心脏瓣膜病再次手术221例临床分析

目的总结既往有二尖瓣闭式扩张术、瓣膜成形术、瓣周漏及生物瓣失功能等的患者再次瓣膜手术的经验。方法自1998年1月至2005年8月,实施心脏瓣膜病再次手术221例,其中急症手术8例。其中二尖瓣闭式扩张后再狭窄105例,二尖瓣或主动脉瓣成形术后复发性瓣膜病变37例,瓣周漏29例,生物瓣衰败18例,其他瓣膜再发病变11例,人工瓣膜机械功能障碍9例,Ebstein畸形矫治术后三尖瓣关闭不全7例,人工瓣膜心内膜炎5例。再次手术方式包括二尖瓣置换、二尖瓣和主动脉瓣双瓣置换、主动脉瓣置换、三尖瓣置换。两次手术间隔时间1～21年。结果全组术后死亡19例,占8．6％。早期死亡主要原因为术后低心排综合征、恶性心律失常、多脏器功能衰竭与肾功能衰竭,其中急症手术8例中死亡3例,术前心功能Ⅳ级者手术死亡9例,病死率为14．5％（9／62例）。结论瓣膜病再次手术危险因素包括急症手术、术前心功能差、合并其他重要脏器功能不全、体外循环时间和主动脉阻断时间长等。针对这些因素积极防治,可以进一步降低这类患者手术病死率和并发症发生率。     

Long-term results of bioprosthetic tricuspid valve replacement: an analysis of 25 years of experience

Background

Current knowledge in long-term results of tricuspid valve replacement is limited. Present study reviews our experience from a consecutive series.

Methods

We retrospectively studied the early and late results of 32 consecutive patients (7 male and 25 female; mean age 60.2 ± 18.1 years) undergoing bioprosthetic tricuspid valve replacement between 1985 and 2010. The etiology is rheumatic in 38 %, congenital in 3 %, endocarditis in 9 %, and functional in 50 %. Patients underwent isolated valve replacement. The remaining underwent combined aortic and tricuspid (n = 5, 16 %), mitral tricuspid (n = 15, 47 %), and aortic, mitral, and tricuspid (n = 1, 3 %) valve replacement. Preoperative liver dysfunction was evaluated using Model for End-stage Liver Disease (MELD) score. Mean follow-up was 5.6 ± 6.8 years (ranging from 0 to 25.0 years).

Results

Hospital mortality was 19 %. On univariate logistic regression analysis, NYHA class IV (p = 0.039, odds ratio 11.3, 95 % confidence interval 1.2–112.5), MELD score (>10) (p = 0.011, odds ratio 21.0, 95 % confidence interval 12.0–222.0) and congestive liver (p = 0.05, odds ratio 9.4, 95 % confidence interval 1.0–93.5) were incremental risk factors for hospital death. The 15- and 25-year actuarial survival were 56.5 ± 10.3 % and 45 ± 13.0 %, respectively. Multivariate analysis using Cox proportional hazard model showed MELD score (p = 0.024, hazard ratio 7.0, 95 % confidence interval 2.1–23.9) and postoperative pulmonary hypertension (p = 0.012, hazard ratio 4.4, 95 % confidence interval 1.4–14.1) were significantly associated with decreased survival. At 15 years, freedom rates from tricuspid valve reoperation, anticoagulation-related bleeding, and valve related events were 85.7 ± 13.2 %,95.7 ± 4.3 % and 81.8 ± 13.2 %, respectively. The linearized incidence of structural valve deterioration was 0.50 %/patient-year, anticoagulation-related bleeding was 0.94 %/patient-year, and valve-related events were 1.52 %/patient-year.

Conclusion

Preoperative hepatic congestion and liver dysfunction which were indicated by the MELD score >10 were associated with poor outcome for patients undergoing tricuspid valve replacement. The MELD score is useful to predict the morality among these patients.     

Percutaneous balloon valvuloplasty of a stenosed bioprosthesis (Carpentier-Edwards xenograft) in the tricuspid valve position

Two patients with increasing stenosis of a bioprosthesis in the tricuspid valve position were treated by percutaneous balloon valvuloplasty (PBV). Tricuspid valve replacement with a Carpentier-Edwards xenograft and mitral valve replacement with a Duromedics mechanical valve had been performed in both of them 2 to 3 years prior to PBV. Echocardiographic studies revealed tricuspid bioprosthetic stenosis with a prolonged pressure half time. After PBV, the calculated valve area and cardiac index increased and the pressure half time was shortened, although improvement of clinical symptoms was not apparent. Complications related to the procedure did not occur. Further studies are required to determine the indications and to see the long term results of PBV on stenosed bioprosthesis in the tricuspid valve position, but for the moment, we consider PBV be tried with caution for a stenosed bioprosthesis in the tricuspid valve position before the decision for re-replacement of the prosthesis.     

