三尖瓣瓣环扩张伴轻度反流的二尖瓣置换术患者同期行三尖瓣成形术的随机对照试验

Concomitant Tricuspid Annuloplasty for Patients with Tricuspid Valve Annulus Dilation and Mild Tricuspid Regurgitation Underwent Mitral Valve Replacement: A Randomized Controlled Trial

目的分析三尖瓣瓣环扩张伴轻度三尖瓣反流（TR）的二尖瓣置换术（MVR）患者同期行三尖瓣成形术对患者心功能及TR程度的影响,为临床决定是否为二尖瓣置换术（MVR）患者同期处理三尖瓣瓣环扩张伴轻度三尖瓣反流（TR）提供客观依据。方法纳入2013年4～10月四川大学华西医院心脏大血管外科36例需施行MVR的患者,术前超声心动图提示全组患者轻度TR、且三尖瓣瓣环舒张期末内径/体表面积〉21 mm/m2。36例患者被随机分为三尖瓣成形组（TAPG组,n=18,其中男7例、女11例）和非三尖瓣成形组（NTAPG组,n=18,其中男6例、女12例）,术后1周、半年复查超声心动图。结果两组患者的年龄、性别、心律、体表面积、术前心功能分级（NYHA）、左心房径（LAD）、左心室径（LVD）、右心房最大长轴径（RAmla）、右心房中部短轴径（RAmmd）、心尖四腔心中部的右心室径（RVD2）、左心室射血分数（LVEF）、左心室短轴缩短分数（LVFS）之间的差异无统计学意义（P〉0.05）。两组患者术后半年左心房室径较术前减小（P〈0.05）。TAPG组患者术后半年左心室长轴切面的右心室径（RVD1）、舒张期右心室游离壁厚度（RVWT）、三尖瓣瓣环舒张期末内径（TVAEDD）、三尖瓣瓣环收缩期末内径（TVAESD）较术前减小（P〈0.05）,三尖瓣环缩短分数（PSTVA）较术前差异无统计学意义（P〉0.05）,TR程度较术前减轻（P〈0.05）,右心室面积变化分数（RVFAC）、右心室射血分数（RVEF）较术前增加（P〈0.05）;NTAPG组患者术后半年RVD1、RVWT较术前增加,TVAEDD、TVAESD、PSTVA较术前差异无统计学意义（P〉0.05）,3D RVEF较术前减小（P〈0.05）,RVFAC增加但小于同期TAPG组患者,TR程度构成比改变（P〈0.05）,但术后出现6例中度及中度以上TR。结论三尖瓣瓣环扩张伴轻度TR的MVR患者同期行三尖瓣成形术将更有利于患者RVD1、RVWT及TVAEDD、TVAESD的减小,TR程度构成比的改善,RVFAC及RVEF的升高。

Objective To investigate effect of cardiac function and tricuspid regurgitation （TR） degree of concomitant tricuspid annuloplasty for patients with tricuspid valve annulus dilation and mild TR underwent mitral valve replacement （MVR）, and provide an objective basis for clinical decision about concomitant tricuspid annuloplasty for patients with tricuspid valve annulus dilation and mild TR underwent MVR. Methods A total of 36 patients who underwent MVR from April to October 2013 in Department of Cardiovascular Surgery, West China Hospital, Sichuan University were enrolled in this study. Preoperative echocardiography showed mild TR and tricuspid valve annular end- diastolic dimension （TVAEDD）/body surface area （BSA）〉21 mm/m2. All the 36 patients were randomly divided into a tricuspid annuloplasty group （TAPG group, n=18, including 7 males and 11 females） and a no tricuspid annuloplasty group （NTAPG group, n=18, including 6 males and 12 females）. One week and 6 months postoperative echocardiography were recorded. Results There were no statistical differences in age, gender, heart rate, body surface area, preoperative cardiac function （NYHA）, left atrium dimension （LAD）, left ventricular dimension （LVD）, maximal long-axis of RA （RAmie）, mid-RA minor distance （RAmrod）, right ventricle dimension （RVD2）, left ventricular ejection fraction （LVEF）, left ventricular fractional shortening （LVFS） between the two groups （P〉0.05）. Six-months postoperative left atrial- ventricular diameter significantly reduced than that before surgery in the two groups （P〈0.05）. In the TAPG group, six-months postoperative right ventricle dimension （RVD1）, right ventricular wall thickness （RVWT）, tricuspid vane annular end-diastolic dimension （TVAEDD）, tricuspid valve annular end-systolic dimension （TVAESD） significantly decreased, while percent shorting of tricuspid valve annulus （PSTVA） did not change significantly （P〉0.05）, TR degree improved significantly （P〈O.05）, right ventricular fractional area change （RVFAC） and right ventricular ejection fraction （RVEF） significantly increased （P〈0.05）. In the NTAPG group, compared with preoperative data, six-months postoperative RVD1, RVWT significantly increased, TVAEDD, TVAESD, PSTVA did not change significantly （P〉0.05）, RVEF reduced significantly （P〈0.05）, RVFAC increased significantly but less than that in the TAPG group at the same period, constituent ratio of TR changed significantly （P〈0.05）, but postoperative moderate or more TR were recorded in 6 patients. Conclusion Concomitant tricuspid annuloplasty for patients with tricuspid valve annulus dilation and mild TR underwent mitral valve replacement （MVR） can help to decrease RVD1, RVWT, TVAEDD and TVAESD, improve the constituent ratio of TR, and increase RVFAC and RVEF.