风湿性三尖瓣病变的瓣膜成形术

作者报道４９例风湿性三尖瓣病变的成形术，占同期三尖瓣病变的１３．５％。以狭窄为主２６例，以关闭不全为主２３例；后瓣与隔瓣交界融合９例，前瓣与隔瓣交界融合７例，前后瓣交界融合５例，混合存在５例。合并瓣下结构病变１７例，联合其它心脏瓣膜手术：双瓣置换３３例，二尖瓣置换１５例，主动脉瓣置换１例。手术采用闭合后瓣的二叶化手术或节段性ＤｅＶｅｇａ成形术；交界融合切开加瓣环成形术；瓣下结构粘连分离加腱索乳头肌劈开加瓣环成形术。术后早期死亡３例，其余４６例术后随访２个月～７年（平均４．２年）。术后半年超声复查右房均有不同程度的缩小，三尖瓣轻到中度反流８例，无反流３８例（８２．６１％），心功能转为Ｉ级３４例、ＩＩ级１０例、ＩＩＩ级２例，无晚期死亡。对手术选择的理论依据进行了讨论     

改良Carpentier法矫治三尖瓣下移畸形

目的探讨改良Carpentier法矫治三尖瓣下移畸形(Ebstein畸形)的手术方法,总结其临床经验。方法回顾性分析2006年6月至2010年8月安徽医科大学第一附属医院13例Ebstein畸形患者手术治疗的临床资料,其中男6例,女7例;年龄(26.8±13.5)岁。所有患者均采用改良Carpentier法矫治,手术方法包括:切除部分房化右心室,折叠环缩三尖瓣瓣环至适当的大小,用自体心包片扩大后瓣叶/隔瓣叶,移位缝合切下的部分前瓣叶(向内旋转后)、后瓣及隔瓣叶缝至正常的瓣环水平,移位相应的乳头肌、腱索,扩大修复瓣叶,加固瓣环,并矫正其他合并的心血管畸形。结果所有患者术后均恢复顺利,无死亡。超声心动图提示:三尖瓣功能良好,三尖瓣瓣叶均在正常位置;三尖瓣有轻度至中度反流3例,无反流或有轻微反流10例。心功能分级(NYHA)I～Ⅱ级。所有患者均得到随访,随访时间3～15个月,平均8个月。术后3个月和1年分别复查超声心动图提示:三尖瓣启闭及右心室功能良好,三尖瓣无明显反流12例,1例出院时三尖瓣有中度反流患者转为轻度反流。所有患者恢复正常的生活或工作。结论改良Carpentier法矫治Ebstein畸形有较好的近期疗效,该手术方法切除无功能的房化右心室后重新缝合塑形,有利于右心室形态重建和功能恢复,通过自体心包片扩大瓣叶、充分的瓣叶移位及后乳头肌、腱索移位重建可达到良好的瓣膜成形效果。     

右室乳头肌切断及隔瓣切开再缝合的实验研究和临床意义

作者为探讨修复成形术治疗创伤性右室前乳头肌断裂和采用经隔瓣切开或圆锥乳头肌切断术径路修补室间隔缺损（ＶＳＤ）的可行性和效果问题，用实验狗１９只，随机分为四组，分别对右室前乳头肌的血供、切断后复位吻合处的愈合过程、负重耐力及功能状态等进行观察。结果证实，创伤性右室前乳头肌断裂，早期及时作修复成形术可获得良好效果。临床对３１例ＶＳＤ伴隔瓣囊窝改变（ｐｏｕｃｈ）患者手术的结果亦证明，经此径路手术效果与动物实验结果相一致，ＶＳＤ冶愈率达１００％。提示本方法值得推荐临床应用。     

