左心瓣膜置换术后三尖瓣关闭不全的外科治疗

Surgical treatment of late tricuspid regurgitation after left cardiac valve replacement

目的 探讨左心房室瓣置换术后三尖瓣关闭不全的外科处理方法。方法 回顾性分析2007年1月至2017年1月我院在左心瓣膜置换术后出现三尖瓣重度关闭不全再次手术42例患者的临床资料。结果 手术患者42(男11,女31)例。年龄30~66(52±11)岁。18例(43%)为人工瓣膜功能正常,其余24例(57%)均并发不同程度的主动脉瓣和(或)二尖瓣瓣周漏。两次手术间隔1~19(11±4)年。采用三尖瓣成型环成形31例;采用三尖瓣置换11例,其中,3例为生物瓣膜,8例为双叶机械瓣膜。术后早期院内死亡6例,病死率为14%,其中三尖瓣成形2例,三尖瓣置换4例。致死原因,右心功能衰竭3例,多脏器功能衰竭2例,因凝血功能障碍,出血导致死亡1例。全组随访37例,随访率88%,随访时间6~120(73±31)个月,失访5例(失访率为12%)。随访病例中,5例三尖瓣人工瓣置换患者三尖瓣功能良好。26例三尖瓣成形患者中无或少量返流22例,中量以上返流4例。结论 左心瓣膜置换术后出现三尖瓣重度关闭不全,行三尖瓣置换或三尖瓣成形术可达到满意疗效。术前心功能的调控及全身各脏器功能的评估是手术成功的保障。依据三尖瓣结构不同的病理改变,选择适合的手术方式也是确保手术成功的关键。

AIM To investigate postoperative results of late tricuspid regurgitation(TR)after left cardiac valve replacement.METHODS The present investigation retrospectively reviewed 42 patients with a history of left-sided valve operations who underwent tricuspid procedures from Jan 2007 to Jan 2017.RESULTS The mean age of the 42 patients(e.g.,11 men and 31 women)was 52±11 years with an age range of 30 to 66 years.The mean time from last surgery was 11±4 years with a range of 1 to 19 years.Mitral perivalvular leakage or aortic perivalvular leakage was found in 24 patients.Surgical technique included tricuspid valve repair in 31 patients,while 11 patients underwent tricuspid valve replacement(e.g.,3 bioprosthetic valve prostheses,8 mechanical valve prostheses).The early mortality rate was 14%(6 of 42 patients;2 repairs,4 replacements).Follow-up was complete in 37 patients(88%)with a median follow-up of 73±31 months(IQR 6~120 months).Amongst patients who underwent tricuspid valve repair,22 had none-to-mild tricuspid regurgitation and 4 had moderate-to-severe tricuspid regurgitation.CONCLUSION Tricuspid valve procedures after left-sided valve operations in rheumatic patients can have good clinical outcomes.The management of left ventricular dysfunction before the operation plays an important role in the entire process.Proper selection of surgery is critical for success.