左心瓣膜置换术后远期三尖瓣关闭不全的外科处理

Surgical Treatment of late tricuspid regurgitation after left cardiac valve replacement

目的 探讨左心瓣膜置换术后远期三尖瓣关闭不全 (TR)发生的可能机制以及外科治疗方法的选择和结果。方法 5 6例左心瓣膜置换术后远期发生TR行再次瓣膜手术的病人 ,10例人工瓣膜功能正常 (A组 )者中行二尖瓣置换 (MVR) 4例 ,主动脉瓣、二尖瓣双瓣置换 (DVR) 6例 ;4 6例人工瓣膜功能障碍 (B组 )者中MVR 36例 ,主动脉瓣置换 (AVR) 4例 ,DVR 6例。在A、B两组中 ,4 6例第 1次手时三尖瓣未见明显异常 ,10例第 1次手术时已行DeVega三尖瓣成形 (TVP) ,第 2次手术时发现缝线断裂 3例 ,缝线撕脱 7例。 5 6例TR病人再次手术时 9例行三尖瓣替换 (TVR) ,其中 6例三尖瓣呈风湿性改变 ;4 7例行TVP。结果 TVP和TVR各死亡 1例 ,病死率 36 %。 5 4例获随访 ,随访时间 6～ 132个月 ,平均 (794±348)个月。 8例TVR病人术后心功能恢复良好 ,4 6例TVP者 4 0例为轻度TR ,5例出现中度TR ,仍需强心、利尿药维持 ,1例再次出现重度TR。结论 左心瓣膜置换术后远期TR可能与持续肺动脉高压、右心室不可逆损害、三尖瓣风湿性病变、左心功能的恢复情况以及持续心房纤颤有关。重度功能性TR和三尖瓣风湿性病变者行TVR的疗效可靠。随访发现部分TVP病人功能性TR仍有逐渐加重趋势。

Objective: To investigate the possible pathogenesis and report the postoperative results of the late tricuspid regurgitation (TR) after left cardiac valve replacement. Methods: 56 patients developed severe TR after left cardiac valve replacement, including 10 patients with normal prosthesis valve function (group A) and 46 patients with prosthesis valve dysfunction (group B). Four patients underwent mitral valve replacement (MVR) and 6 patients underwent mitral and aortic valve replacement (DVR) in group A. In group B, 36 patients received MVR, 4 aortic valve replacement (AVR) and 6 DVR. Ten patients underwent tricuspid De Vega annuloplasty and 46 patients' tricuspid valves were normal during the initial operation. The surgical treatment of tricuspid valve included tricuspid valve replacement (TVR) in 9 and tricuspid valve plasty (TVP) in 47 at the second operation. Results: Two patients died postoperatively with hospital mortality of 3.6%. The 54 survivors were followed up from 6 to 132 months, mean 79.4 months. The heart function improved significantly in 8 after TVR and 40 after TVP. However, echocardiography showed moderate TR in 5 and severe TR in 1 patient after TVP and medical treatment was needed. Conclusion: The sustained pulmonary hypertension, irreversible right heart impairment, resumption of left ventricular function and sustained atrial fibrillation may be responsible for the development of late TR after left cardiac valve replacement. TVR may achieve a reliable result for severe functional TR and rheumatic tricuspid valve lesion. In some patients with TVP during the follow up, the TR might become more serious.