三尖瓣置换术的围术期和术后中期临床疗效

Perioperative and mid-term clinical curative effect of tricuspid valve replacement

目的分析三尖瓣置换术的围术期和术后中期临床疗效。方法回顾性分析上海交通大学附属胸科医院心血管外科2007年5月—2013年12月收治的132例行三尖瓣置换术连续病例的围术期临床资料和术后中期随访结果。根据人工瓣膜种类将患者分为机械瓣组(48例)和生物瓣组(84例)。所有患者均行全身麻醉,于低温体外循环或常温体外循环下行手术。随访采用门诊和电话随访相结合的方法。记录患者围术期死亡和并发症情况,术后中期随访结果。结果围术期死亡10例(7.6%,10/132),术前纽约心脏病学会(NYHA)心功能分级均为Ⅲ或Ⅳ级,其中9例为三尖瓣置换合并同期其他心脏手术的患者,1例为Ebstein畸形患者;余122例患者的平均住院时间为(33.8±12.3)d,术后住院时间为(13.5±5.4)d。机械瓣组的围术期病死率为6.25%(3/48),与生物瓣组的8.33%(7/84)的差异无统计学意义(P>0.05)。围术期NYHA心功能分级为Ⅳ级患者的病死率为4/6,显著高于NYHA心功能分级Ⅲ级患者的6%(6/100,P=0.001)。术后并发症包括急性肾衰竭16例,术后出血6例,Ⅲ度房室传导阻滞5例,轻微或轻度瓣周漏3例。6例失访,116例患者随访时间5~84个月,平均随访时间为(33.6±22.5)个月。随访期间死亡7例,其中心源性死亡5例,肠癌晚期死亡1例,不明原因死亡1例。存活的109例患者NYHA心功能分级Ⅰ或Ⅱ级,有33例患者仍每日服用利尿剂;1例发生脑血管意外昏迷,1例发生阿斯综合征的患者安装心脏永久性起搏器后病情稳定,1例年轻女性生物瓣置换患者术后3年随访时已怀孕。中期随访中,死亡患者的平均年龄为(63.9±8.8)岁,术前平均总胆红素水平为(51.0±26.4)μmol/L,均显著高于存活患者的(51.8±12.0)岁和(27.6±23.8)μmol/L(P值分别为0.011、0.014)。结论三尖瓣置换术的手术病死率较高,加强对三尖瓣病变患者的随访,及时、有效的三尖瓣置换术可获得满意的围术期和中期临床疗效。

Objective To analyze the curative effect of tricuspid valve replacement （TVR） during perioperative period and mid-term follow-up. Methods Totally 132 patients underwent TVR in our hospital between May 2007 and December 2013. We reviewed their perioperative and mid-term clinical outcomes in this study. Mechanical valve was used in 48 patients and bioprosthetic valve was implanted in 84 patients. The operation was performed under cardiopulmonary bypass at normothermia or 32 ＂（3 after general anesthesia. Follow- up information was obtained from outpatient service and telephone interviews with patients or family members. Results Ten patients （7.6%, nine undergoing concomitant valve procedures and one with Ebstein deformity） died during perioperative period, and their preoperative New York Heart Association （NYHA） classification was grade Ⅲ or IV. The mean hospital stay was （33.8 ± 12.3） d and postoperative in-hospital time was （ 13.5 ± 5.4） d in the other 122 survivors. Perioperative mortality was 6.25% （3/48） in mechanical valve group, which was not significantly different from that in bioprostheses group （8.33 %, 7/84, P〉0.05）. Perioperative mortality was 66.7% （4/6） in the patients with NYHA classification IV, which was significantly higher than that in those with NYHA classification Ⅲ （6%, 6/100, P = 0. 001）. Acute renal failure occurred in 16 patients, bleeding in 6,complete cardiac block in 5, and mild perivalvular leakage in 3 after surgery. Six patients did not complete follow- up. The mean duration of follow-up was （33.6±22.5） months （range, 5- 84 months） in 116 patients. Mid-term follow-up showed that 5 patients died of cardiac related diseases, one died of advanced intestinal cancer and one died of unknown reason. NYHA classification was grade I or Ⅱ in 109 survivors and 33 of them still used loop diuretic daily. Cerebrovascular accident occurred in one patient who was still in coma. Adams-Strokes syndrome occurred in one patient whose condition became stable after implantation of permanent pacemaker. A young woman was pregnant 3 years after TVR with bioprostheses. The mean age and preoperative total bilirubin in the dead patients were （63.9 ± 8.8） years and （51.0 ± 26.4） μmol/L, respectively, which were significantly higher than those in the survivors （E51.8 ± 12.01 years and E27.6 ± 23.8] μmol/L, P = 0.011 and 0.014）. Conclusion TVR has a high mortality, and perioperative and mid-term clinical outcomes are satisfying after timely and effective TVR with the standard follow-up.