微创三尖瓣补片扩大成形用于再次心脏手术

The application of minimally invasive tricuspid valvuloplasty technique with patch augmentation in reoperative cardiac surgery

目的探讨心脏不停跳胸腔镜微创技术和瓣叶扩大成形技术在心脏术后三尖瓣重度关闭不全中的应用效果。方法 2015年1月至2017年8月,纳入我院行腔镜下瓣叶扩大三尖瓣成形的再次手术患者。经股动静脉插管建立体外循环,在心脏不停跳常温体外循环下进行。补片扩大三尖瓣前瓣和后瓣,根据需要综合采用人工瓣环、瓣叶松解等其他成形技术。结果共纳入28例患者,男5例、女23例,平均年龄(55.6±10.1)岁。1例患者因重度胸腔粘连转为正中切口,其余27例患者行全腔镜下瓣叶补片三尖瓣成形,无中转三尖瓣置换的患者,手术死亡2例。全部患者获得随访,平均随访时间(7.4±5.0)个月,无晚期死亡和再次手术患者。三尖瓣反流面积由术前的(20.7±10.1)cm^2降至最近一次超声随访的(3.3±3.3)cm^2。结论在心脏手术后孤立性三尖瓣关闭不全的患者,采用微创加瓣叶扩大成形的方法可提高三尖瓣成形的成功率,减少手术创伤。

Objective To evaluate the efficacy of a combination of beating-heart minimally invasive approach and leaflets augmentation technique treating severe tricuspid regurgitation （TR） after cardiac surgery. Methods From January 2015 to August 2017, patients undergoing reoperative tricuspid valve repair （TVP） with minimally invasive approach and leaflets augmentation were enrolled. Cardiopulmonary bypass （CPB） was established via femoral vessels and the procedures were performed on beating heart with normothermic CPB. A bovine pericardial patch was sutured to leaflets to augment the native anterior and posterior leaflets. Other repair techniques, such as ring implantation and leaflet mobilization, were also applied as needed. Results A total of 28 patients （mean age 55.6±10.1 years, 5 males, 23 females） were enrolled. One patient was converted to median sternotomy due to pleural cavity adhesion. Twenty-seven patients underwent totally endoscopic TVP with leaflets augmentation. No patients was transferred to tricuspid valve replacement. Two patients died in hospital. All patients were followed up for 7.4＋5.0 months and there was no late death and reoperation. Regurgitation area was converted from 20.7±10.1 cm2 to 3.3±3.3 cm2 after TVP according to the latest echocardiography （P〈0.001）. Conclusion Minimally TVP with leaflets augmentation is effective in treating severe isolated TR after primary cardiac surgery. It can significantly increase success rate of tricuspid valvuloplasty and decrease the surgical trauma.