继发性三尖瓣反流的治疗策略分级及其手术效果

目的:旨在随访继发性三尖瓣反流采用不同策略分级治疗后的疗效,验证策略分级的可行性,并总结影响三尖瓣反流复发的因素。方法:选取左心瓣膜疾病合并继发性三尖瓣反流的患者217例。根据三尖瓣瓣环直径指数和瓣叶闭合高度,把三尖瓣反流情况分为Ⅰ、Ⅱ、Ⅲ、Ⅳ四级,结合术前反流程度、肺动脉压力等选择最终三尖瓣成形方法。随访术后1周、术后近期(3~12个月)及术后中期(13~96个月)的三尖瓣功能。结果:共有Ⅰ级患者66例,30.3%未给于三尖瓣同期处理,63.6%采用线性Devega成形;Ⅱ级患者73例,82.2%采用线性Devega成形,17.8%使用成形环处理;Ⅲ~Ⅳ级患者78例,70.5%使用成形环。术后中期随访患者113例(52.1%),平均随访时间(45.0±21.9)个月。术后中期与术前比较,左心房前后径(49.0±11.4)mm vs(53.5±12.7)mm]、肺动脉收缩压(32.4±8.6)mmHg vs(49.1±18.7)mmHg,1 mmHg=0.133 kPa]、三尖瓣瓣环直径指数(17.2±2.0)mm/m2 vs(23.0±3.7)mm/m2]和瓣叶闭合高度(3.3±1.1)mm vs(4.5±2.1)mm]均明显减低(P均<0.0001)。最终共9例患者再次出现中量及以上程度三尖瓣反流,1例是Ⅰ级患者,余下8例均是Ⅲ~Ⅳ级患者。结论:继发性三尖瓣反流采用不同策略分级治疗,可以获得较满意的术后疗效,避免患者术后严重反流复发,有效降低三尖瓣再次手术的可能性。

Surgical Outcomes and Management Strategy for Treating Patients With Secondary Tricuspid Valve Regurgitation With Various Levels

Objectives:The main goal of this study was to follow up the surgical outcomes in treating secondary tricuspid regurgitation(TR)after stratifying TR into different levels,to verify the feasibility of this stratification strategy,to summarize the influence factors of TR recurrence post surgical treatmentt.Methods:Two hundred and seventeen patients with left-sided valvular disease and secondary TR were enrolled.Depending upon the tricuspid annular diameter index and tethering distances,the tricuspid valve was stratified into four levels(Ⅰ,Ⅱ,Ⅲ,Ⅳ).The different surgical approaches were chosen based on the different stratification levels,TR degree and pulmonary artery systolic pressure(PASP).The immediate(1 week),early(3-12 months)and mid-term(13-96 months)outcomes of tricuspid valve after leftsided valvular operations were followed up.Results:There were 66 patients in the stratification levelⅠ,30.3%patients received no surgical treatment,63.6%patients underwent modified Devega procedure.There were 73 patients in the stratification levelⅡ,82.2%patients underwent modified Devega procedures,and 17.8%patients were treated with annuloplasty rings.There were 78 patients in the stratification levelⅢ-Ⅳ,70.5%patients were treated with annuloplasty rings.Totally,one hundred thirteen patients were followed up for 13 to 96 months(mean:45.0±21.9 months).Compared with preoperative data,the left atrial anterior-posterior diameter(49.0±11.4]mm vs53.5±12.7]mm),pulmonary artery systolic pressure(32.4±8.6]mmHg vs49.1±18.7]mmHg),tricuspid annular diameter index(17.2±2.0]mm/m2 vs23.0±3.7]mm/m2)and tethering distances(3.3±1.1]mm vs4.5±2.1]mm)were markedly decreased(all P<0.0001)during follow-up.During the follow-up,moderate or severe TR recurrence occurred in nine patients,including one with level I,the others with level III-IV.Conclusions:Preoperative evaluation of secondary TR with above stratification method is feasible and a reasonable tricuspid valvular repair approach could be achieved according to this stratification method.Satisfactory postoperative tricuspid valvular function is evidenced in this patient cohort.Our results show that this strategy could avoid severe TR recurrence and reduces the rate of tricuspid valvular re-operations.