三尖瓣脱垂的外科治疗

目的探索应用三尖瓣脱垂瓣缘折叠缝合技术治疗三尖瓣关闭不全的外科方法和疗效。方法1997年4月至2006年3月为6例先天性三尖瓣前叶腱索缺如和3例外伤性腱索断裂的患者实施了外科矫治手术,其中男性6例,女性3例,年龄8～57岁。术前9例患者均有三尖瓣重度关闭不全,右心室前后径均值为(43.6±4.2)mm。5例患者心功能为Ⅲ级,4例为Ⅳ级。连续对折缝合脱垂的三尖瓣瓣缘,折叠缝合脱垂瓣叶相对应的瓣环,并用成形环固定成形后三尖瓣瓣环。结果9例患者术后恢复顺利,无死亡。术后超声心动图检查示:6例患者三尖瓣对合良好无反流,3例患者有少量反流。所有患者术后右心室前后径均显著减小,术后均值为(24.0±1.8)mm,与术前相比差异有统计学意义(P<0.01)。3例房颤心律的患者均转为窦性心律。患者随访1～109个月,除1例患者外,其他8例患者三尖瓣成形效果稳定。8例患者心功能为Ⅰ～Ⅱ级,1例为Ⅲ级。结论应用三尖瓣脱垂瓣叶及其相对应的瓣环折叠技术,可有效修复先天性三尖瓣部分腱索缺如和胸外伤后三尖瓣腱索断裂所致的三尖瓣重度关闭不全。     

修复胸部闭合伤致三尖瓣乳头肌断裂一例

患者　男 ,34岁。在工地被下滑的滚石从背部击倒 ,当即感心悸 ,胸闷 ,气促。受伤后第 5天发生右心衰 ,经药物治疗好转。检查 :左前胸壁局部皮下瘀血 ,胸骨左缘 3～ 5肋间及剑突下可闻及 级收缩期杂音。患者在住院检查期间再度出现右心衰表现 ,经对症治疗后右心衰得到控制。超声心动图检查示三尖瓣前叶腱索断裂 ,瓣叶呈连枷样运动 ,重度三尖瓣关闭不全 ,右房及右室内径增大。在体外循环下经右房切口探查三尖瓣 ,见三尖瓣前叶主乳头肌根部完全断裂 ,瓣环口增宽可容纳 4指。切开右室前壁 ,在室间隔找到乳头肌附着处 ,用 4/ 0带垫片涤纶线褥式…     

室间隔缺损合并隔瓣膨出的手术治疗

室间隔缺损合并隔瓣膨出的手术治疗毛志福，高尚志，林道明，涂仲凡，姚震１９８５年９月～１９９３年４月我们采用隔瓣切开或圆锥乳头肌切断的方法，对３１例室间隔缺损（ＶＳＤ）合并隔瓣囊袋状膨出（ｐｏｕｃｈ病人行手术治疗，获得良好效果。临床资料本组３１例占同期...     

Ebstein 畸形解剖纠治术

目的 总结20例Ebstein畸形解剖纠治术的近期效果。方法 1997年12月至2000年9月,对20例Ebstein畸形患者行解剖纠治术,其中男8例,女12例,年龄3-32岁,平均11岁,Carpentier分型;A型2例,B型4例,C型14例,手术方法;梯形或三角形切除绝大部分房化右心室,沿瓣环切下下移的后瓣及其相连的乳头肌,必要时切下部分或全部隔叶,折叠缝合瓣环,使其恢复大小。将瓣叶根部移植于正常瓣环水平,并对瓣叶组织进行修复,重新移植或固定乳头肌,处理合并病变,合并手术包括：Rastalli手术1例、房间隔缺损修补术5例、缝闭卵圆孔4例、室间隔缺损修补术2例、动脉导管未闭直视缝闭术1例。结果 患者术后均恢复顺利。心功能均恢复I级,术前12例重度三尖瓣关闭不全患者,术后8例三尖瓣返流消失,4例三尖瓣轻度返流;8例中度关闭不全患者,术后7例三尖瓣返流消失,1例轻度三尖瓣返流;三尖瓣叶均在正常水平,房化心室基本消失,术后随访时间1-17个月,平均6个月,患者活活动量恢复正常,超声心动图检查;17例三尖瓣返流消失,2例中度三尖瓣返流,1例轻度三尖瓣返流。结论 Ebstein畸形解剖纠治术的近期效果良好,可能使绝大多数患者免于三尖瓣替换术,远期结果有待进一步观察。     

