风湿性心脏病左心瓣膜置换术后晚期重度三尖瓣关闭不全的外科治疗

目的 探讨风湿性心脏病(风心病)左心瓣膜置换术后晚期重度三尖瓣关闭不全(TR)的发生机制、手术指征、手术方法和疗效.方法 风心病左心瓣膜置换术后5～16年出现重度TR病人37例,均有不同程度的右心衰竭表现,左室射血分数(LVE)0.52±0.05,肺动脉收缩压(37.6±7.8)mm Hg.经右胸前外侧切口或正中切口再次手术行三尖瓣置换(TVR)25例,改良DeVega环缩术4例,带环成形术8例.结果 术后住院死亡4例,其中死于呼吸衰竭2例、多脏器功能衰竭和肾功能衰竭各1例.随访2个月～10年,死于右心衰竭3例,严重心律失常1例;生存的25例临床症状均有明显改善.结论 左心瓣膜置换术后晚期重度TR与肺动脉高压持续存在、风湿性三尖瓣病变、初次未作三尖瓣环缩术或方法不确实等有密切关系.左心功能良好、右室收缩功能无严重损害,无严重肺动脉高压是再次手术的指征,并主张尽早行TR纠正术.保留全瓣结构行三尖瓣置换有助于提高手术疗效.影响术后长期疗效仍是右室收缩功能.

Surgical treatment of severe tricuspid regurgitation late left-sided heart valve replacement in patients with rheumatic valve disease

Objective To summarize the surgical results of severe trcuspid regurgitation(TR)late afte left-sided heart valve replacement in patients with rheumatic valve disease,and to investigate the possible pathogenesis of late TR,surgical indictation and metnods.Methodd Thirty-seven patients developed severe TR 5-16 years later after rheumatic mitral or/and aortic valve replacement.All of them had various degree of right heart failure.The mean left ventricular ejection fraction(LVEF)was 0.52.±0.05. and the mean pulmonary pressure was(37.6±7.8)mmHg.Tricuspid valve repacement(TVR)was performed in 25 cases,modified DeVega annuloplastyin 4,and ring ammuloplasty in 8 throrgh right anterio-lateral thoracotomy or middle sternotomy.Rsesults Four patients died postoperatively with hospital mortality of 10.8%.Another 4 patients died(right heart failure in 3 and ventricular arrhythmian in 1)during 2 months to 10 years follow-up period.The clinical maniifestations were significantly improvd in al survivores.Conchusion The mechanisms of late sever TR wered closely correlated with sustainedd pulmonary phypertension,rheumatic tricuspid lesion,ignored tricuspid annular dilation during the first procedure,and incorrect methods of annuloplasty or uncompetence of the procedure.The surgical indication for late severe TR is that the left ventrcular must be in the normal scope,right ventrcular function is not severely damaged,and there is no severe pulmonary hypertension.Early surgical intervention is encouraged in order to obtain better surgical outcomes.TVR with the preservation of total tricuspid structures may improve right heart function and surgical outcomes.Potoperative long-term outcomes mainly depend on right ventricular function.