腔镜不停跳术对左心瓣膜置换术后远期三尖瓣重度反流疗效分析

目的 总结左侧心脏瓣膜置换术后远期出现孤立性重度三尖瓣关闭不全患者的腔镜辅助不停跳三尖瓣手术治疗经验。方法 11例心脏瓣膜疾病患者行左心瓣置换术后远期发生重度三尖瓣关闭不全并右心衰竭,8例出现心脏恶病质综合征及肝肾功能不全,予行再次三尖瓣手术,包括人工瓣环成形术2例,行三尖瓣置换术9例,其中置换生物瓣5例,双在叶机械瓣4例;在腔镜辅助下行心脏不停跳再次手术5例,常规再次心脏停搏手术6例。结果 2例围术期死亡,均为停跳组瓣膜置换病人。术后心包引流液量心脏不停跳组明显少于停跳组（P<0.05）。停跳组术后严重低心排血量综合征4例,不停跳组1例。两组术后1月复查超声心动图,右心房、室均明显缩小,三尖瓣无或少量反流,两组间无明显差异。获长期随访5例、随访时间25~86月、心功能Ⅱ级3例、Ⅲ级2例。结论 左心瓣膜置换术后远期孤立性重度三尖瓣关闭不全合并右心衰的再次手术死亡率高、合理掌握手术指征、手术时机、积极开展微创不停跳手术和良好的围术期治疗是手术成功的关键。对于终末期病例,手术死亡率高,应积极开展针对右心系统的心脏超声及磁共振检测指标,综合评估手术风险,常规换瓣手术指征需慎重,必要时可考虑微创经皮导管瓣膜植入术。

Effect of video-assisted and beating heart surgical treatment of tricuspid regurgitation late after valve replacement of left heart

Objective To investigate the outcome of video-assisted and beating heart surgical treatment of severe tricuspid regurgitation late after valve replacement of left heart. Methods Eleven patients with severe tricuspid insufficiency,with the diagnosis conformed by echocardiogram,were treated surgically after left heart valve replacement from February 2009 to February 2018, including 8 mitral valve replacements and 3 double valve replacements. DeVega repair of tricuspid bad been used in 9 patients in the first operation. Results Tricuspid repair was performed in 2 patients,tricuspid replacement was done in 9 patients. The mechanical valves were implanted in 4 patients and biothesis valves in 5 patients.The low cardiac output and multiple organ failure were the causes of death. Two patients died during perioperative period （total hospital mortality was 18%）, both were valve replacement patients in cardioplegia group. Postoperative pericardial drainage volume in beating group were significantly less than those in cardioplegia group （P<0.05）. There were 4 cases of severe low cardiac output syndrome in cardiaplegia group and 1 case in beating group. Echocardiography showed that the right atrium and ventricle were significantly reduced and there was no or mild tricuspid regurgitation in the two groups. There was no significant difference between the two groups. The patients were followed up for 5.1 years （7 months~8 years）. Among the survivors, all patients showed improvement of symptoms,while most patients needed medical therapy. Conclusion The surgical intervention should be earlier before the onset of severe right ventricular failure. Minimally invasive beating heart surgery and proper peri-operative care is the key to successful operation. For end-stage cases, surgical mortality is high, the indication of valve replacement surgery should be cautious, cardiac ultrasound and magnetic resonance detection indicators for the right cardiac system should be actively carried out, and the surgical risk should be comprehensively evaluated.