三瓣膜修复治疗风湿性心脏瓣膜病的近中期效果观察

Observation on the early and mid-term effects of triple valve repair for rheumatic heart valve disease

目的探讨应用三瓣(主动脉瓣、二尖瓣和三尖瓣)膜修复手术治疗风湿性心脏瓣膜病的近中期临床疗效。方法病例系列报告。纳入2018年1月—2022年6月南京鼓楼医院心胸外科风湿性心脏病(RHD)患者38例。38例中,男10例、女28例,年龄38~69(53.2±8.8)岁。纽约心脏协会心功能分级:Ⅰ级17例,Ⅱ级8例,Ⅲ级10例,Ⅳ级3例。合并二尖瓣中度及以上反流20例,合并主动脉瓣中度及以上反流18例,合并主动脉瓣狭窄18例,合并三尖瓣中度及以上反流19例。患者均采用胸骨正中切口行三瓣膜修复术治疗。观察指标:(1)观察术中体外循环时间、主动脉阻断时间及手术时间;术中经食管心动超声检查,观察瓣膜修复效果。(2)观察患者术后24 h胸腔、心包纵隔引流量,心脏外科重症监护病房(CICU)住院时间,术后低心排血量综合征、低氧血症、严重心律失常、包积液等严重并发症发生情况,以及有无因术后出血二次开胸手术。术后出院前复查经胸心脏超声,观察主动脉瓣、二尖瓣、三尖瓣反流情况。(3)出院后定期随访,复查经胸超声心动图,观察有无瓣周漏、瓣膜修复后反流情况、二尖瓣舒张期峰值流速、二尖瓣平均跨瓣压差;复查心电图,观察有无持续性房颤;观察心血管相关不良事件的发生情况,以及因瓣膜反流需二次手术情况。结果(1)38例患者均完成三瓣膜修复。术中体外循环时间97~205(138±30)min、主动脉阻断时间76~149(106±26)min,手术时间96~255(161±55)min。术中经食管心动超声检查提示,术前主动脉缩流颈(4.2±0.7)mm;瓣膜修复后主动脉瓣轻中度反流2例,二尖瓣轻中度反流2例,其余患者无反流或轻微反流,均无收缩期前向运动现象。(2)38例患者术后CICU住院时间2.0(2.0,2.5)d,胸腔、心包纵隔24 h引流量270(225,465)mL。术后切口愈合良好,无低心排血量综合征、低氧血症、严重心律失常等并发症发生,无二次开胸病例,无术后早期死亡病例。出院前复查心脏超声显示,38例患者术后均无瓣膜狭窄,主动脉瓣和二尖瓣轻中度反流各2例,三尖瓣轻中度反流4例,其余瓣膜均轻微或轻度反流。(3)38例患者均获随访,随访时间3~54(22.3±4.5)个月。随访期间38例患者胸闷、气喘、心悸、头晕症状均得到不同程度地改善,活动耐力较术前明显增加,无心血管不良事件发生,无一例患者死亡。末次随访复查经胸超声心动图显示:主动脉瓣和二尖瓣均无狭窄,主动脉瓣和二尖瓣轻中度反流各3例,其余瓣膜均是轻微或者轻度反流;二尖瓣舒张期峰值流速0.8~1.9(1.3±0.3)m/s,二尖瓣平均跨瓣压力差2.6~4.8(3.1±1.4)mmHg(1 mmHg=0.133 kPa)。复查心电图,24例行房颤射频消融的患者残留房颤3例,未见新发术后心律失常患者。结论对于风湿性心脏病累及三瓣膜的患者,若二尖瓣有修复可能性,三尖瓣轻度以上功能性瓣膜反流,主动脉瓣瓣叶质量尚可、中度以下狭窄或关闭不全,可同期行三瓣膜修复术,并可有效改善患者术后近中期瓣膜反流情况,获得较好的近中期临床疗效。

