胸腔镜下二尖瓣置换同期行三尖瓣成形术的疗效分析

Analysis of the curative effect after thoracoscopic mitral valve replacement and tricuspid valvuloplasty

目的 探讨胸腔镜下二尖瓣置换术(MVR)同期行三尖瓣成形术(TVP)的疗效。方法 选取2020年5月至2022年5月汕头市中心医院收治的接受胸腔镜下MVR+TVP的患者102例进行回顾性研究。收集患者的临床资料,所有患者均确诊为中-重度风湿性二尖瓣病变,且合并中度及以上的三尖瓣反流(TR),入院后完善常规检查,行MVR+TVP。记录两组患者的手术时间、主动脉阻断时间、体外循环时间、呼吸机辅助时间、术后24 h胸腔引流量、术后住院时间及并发症发生情况;比较手术前后的左心室前后径、左室射血分数(LVEF)、右室舒张末径(RVEDD)、右心房内径(RA)、肺动脉压力。术后随访1年,根据患者病情是否复发,分成复发组(n=20)、非复发组(n=82),比较两组临床资料,经多因素Logistic回归模型分析患者术后病情复发的独立危险因素。结果 患者平均手术时间为(258.54±20.06)min,主动脉阻断时间为(140.66±13.58)min,体外循环时间为(215.65±20.67) min,呼吸机辅助时间为(22.06±1.39) h,术后24 h胸腔引流量为(220.74±10.93) mL,术后住院时间为(8.76±1.05) d。102例患者并发症发生率为15.69%。患者术后1周的左心室前后径、RVEDD、RA、肺动脉压力分别为(43.69±4.87) mm、(61.35±5.19)%、(29.52±3.69) mm、(31.25±5.40) mm、(25.98±4.27) mmHg,术后6个月的分别为(44.13±4.91) mm、(60.87±4.73)%、(30.04±4.10) mm、(31.69±5.37) mm、(25.13±6.48) mmHg,均低于术前[(50.87±6.35) mm、(61.47±4.92)%、(36.94±4.51) mm、(42.19±6.72) mm、(48.52±7.84) mmHg],差异均有统计学意义(P<0.05)。多因素Logistic回归分析结果提示,术前重度TR、术后6个月肺动脉压力增高是患者胸腔镜下MVR+TVP术后病情复发的危险因素,人工瓣环成形术是预防病情复发的保护因素(P<0.05)。结论 胸腔镜下MVR+TVP能改善中-重度风湿性二尖瓣病变合并中度及以上TR患者的心功能与肺动脉压力,未引起严重并发症,安全性高,但患者术后病情复发仍受术前TR程度、术后肺动脉压力变化、三尖瓣成形术方式的影响。

Objective To investigate the efficacy of thoracoscopic mitral valve replacement(MVR) accompanied by tricuspid valvuloplasty(TVP).Methods A retrospective study was performed on 102 patients who underwent thoracoscopic MVR+TVP from May 2020 to May 2022 in Shantou Central Hospital.Clinical data of patients were collected.All patients were diagnosed with moderate to severe rheumatic mitral valve disease combined with moderate or above tricuspid regurgitation(TR).Routine examination was completed after admission and MVR+TVP was performed.The operative time,aorta occlusion time,cardiopulmonary bypass time,ventilator assistance time,thoracic drainage volume 24 h after surgery,postoperative hospital stay and complications were recorded,and left ventricular anteropodiastolic diameter,left ventricular ejection fraction(LVEF),right ventricular end-diastolic diameter(RVEDD),right atrial inner diameter(RA) and pulmonary artery pressure before and after surgery were compared.Patients were divided into relapse group(n=20) and non-relapse group(n=82) according to whether their disease recurred or not.The clinical data of the two groups were compared,and the independent risk factors of postoperative relapse were analyzed by multivariate Logistic regression model.Results The mean operation time of patients was(258.54±20.06) min,aortic occlusion time was(140.66±13.58) min,cardiopulmonary bypass time was(215.65±20.67) min,ventilator assistance time was(22.06±1.39) h,thoracic drainage volume 24 h after surgery was(220.74±10.93) mL,and postoperative hospital stay was(8.76±1.05) d.The complication rate of 102 patients was 15.69%.The anterior and posterior left ventricular diameter,RVEDD,RA and pulmonary artery pressure at 1 week were(43.69±4.87) mm,(61.35±5.19)%,(29.52±3.69) mm,(31.25±5.40) mm,(25.98±4.27) mmHg,respectively,and those indexs at 6 months after surgery were(44.13±4.91) mm,(60.87±4.73)%,(30.04±4.10) mm,(31.69±5.37) mm,(25.13±6.48) mmHg,respectively,which were lower than those before surgery [(50.87±6.35) mm,(61.47±4.92)%,(36.94±4.51) mm,(42.19±6.72) mm,(48.52±7.84) mmHg],the difference were statistically significant(P<0.05).Multivariate Logistic regression analysis indicated that severe TR before surgery and increased pulmonary artery pressure 6 months after surgery were risk factors for the recurrence of patients after thoracoscopic MVR+TVP,and artificial valvuloplasty was a protective factor for the prevention of recurrence(P<0.05).Conclusion Thoracoscopic MVR+TVP can improve the cardiac function and pulmonary artery pressure in patients with moderate to severe rheumatic mitral valve disease combined with moderate or above TR,without causing serious complications and with high safety.However,the recurrence of patients' postoperative disease is still affected by the degree of TR before surgery,the change of pulmonary artery pressure after surgery,and the mode of tricuspid valvuloplasty.