风湿性三尖瓣器质性病变的外科治疗

目的：根据三尖瓣不同类型病变,探讨对三尖瓣器质性病变比较合理的处理方法。方法：根据超声心动图检查及手术探查结果进行分析,依据不同病理改变决定手术方式,行三尖瓣器质性病变瓣膜成形术和瓣膜置换术53例。以瓣环扩大、瓣叶增厚、关闭不全为主的患者采用改良Kay法或节段性DeVega成形术;交界粘连融合以狭窄为主则切开交界融合,切开处以小垫片缩环,交界对拢缝组成统一瓣;成形失败者行三尖瓣置换术。结果：采用改良Kay法或节段性DeVega成形术43例,切开粘连交界对拢缝合5例,置换生物瓣1例,机械瓣4例,术后早期死亡3例。随访50例,随访时间5个月－9年,随访率为94％,其中1例5年后死于心力衰竭。超声心动图示三尖瓣无反流41例,轻至中度反流8例。心功能恢复到Ⅰ-Ⅱ级44例,Ⅲ级5例。结论;三尖瓣器质性病变绝大部分均可采用瓣膜成形术,三尖瓣置换术的远期效果较为满意。     

无支架二尖瓣制备、保存和体外三尖瓣置换技术探讨

目的观察深低温保存猪二尖瓣超微结构,探索无支架二尖瓣制作方法和置换三尖瓣技术。方法采用猪二尖瓣制成无支架瓣膜,抗生素灭菌深低温保存,透射电子显微镜观察深低温保存１个月的猪二尖瓣组织结构。将离体猪心三尖瓣切除,将无支架猪二尖瓣前瓣环缝合于隔瓣环,二尖瓣后瓣环缝合于三尖瓣前后瓣环,两乳头肌缝合于右心室前壁,完成无支架二尖瓣置换三尖瓣,注水试验观察瓣膜启闭功能。结果透射电子显微镜观察到,深低温保存猪二尖瓣内皮细胞结构完整,胶原纤维结构致密,排列整齐,成纤维细胞胞膜完整,细胞核无固缩现象,线粒体无明显肿胀。无支架二尖瓣置换的离体猪心三尖瓣启闭功能良好。结论深低温保存的无支架猪二尖瓣结构完整,活性得到很好保持。瓣膜设计合理,用此瓣膜置换三尖瓣技术可行     

无支架房室瓣膜替换三尖瓣的实验研究

探索无支架房室瓣膜替换三尖瓣外科技术。方法选用深低温保存犬二尖瓣制成的无支架房室瓣膜１０枚,体外循环下将其前叶缝合于犬三尖瓣隔瓣环,后叶缝合于三尖瓣前后瓣环,两乳头肌缝合于右室前壁。血流动力学监测,测定计算移植瓣膜跨瓣压差、瓣口面积,超声心动图测定其功能。结果１０条犬均顺利脱落ＣＰＢ。无房室传导阻滞。术后血流动力学稳定,术后无支架瓣膜平均跨瓣压差１５２ｍｍＨｇ±０．４２ｍｍＨｇ（１ｍｍＨｇ＝０．１３３ｋＰａ）。１０条犬中,仅２条犬因手术失误造成少～中量返流。结论同种二尖瓣制成的无支架房室瓣膜设计合理,植入技术可行,在三尖瓣位置上近期血流动力学性能优良。     

A successful valve repair case of isolated tricuspid regurgitation due to traumatic lacerated papillary muscle of the tricuspid valve

A case of tricuspid valve regurgitation due to a non-penetrating chest trauma was presented. This case involves a 20-year-old man, who was admitted to a nearby hospital because of rib fracture, mandibular fracture, and hemorrhage of the left hemopneumothorax, caused by a traffic accident. Palpitation and chest discomfort were observed at admission time, but there was no follow-up. Tricuspid regurgitation was pointed out during surgery for the mandibular fracture, and he continued follow up treatment at an outpatient clinic. However his palpitation and chest discomfort worsened, and he was admitted to our department 8 month after injury. During surgery to repear the tricuspid valve, a papillary muscle rupture, valve cusp laceration, and anulus dilatation were found. We performed a papillary muscle repair (chorda tendineae reconstruction), valve cusp suture, and annuloplasty. Absence of the left pericardium was observed during the operation. We reported valve repair of traumatic tricuspid regurgitation which with papillary muscle rupture. Due to its rarity and the fact that there has been no reported cases of papillary muscle repair for traumatic tricuspid regurgitation in Japan, we used resarched information on the subject.     