Objective This study was performed to explore the early and mid-term clinical outcomes of"three-valve"(aortic,mitral,and tricuspid valves)repair surgery in the treatment of rheumatic heart valve disease.Methods This work was a case series report.From January 2018 to June 2022,a total of 38 patients with rheumatic heart disease(10 males and 28 females)in the Department of Cardiothoracic Surgery,Nanjing Drum Tower Hospital were examined.The age was 38-69(53.2±8.8)years.The New York Heart Association classification gradeⅠwas found in 17 patients,gradeⅡwas found in eight patients,gradeⅢin 10 patients,and gradeⅣin three patients.Mitral valve regurgitation was moderate and above for 20 patients.Aortic valve regurgitation was moderate and above for 18 patients.Aortic valve stenosis was moderate and above for 18 patients.Tricuspid valve regurgitation was moderate and above for 19 patients.All the patients were treated with triple valve repair through sternotomy incision.The observation indexes were obtained as follows:(1)intraoperative cardiopulmonary bypass time,aortic cross-clamp time,operative time,and intraoperative transesophageal cardiac ultrasonography were used in assessing the effect of valve repair;(2)drainage volume 24 h after operation,cardiac intensive care unit(CICU)time,low cardiac output syndrome,hypoxemia,severe arrhythmias,pericardial effusion,and presence of secondary open-heart surgery due to postoperative bleeding were used.Transthoracic echocardiography was performed before discharge to observe the regurgitation of aortic,mitral,and tricuspid valves.(3)The patients were followed up regularly after discharge from the hospital,and transthoracic echocardiography was repeated to observe the presence of perivalvular leakage,regurgitation after valve repair,peak mitral diastolic flow velocity,and average mitral transvalvular pressure difference;electrocardiogram was repeated to observe the presence of persistent atrial fibrillation.The occurrence of cardiovascular-related adverse events and the need for secondary surgery because of valve regurgitation were observed during the follow-up period.Results(1)All 38 patients completed triple valve repair.Cardiopulmonary bypass time was 97-205(138±30)min;aortic cross-clamp time was 76-149(106±26)min;and operative time was 96-255(161±55)min.Intraoperative transesophageal cardiac ultrasonography showed preoperative aortic vena contracta(4.2-0.7)mm.Only mild-to-moderate postoperative regurgitation of the aortic valve was observed in two patients,and mild-to-moderate regurgitation of the mitral valve was observed in two patients.The other patients showed no regurgitation or mild regurgitation,no patient presented systolic anterior motion.(2)CICU stay was 2.0(2.0,2.5)d,and the drainage was 270(225,465)mL 24 h after operation in all 38 patients.The patients recovered well after surgery,with good incisional healing and without complications,such as low cardiac output syndrome,hypoxemia,or severe arrhythmias.In addition,no indications for secondary surgery were observed,and no early postoperative death occurred.Regular follow-up with transthoracic echocardiography before discharge showed no valve showing stenosis,two patients of aortic valve and mitral valve showed mild-to-moderate regurgitation,four patients of tricuspid valve showed mild-to-moderate regurgitation,and the rest of the valves had sub-mild regurgitation.(3)After 3-54(22.3±4.5)months of follow-up,shortness of breath,palpitations,and dizziness were alleviated to varying degrees in 38 patients,activity endurance increased significantly compared with that before operation,no cardiovascular adverse events occurred,and no patient died.Transthoracic echocardiography at the last follow-up review showed no stenosis of the aortic and mitral valves,three patients of the aortic valve and mitral valve showed mild-to-moderate regurgitation,and the rest of the valves had sub-mild regurgitation.The peak mitral diastolic flow velocity was 0.8-1.9(1.3±0.3)m/s,and the average mitral transvalvular pressure was 2.6-4.8(3.1±1.4)mmHg(1 mmHg=0.133 kPa)at the last follow-up.Reexamination of electrocardiogram showed three patients of residual atrial fibrillation in 24 patients who underwent radiofrequency ablation of atrial fibrillation,and the remaining patients did not develop new-onset postoperative arrhythmia.Conclusion For patients with rheumatic heart disease involving three valves,mitral valve with possibility of repair,tricuspid valve with more than mild functional valve regurgitation,aortic valve leaflets with fair quality,and less than moderate stenosis or regurgitation,triple valve repair can be performed,which can improve outcomes and thereby effectively improves patients'early and mid-term valve regurgitation after operation and early and mid-term clinical efficacy.