左心瓣膜术后三尖瓣关闭不全再次手术治疗的研究进展

Surgical treatment for tricuspid regurgitation after left-sided valve surgery

左心瓣膜术后三尖瓣关闭不全会影响左心瓣膜手术的远期预后.再次手术的时机和方式对患者的预后有重要影响.目前指南中对于左心瓣膜术后三尖瓣关闭不全患者再次行三尖瓣手术的时机尚无明确建议,但在发生不可逆性右心功能不全之前行手术治疗是较为公认的观点.虽然三尖瓣关闭不全外科治疗首选三尖瓣成形术,但对于存在明显的三尖瓣瓣叶风湿性病变挛缩增厚、右心室或三尖瓣环重度扩大者,行三尖瓣生物瓣置换术可能是更好的选择.采用微创右胸小切口入路、心包-右心房直接切开暴露三尖瓣、真空辅助下单根股静脉插管引流和心脏不停跳等联合微创技术能够有效降低术后出血和手术病死率.随着介入技术的发展,经导管三尖瓣成形或置换手术可能在不久的将来成为治疗左心瓣膜术后三尖瓣关闭不全的可选方案.

Late tricuspid regurgitation after left-sided valve surgery can negatively affect long-term prognosis.The surgical timing and strategy of tricuspid valve reoperation will have important impact on the surgical outcomes.However,there is no clear recommendations of the surgical timing for this condition in the current guidelines.Generally,tricuspid valve reoperation should be performed before irreversible right heart failure occurs.Although tricuspid valve repair is the first choice for tricuspid regurgitation,bioprosthetic tricuspid valve replacement might be a reliable alternative when tricuspid leaflets have severe rheumatic damage or right ventricle and tricuspid annulus significantly dilate.Combined minimally invasive surgical techniques,including right minithoracotomy approach,accessing the right atrium directly through the pericardium with limited dissection,peripheral cannulation strategy with the vacuum-assist single venous drainage technique and heart beating technique,can significantly decrease the operative mortality and postoperative bleeding.With development of interventional therapy,transcatheter tricuspid valve repair or replacement may become alternatives for tricuspid regurgitation after left-sided valve surgery in the future.