左心瓣膜置换术后重度三尖瓣关闭不全的内外科治疗比较及危险因素分析

Comparison and analysis of risk factors of patients with isolated tricuspid regurgitation following left cardiac valve replacement underwent surgical and medicine treatment

目的探讨左心瓣膜置换术后远期发生重度三尖瓣关闭不全行外科手术治疗和内科药物治疗的疗效差异,并分析影响术后生存的危险因素。方法回顾性分析2010年1月至2014年12月在上海长海医院73例左心瓣膜置换术后远期发生重度三尖瓣关不全住院治疗患者的临床资料并进行随访。其中,行手术治疗55例,内科保守治疗18例。比较两组的远期生存情况,分析影响术后远期生存的危险因素。结果随访时间(37.2±15.2)月,随访率97%。手术组术后住院死亡3例,术后远期死亡7例。内科组出院后远期死亡8例。两组的Kaplan-Meier生存曲线有统计学差异(Log-rankP=0.011),手术组和内科组1年,2年,3年生存率分别为92.7%,88.3%,83.0%vs 83.3%,70.9%,55.9%。单因素分析结果显示,术前NYHA心功能Ⅳ级、血肌酐、白蛋白、总胆红素、左心室射血分数、右心室大小与术后远期生存有关,多因素CoX回归分析结果显示,术前血肌酐值(HR=1.077,95%CI:1.015-1.143,P=0.014)、左室射血分数(HR=0.569,95%CI:0.352-0.922,P=0.022)为影响术后远期生存的独立危险因素。结论左心瓣膜置换术后重度三尖瓣关不全的患者手术治疗比内科治疗有更好的1年,2年,3年生存率,但仍需进一步的随访研究。术前血肌酐值、左室射血分数是影响术后远期生存的独立危险因素。

Objective To investigate the effect of surgical treatment and drug therapy on the patients with severe tricuspid in-sufficiency after left heart valve replacement, and analyze the risk factors of postoperative survival.Methods The clinical data of 73 patients with severe tricuspid insufficiency insufficiency after left heart valve replacement in Chang-hai Hospital from December 2014 toJanuary 2010 were analyzed retrospectively. 55 cases received surgical treatment, and 18 cases with internal medicine. The long-termsurvival of the two groups was compared, and the risk factors of long-term survival after operation were analyzed.Results The follow-up time were（37.2＋15.2） months, and the follow-up rate was 97%. In the surgical group, postoperative death occurred in 3 cases,and postoperative long-term death occurred in 7 cases. In the internal medicine, postoperative death occurred in 8 cases after dischargefrom hospital. Kaplan-Meier survival curves of the two groups were statistically significant（P = 0.011 Log-rank）, operation group andDepartment of internal medicine group 1 years, 2 years, 3 year survival rates were 92.7%, 88.3%, 83.0% vs 83.3%, 70.9%, 55.9%,respectively. One-way ANOVA analysis showed that NYHA class IV, serum creatinine, albumin, total bilirubin, left ventricular ejec-tion fraction and right heart size were associated with long-term survival. Cox regression analysis showed that preoperative serum creati-nine values（HR= 1.077, 95%CI： 1.015-1.143,P = 0.014） and left ventricular ejection fraction（HR = 0.569, 95%CI： 0.352-0.922,p= 0.022）were independent risk factors for long-term survival after surgery.Conclusion Surgical treatment of patients with se-vere tricuspid insufficiency after left heart valve replacement is better than that internal medicine treatment for 1 years, 2 years and 3years survival rate. Preoperative serum creatinine value and left ventricular ejection fraction were an independent risk factor for long-term survival after operation.