微创三尖瓣手术治疗左心瓣膜术后三尖瓣关闭不全的近期疗效分析

Short-term outcomes of minimally invasive reoperation for tricuspid regurgitation after left-sided valve surgery

目的探讨微创三尖瓣手术治疗左心瓣膜术后重度三尖瓣关闭不全的效果.方法回顾性分析2015年1月至2018年12月在复旦大学附属中山医院心外科接受微创三尖瓣手术治疗的89例左心瓣膜术后重度三尖瓣关闭不全患者的资料.男性21例,女性68例,年龄(56.4±7.9)岁(范围:41-74岁).本次手术距上次左心瓣膜手术时间为(14.1±6.1)年(范围:4-33年).手术采用右胸第4肋间小切口入路、股动静脉插管辅以负压单根静脉管引流技术、心脏不停跳、经皮临时起搏导线置入等多种微创技术,同时加强术前右心功能的优化.结果81例患者接受单纯三尖瓣生物瓣置换,8例接受三尖瓣成形.手术病死率为3.4%(3/89),其中2例死于低心排血量,1例死于右心功能不全致全身多器官功能衰竭.术后血液滤过治疗率为5.6%(5/89),术后永久性起搏器植入率为1.1%(1/89),术后无患者发生脑梗死.机械通气时间为24(24)h[M(QR)],ICU停留时间为2.5(3.0)d.出院时复查超声心动图,三尖瓣反流中度2例,轻中度4例.结论对于左心瓣膜术后严重三尖瓣关闭不全,多种微创技术的联合应用可降低手术病死率和术后并发症发生率.微创三尖瓣生物瓣置换对于左心瓣膜术后严重的三尖瓣关闭不全是一个可靠的选择.

Objective To examine the short-term outcomes of minimally invasive reoperation for severe tricuspid regurgitation after left-sided valve surgery.Methods From January 2015 to December 2018,a total of 89 patients with severe tricuspid regurgitation after left-sided valve surgery received reoperation in Department of Cardiovascular Surgery,Zhongshan Hospital,Fudan University were included in this study.There were 21 males and 68 females,aging of(56.4±7.9)years(range:41 to 74 years).The interval between previous left-sided valve surgery and tricuspid reoperation was(14.1±6.1)years(range:4 to 33 years).A combination of multiple minimally invasive techniques were adopted,including endoscopy-assist right minithoracotomy approach,peripheral cannulation strategy with the vacuum-assist single venous drainage technique,heart beating technique,and temporary percutaneous pacemaker implantation,with a concomitant enhancement in preoperative right cardiac function optimization.Results All patients received minimally invasive isolated tricuspid valve replacement(n=81)or tricuspid valve repair(n=8).After the application of multiple minimally invasive techniques,the operative mortality rate was only 3.4%(3/89).The causes of death were progressive right heart failure with multiorgan failure(n=1)and low cardiac output associated with postoperative bleeding(n=2).Regarding to the perioperative complications,renal replacement therapy rate was 5.6%(5/89),permanent pacemaker implantation rate was 1.1%(1/89),and the incidence of stroke was 0.Mechanical ventilation time was 24(24)hours,ICU stay time was 2.5(3.0)days(M(QR)).During the short-term follow-up,there were no case of severe tricuspid regurgitation,2 cases of moderate regurgitation,4 cases of mild-to-moderate regurgitation.Conclusions For severe tricuspid regurgitation after left-sided valve surgery,the advanced minimally invasive techniques can significantly reduce the operative mortality and morbidity.Minimally invasive bioprosthetic tricuspid valve replacement is a reliable alternative for severe tricuspid regurgitation after left-sided valve surgery.