Ebstein畸形的再次手术策略及中远期结果分析

目的 分析Ebstein畸形的再次手术策略及中远期结果.方法 回顾性分析阜外医院2002年7月至2017年7月因三尖瓣反流行再次三尖瓣手术的23例Ebstein畸形患者的临床资料(同期手术共421例),其中男9例(39.1％)、女14例(60.9％),中位年龄28.0(19.0,45.0)岁.结果 8例(34.8％)患...     

Valve-on-valve technique for replacement of degenerated tricuspid bioprosthetic valve without explantation

A 73-year-old woman admitted to our hospital with shortness of breath and edema of the lower extremities was diagnosed with right ventricular failure stemming from tricuspid valve regurgitation. She had undergone mitral valve replacement (MVR) with a mechanical valve at the age of 51, and reoperative MVR with mechanical valve, tricuspid valve replacement (TVR) with bioprosthetic valve, and pacemaker implantation at the age of 63. Reoperative TVR was performed when the patient failed to respond to drug therapy. A beating heart cardiopulmonary bypass procedure was performed in which only the bioprosthetic valve leaflet was excised, and reoperative TVR was performed with a 27-mm OptiForm^TM mechanical mitral valve (Sulzer Carbomedics Inc., Austin, TX, USA) by the valve-on-valve technique. The operative course was uneventful. The technique used here appears to be an effective approach to reoperative TVR, in this instance making it possible to avoid the risks associated with excision of the old prosthesis.     

Double bioprosthetic valve replacement in right-sided carcinoid heart disease

A patient with tricuspid and pulmonary regurgitation due to carcinoid syndrome successfully underwent double bioprosthetic valve replacement. This technique avoids anticoagulation treatment in a patient with hepatic dysfunction and facilitates future hepatic de-arterialization as a treatment option in carcinoid disease. Advances in treatment of carcinoid syndrome may have reduced the risk of early bioprosthetic degeneration.     

Tricuspid valve replacement: an analysis of 25 years of experience at a single center

BACKGROUND: Tricuspid valve replacement is seldom used in clinical practice, but the choice between mechanical and biologic prostheses remains controversial. METHODS: Between 1977 and 2002, 97 patients underwent tricuspid valve replacement and were followed at the Montreal Heart Institute Valve Clinic. Patients underwent replacement with bioprostheses (n = 82) and mechanical valves (n = 15). RESULTS: Patients with bioprosthetic tricuspid replacements averaged 53 +/- 13 years of age compared with 48 +/- 11 years in those with tricuspid mechanical valve replacements (p = 0.2). Isolated tricuspid valve replacement was performed in 11 patients (73%) in the mechanical valve group compared with 31 patients (38%. p = 0.01) in the bioprosthetic replacement group. In patients undergoing bioprosthetic tricuspid replacement, 51 (62%) underwent multiple associated valve replacements. The 5-year survival after tricuspid replacement averaged 60% +/- 13% in the mechanical valve group and 56% +/- 6% in the biologic replacement group (p = 0.8). The 5-year freedom rate from tricuspid valve reoperation averaged 91% +/- 9% in patients with mechanical valves and 97% +/- 3% in those with biologic valves (p = 0.2). CONCLUSIONS; Patient survival after tricuspid valve replacement is suboptimal but related to the clinical condition at operation. The use of biologic prostheses for tricuspid valve replacement remains a good option in young patients because of limited life expectancy unrelated to the type of tricuspid prostheses at long-term follow-up.     

Tumor‐like tricuspid myxomatus degeneration with a primary cardiac leiomyoma: A rare case report

We present an unusual case of a 47‐year‐old male with a cardiac mass arising from the tricuspid valve, which was misdiagnosed as a cystic myxoma. The patient received successful resection of the pathological tissue and tricuspid valvuloplasty. The mass turned out to be tricuspid cystic myxomatus degeneration with a primary cardiac leiomyoma finally. There was no recurrence after complete resection and tricuspid valvuloplasty by 1‐year follow‐up. To our best of our knowledge, only several cases of primary cardiac leiomyoma have been reported, and this is the first case of primary cardiac leiomyoma involving the tricuspid valve in an adult man. The present case suggests that the tricuspid valve should be another rare site of primary cardiac leiomyoma.     

Mechanical Valve Replacement Versus Bioprosthetic Valve Replacement in the Tricuspid Valve Position

Background

The purpose of this study was to evaluate the clinical outcomes and risk of tricuspid valve replacements and to compare bioprosthetic versus mechanical valves.

Methods

Between 1991 and 2009, 104 consecutive patients (71 women; mean age, 57 ± 10.8 years) with tricuspid valvular disease underwent mechanical TVR (mechanical group; n = 59) or bioprosthetic TVR (bioprosthesis group; n = 45). Follow‐up was complete in 97.1% (n = 101) with a median duration of 49.9 months (range 0–230 months).

Results

Hospital mortality after mechanical TVR and bioprosthetic TVR was not different on adjusted analysis by propensity score. Ten‐year actuarial survival after mechanical and bioprosthetic TVR was 83.9 ± 7.6% and 61.4 ± 9.1%, respectively (p = 0.004). However, there was also no significant difference in terms of adjusted analysis by propensity score (p = 0.084). No statistically significant difference was detected between mechanical and bioprosthetic valves in regard to event‐free survival.

