From January 1994 to August 2014,TVR was performed in 173 patients at our institution. The etiology was rheumatic heart disease in 65 cases,congenital heart disease in 87 cases,infective endocarditis in 13 cases,cardiac tumor in 5 cases,and degenerative valve disease in 3 cases. Mechanical prostheses was replaced in 89 cases,bioprostheses was replaced in 84 cases. Univariate Cox proportional hazards regression was used to determine predictors of in-hospital death. Follow-up was completed in 137 cases. The long-term survival rates and freedom from reoperation rates were estimated using the Kaplan-Meier method. Results： ① The hospital mortality was 13. 37%（ 23 /172）,among these patients,16 cases died of serious heart failure,2 cases died of ventricular fibrillation,3 cases died of multi organ dysfunction,2 died of serious infection. Severe pulmonary hypertension,ascites,and infective endocarditis were associated with in-hospital death,while the prostheses material was not an independent risk factor for early mortality. ②Follow-up was completed in 137（ 91. 95%）out of 149 survivors. Mean time of follow-up was（ 118. 5 ± 26. 8） months. 10 and 15 years survival rate after mechanical TVR was 65. 2% 、47. 8% respectively,while the 10 and 15 years survival rate after bioprostheses TVR was 87. 8% 、76. 0% respectively. Kaplan-Meier survival regression analysis indicated the long-term survival rate was higher in bioprostheses TVR group（ P = 0. 03）,while there was no significant difference in the rate of freedom from reoperation between the two groups. Conclusion： TVR remains a high risk operation. Thelong term outcome was acceptable,while bioprostheses may have an advantage in the long-term survival over mechanical prosthesis.