三叶草术在三尖瓣关闭不全处理中的临床应用和研究

Clover technique for the treatment of complex tricuspid valveinsufficiency

目的评估三叶草术治疗因严重脱垂和粘连挛缩导致的三尖瓣关闭不全的疗效。方法自2016年3月至2018年11月,对28例患者因瓣叶脱垂或瓣叶挛缩及粘连导致严重三尖瓣关闭不全实施三叶草术,同期瓣环成形术27例(97%)。其中风湿性病变19例(68%)、心内膜炎4例(14%)、退行性病变3例(11%)以及右心室缺血性病变(起搏导线压迫隔瓣叶1例)2例(7%)。单个瓣叶脱垂或损坏造成的关闭不全7例(23%)、两个瓣叶受累13例(46%)和三个瓣叶全部受累6例(21%),其余2例存在严重瓣膜粘连。结果全组无住院期间死亡,1例术后自动出院,余27例随访0.25~1.7年,平均(1.2±0.8)年,1年生存率100%。随访末次超声心动图检查示三尖瓣中度以下反流25例(88.7%)、中度反流(2+/4+)2例(9.6%)和重度关闭不全(4+/4+)1例(3.6%)。全组28例术后三尖瓣口面积和跨瓣压差分别为(4.3±0.6)cm^(2)和(2.8±1.4)mmHg(1 mmHg=0.133 kPa),无明显狭窄。结论三叶草术在对各种原因导致的三尖瓣反流(除瓣膜缺失严重或挛缩较重伴有钙化)的外科治疗中简单安全,是瓣环成形手术有效补充措施。

Objective This study assesses the results of the clover technique for the treatment of tricuspid regurgitation(TR)due to severe prolapse or tethering.Methods From March 2016 to November 2018,28 patients with severe TR due to prolapsing or tethered or adhesion leaflets underwent clover technique.Annuloplasty was associated in 27 patients(97%).The aetiology of TR was rheumatic in 19 cases(68%),subacute bacterial endocarditis in 4(14%),degenerative in 3(11%)and ischemia of right ventricular(the peacing leads compress the septum leaflet in 1 case)in 2(7%).The main mechanism of TR was prolapse/flail of one leaflet in 7 patients(23%),of two leaflets in 13 patients(46%)and of all three leaflets in 6 patients(21%).The remaining 2 patients(7%)presented with severe leaflets’tethering.Results None deaths occurred during hospitalisation and one patient dischargedvoluntary 12 days after surgery.Follow-up of the 27 hospital survivors was 100%complete[mean length(1.2±0.8)years,range 0.25-1.70 years].At the last echocardiogram,no or mild TR was detected in 25 patients(88.7%),moderate(2+/4+)in two(9.6%)and severe(4+/4+)in one patient(3.6%).Mean tricuspid valve area and gradient were(4.3±0.6)cm^(2) and(2.8±1.4)mmHg(1 mmHg=0.133 kPa).There was no obvious valve stenosis in all cases.In all patients,echocardiography was performed and no signs of tricuspid stenosis were detected.At the multivariable analysis,the degree of TR at hospital discharge was identified as the only predictor of TR 2+at follow-up.Conclusion Clover procedure is simple and safe in the surgical management of various causes of TR besides severe tethering and calcification,it is an effective supplementary measure for annuloplasty.