三尖瓣乳头肌移植的研究

目的;观察犬的三尖瓣乳头肌断裂后原位修复或异位修复后的组织愈合情况和功能状态,为临床工作提供实验依据。方法：将12条杂交犬随机等分为4组,A组：前乳头肌原位移植;B组：前乳头肌异位移植;C组：后乳头肌原位移植;D组;后乳头肌异位移植。分别于术前;术后、术后4周观察心脏瓣膜关闭情况,测量血流动力学指标并观察术后4周乳头肌的组织学变化。结果;4组犬术后血流动力学稳定,乳头肌原位或异位修复后组织愈合及瓣膜关闭良好。结论：乳头肌离断后无论原位或异位移植均能良好愈合,修复后的乳头肌功能良好。     

Closure of Isolated Ventricular Septal Defect with Detachment of the Tricuspid Valve

Detachment of the septal leaflet of the tricuspid valve is an alternative technique for obtaining complete visualization of a perimembranous ventricular septal defect (VSD) in cases where the VSD is obscured by the chordae tendineae or a pouch formation of the septal leaflet. This method presents theoretical concerns because it has the potential for causing postoperative valvular insufficiency. We therefore evaluated valvular function in patients who underwent VSD closure with detachment of the tricuspid valve. In a consecutive series of 153 patients who underwent VSD closure using a transatrial approach, 13 had incision of the tricuspid valve. Follow-up echocardiographic studies were performed on these patients at least 1 year following operation. There were no operative deaths. Color Doppler echocardiography revealed no residual shunt in any of these patients. Ten patients had no evidence of tricuspid stenosis or regurgitation. One patient had trivial tricuspid regurgitation. Moderate tricuspid regurgitation was observed in two patients of these, one patient was a small infant who had a VSD complicated by pulmonary hypertension. The other patient had a VSD with a mitral cleft, pulmonary hypertension, and Down's syndrome. The incised tricuspid valve was resus-pended by solely running sutures. In conclusion, detachment of the tricuspid valve is a safe and useful method for adequate exposure of a VSD. However, this method should be avoided in patients with Down's syndrome and in small infants. Furthermore, repair of the incised valve should not be performed using only running sutures.     

A case of successful surgical treatment of straddling tricuspid valve associated with dextrocardia and VSD

A case of straddling tricuspid valve associated with dextrocardia and VSD was presented. Closure of ventricular septal defect and tricuspid valve replacement were performed on this patient. Since the straddling septal leaflet of the tricuspid valve shared a posterior papillary muscle in the left ventricle with the posterior mitral leaflet, division of this papillary muscle was thought to induce papillary muscle dysfunction of both leaflet. Hence, the chordae of straddling tricuspid leaflet was detached from the shared papillary muscle and the ventricular septal defect was closed by a large pericardial patch. Because of peculiar anatomy of the conduction system in this situation, the junctional area of the inlet septum and tricuspid annulus was avoided from stitching in VSD closure. Suture through the tricuspid septal leaflet and pericardial patch for VSD were used for tricuspid valve replacement as well. The patient showed uneventful postoperative course without any conduction disturbance including the right bundle branch block.     

Severe tricuspid regurgitation following blunt chest trauma: indication for emergency surgery.

A 24-year-old man with polytrauma and severe posttraumatic tricuspid regurgitation due to rupture of all three papillary muscles was subjected to emergency operation 3 days after a car accident. At operation, all three papillary muscles of the tricuspid valve were reinserted. Severe tricuspid regurgitation after blunt chest trauma is an indication for emergency surgical treatment, and can be performed with a low operative risk.     

