中-重度功能性三尖瓣关闭不全瓣膜置换与成形手术近远期效果的比较研究

Immediate and long-term outcomes of tricuspid valve replacement versus repair for functional tricuspid regurgitation

目的功能性三尖瓣关闭不全常见于风湿性瓣膜病患者,常用的手术治疗方式包括三尖瓣置换和三尖瓣成形,但是何种术式疗效更好,目前还不清楚。本研究回顾性比较三尖瓣置换和三尖瓣成形治疗功能性三尖瓣关闭不全的近期、远期疗效。方法回顾性分析1998年11月至2009年12月共68例功能性三尖瓣关闭不全患者临床资料,其中45例接受了三尖瓣成形手术,23例接受了三尖瓣置换手术。结果三尖瓣置换组平均年龄小于三尖瓣成形组[(43.7±22.3)岁vs.(45.9±21.3)岁,P=0.035],三尖瓣置换组术前平均三尖瓣反流量明显大于三尖瓣成形组[(21.9±35.4)mlvs.(19.8±24.5)ml,P<0.001]。三尖瓣置换组平均体外循环时间及主动脉阻断时间明显长于三尖瓣成形组[(152.0±52.0)minvs.(122.6±57.6)min,(86.6±20.6)minvs.(81.5±33.5)min,均P<0.001],三尖瓣置换组术后早期正性肌力药物用量也明显高于成形组(P<0.001)。三尖瓣置换组ICU停留时间明显长于三尖瓣成形组[(97.2±75.3)hvs.(83.7±47.5)h,P<0.001]。两组术后早期并发症发生率没有差异(30.4%vs.17.8%,P=0.234),但是三尖瓣置换组死亡率明显高于三尖瓣成形组(30.4%vs.11.1%,P=0.048)。术后随访时间为17个月至10年,三尖瓣置换组随访率93.8%,三尖瓣成形组随访率97.5%(P<0.001)。三尖瓣成形组三尖瓣反流复发率明显高于三尖瓣置换组(64.1%vs.20.0%,P<0.001),但两组中、重度三尖瓣反流复发率没有差异。术后1年、3年、5年、7年和10年实际生存率两组之间没有差异。结论三尖瓣成形术治疗功能性三尖瓣关闭不全的早期效果优于三尖瓣置换术,主要包括正性肌力药用量小、呼吸机辅助时间短、ICU停留时间短和死亡率较低。但三尖瓣置换患者远期复发率明显低于三尖瓣成形患者,两组之间的10年实际生存率没有差异。

Objective Functional tricuspid regurgitation(FTR)is very common in patients with rheumatic heart valve diseases.For moderate and(or)severe FTR,although heart valve replacement and repair procedures both can correct this heart valve disorder,it remains unclear which one can bring more benefits to patients with FTR.We aimed to examine the immediate and long term outcomes of FTR patients retrospectively.Methods From November,1998 to December,2009,68 patients admitted to our hospital and underwent tricuspid valve replacement or repair operation,of which 45 patients underwent anuloplasty procedure and 23 patients underwent tricuspid valve replacement.We compared clinical data of these patients retrospectively.Results The average age of patients in repair group were greater than those in replacement group[(43.7±22.3)years vs.(45.9±21.3)years,P=0.035].The grade of tricuspid regurgitation in replacement group was much more severer than that in repair group[(21.9±35.4)ml vs.(19.8±24.5)ml,P<0.001].The average time required for aorta clamping,cardiopulmonary bypass in replacement group were much longer than that in repair group[(152.0±52.0)min vs.(122.6±57.6)min,(86.6±20.6)min vs.(81.5±33.5)min,P<0.001,respectively].Early after surgery,the usage of inotropic agents in replacement group were much more than that in repair group,consequently,the staying time of ICU in replacement group was much longer than that in repair group[(97.2±75.3)h vs.(83.7±47.5)h,P<0.001]Although the postoperative complication morbidity showed no difference between these two groups(30.4%vs.17.8%,P=0.234),the mortality in replacement group was much higher than that in repair group(30.4%vs.11.1%,P=0.048).The follow up time ranged from 17 months to 10 years.The rates of follow-up were 93.8%and 97.5%in replacement and repair group respectively.The total rate of recurrence in repair group was much higher than that in replacement group(64.1%vs.20.0%,P<0.001),but for patients with moderate and severe grade FTR,the difference was not significant.Additionally,the actual survival showed no difference between these 2 groups on 1,3,5,7,10 years after surgery.Conclusions For FTR patients,valve replacement brings less benefit than anuloplasty in early postoperative period.However,in the long term,more patients who underwent valve replacement were free of recurrent regurgitation than those received anuloplasty,yet there is no difference on the actual survival rate.