Subacute tricuspid valve rupture after traumatic cardiac and pulmonary contusions

Tricuspid valve rupture is a rare complication after blunt chest trauma. We report the unusual presentation of a patient that suffered traumatic cardiac and pulmonary contusions, contributing to the rupture of the posterior papillary muscle of the tricuspid valve 24 hours after presentation. We believe that this is the first reported case of subacute tricuspid valve rupture after a normal echocardiogram at admission after blunt chest trauma.     

Massive calcification of the tricuspid valve papillary muscles in right ventricular endomyocardial fibrosis

Right-sided forms account for one-fourth of endomyocardial fibrosis cases in central Africa. A 50-year-old female patient with endo- myocardial fibrosis presented with unusual calcifications of the right ventricular endocardium that embedded the tricuspid valve papillary muscles. Bioprosthetic tricuspid valve replacement together with right ventricular endocardectomy was performed with a good clinical outcome.     

Accessory tricuspid valve--a report of two cases]

Accessory tricuspid valve is a rare cardiac anomaly. We describe two cases with accessory tricuspid valve. Case 1: A 7-year-old boy underwent repair of tetralogy of Fallot. Under deep hypothermic cardiopulmonary bypass, right ventricle was opened. An accessory tricuspid leaflet was noted to the right side of the VSD attaching to the infundibular septum from medial papillary muscle as a chordal origin. After excision of the accessory tricuspid leaflet, the VSD was closed with a Dacron patch followed by relieve of the right ventricular outflow obstruction and pulmonary valvotomy. Case 2: A 8-year-old boy had Rastelli operation to correct transposition of the great arteries. An accessory leaflet originated from the medial papillary muscle and was floating like a parachute in the way between VSD and aorta. There was no additional apparatus in the pathway between the VSD and aorta after excision of the accessory tricuspid leaflet. Intraventricular tunnel was created with a Dacron patch. Extracardiac conduit between the right ventricle and the distal pulmonary artery was constructed using a valved pericardial roll.     

Tricuspid valve replacement after cardiac transplantation.

Tricuspid regurgitation, a fairly common finding after cardiac transplantation, is generally mild or moderate, and is not clinically significant. The etiology of tricuspid regurgitation is not entirely understood, and experience with valve replacement after cardiac transplantation is limited. We describe a case of progressively severe tricuspid regurgitation ultimately requiring tricuspid valve replacement. At operation, the ruptured chordae of the posterior part of anterior and septal leaflet with resulting partially flail leaflets were found. Examination of the papillary muscle showed origins of several of the ruptured chordae. Damage to the tricuspid subvalvular apparatus at endomyocardial biopsy appeared to be a possible cause. A 31-mm Carpentier-Edwards porcine valve was implanted. This was because replacement with a mechanical prosthesis would prevent future right-side heart catheterization and endomyocardial biopsy and in valve repair, the patient remains exposed to the risk of the recurrence of chordal rupture. We discuss proposed causes and choices in surgical technique.     

Surgical treatment of rheumatic tricuspid valve disease

The rheumatic tricuspid valve is relatively rare in this country. We report the study on surgical treatment of 27 patients with rheumatic tricuspid valve. Surgical procedure on 7 cases out of them was tricuspid valve replacement (TVR) with bioprosthesis and tricuspid valvuloplasty (TVP) was performed in the remaining 20 cases. There were two operative deaths in TVR group, however, there were no major complications, such as thrombosed valve, the valve dysfunction or prosthetic valve endocarditis in the remaining five cases after the operation. The method of TVP in twenty cases consisted of two Kay's TAPs, six tricuspid commissurotomies (OTC), ten OTC with Key's TAPs and two OTC with DeVega's TAPs. Doppler cardiography (DCG) revealed residual tricuspid regurgitation (TR) more than 3/4 degrees in 7 cases of TVP group immediately after operation. Moreover, the increment of residual TR was seen in 7 cases during the following period and TVR was performed in 3 cases out of these 7 cases. In conclusion, it is suggested that TVR may be preferred to TVP for the rheumatic tricuspid valve because of severe residual TR in many cases of TVP group.