Conclusions

Mechanical TVR is not inferior to bioprosthetic TVR in terms of occurrence of valve‐related events, especially anticoagulation‐related complications. doi: 10.1111/jocs.12093 (J Card Surg 2013;28:212–217)     

Observation of the right atrial wall suture line after tricuspid valve supra-annular implantation

Strength of the right atrial wall suture line after tricuspid valve supra-annular implantation (TVSI) is controversial. We observed the right atrial supra-annular position of a 63-year-old male during his third mitral operation who underwent mitral valve replacement (MVR) and TVSI 15 years ago. Eight years later, he received the second MVR and removal of the bioprosthetic valve from the tricuspid position due to primary tissue failures. The annular size of the tricuspid valve had decreased enough to be fixed by tricuspid annuloplasty (TAP) and re-TVSI was not needed at that time. In this operation, 7 years following bioprosthetic valve removal, the circularly bulging atrial wall still remained and seemed to have enough strength for holding the prosthetic valve. This finding may support the conclusion that the right atrial wall has enouth strength for holding a prosthetic valve in position.     

A case report of isolated congenital tricuspid regurgitation

Reports of isolated congenital tricuspid regurgitation are very rare. A 20-year-old female with severe tricuspid regurgitation was reported. The patient was admitted to our hospital with complaints of easy fatigability and palpitation. Right ventriculogram showed severe tricuspid regurgitation. She was treated with tricuspid valve replacement with a 33 mm bioprosthetic valve. Seven surgical treated cases of isolated congenital tricuspid regurgitation including our case were collected from literature and reviewed.     

Outcome of tricuspid valve surgery in the presence of permanent pacemaker

Objectives

Given the paucity of available literature, we sought to evaluate the mechanisms of tricuspid regurgitation and the outcomes of tricuspid valve surgery in the presence of permanent pacemakers.

Physiological Manometric Tested Tricuspid Valvuloplasty

Tricuspid insufficiency associated with severe left-sided valvular heart disease carries a poor prognosis. Twenty-two patients with severe pulmonary hypertension and tricuspid insufficiency underwent a tricuspid valvuloplasty in addition to left-sided single or double valve replacement. The tricuspid valvuloplasty was performed after weaning the patient from cardiopulmonary bypass. The efficacy of the tricuspid valvuloplasty was gauged by continuous right atrial pressure recordings as the annuloplasty was completed. Obliteration of the peak of the V wave of the right atrial pressure recordings indicated that the tricuspid annuloplasty was secured. Twenty-one patients were long-term survivors, and 19 patients are in good condition for an average follow-up of 6.1 years (1 to 12 years postoperatively).     

Excision of tricuspid valve with later replacement in endocarditis of drug addiction.

Staphylococcal endocarditis in a drug addict was controlled only after excision of the tricuspid valve. Total absence of the tricuspid valve was tolerated well for 18 months, at which time deteriorating liver function prompted the insertion of a bioprosthetic valve into the tricuspid ring. The haemodynamic and clinical results after two years of follow-up have been excellent.     

Early acute thrombosis of bioprosthetic mitral valve presenting with cardiogenic shock

Early thrombosis of bioprosthetic mitral valves is an extremely rare occurrence. We present an unusual case of a patient with polycythemia presenting with cardiogenic shock, secondary to acute thrombosis of a bioprosthetic mitral valve which was placed 14 months prior to presentation. Our report also reviews predisposing factors and treatment options for bioprosthetic mitral valve thrombosis.     

Excision of Papillary Fibroelastoma Arising from the Septal Leaflet of the Tricuspid Valve

A case of a papillary fibroelastoma (PFE) arising from the tricuspid valve was reported. It was incidentally detected by two-dimensional transthoracic echocardiography. Prior to 1977, these tumors were exclusively found at postmortem examination. This is only the fourth reported case of a tricuspid valve PFE found by echocardiography, treated by excision, and with tricuspid valvuloplasty preserving the native valve.     

Surgery for the valvular disease in children

We report the results and long-term follow up in 34 children (17 girls and 17 boys, aged 12 days to 13 years, average age 3.3 years, average body weight 11.7 kg) who underwent valvular surgery in the period between May 1989 and November 1996. Operative mortality was 11.8%. Actuarial survival curves (including hospital mortality) indicate a 68.6% survival rate at 5 years and that 64.7% of patients are free from reoperation at 5 years. For aortic regurgitation two patients applied aortic valvuloplasty and four applied aortic valve replacement. Nine children had aortic stenosis, three of them had balloon valvuloplasty, seven had valvotomy, two had aortic valve replacement. Ten patients were treated for mitral regurgitation. There were nine valvuloplasty and four mitral valve replacement including three times of reoperation. One membranous pulmonary atresia and seven pulmonary stenosis children had valvotomy. There were four cases of tricuspid disease. One had tricuspid valve stenosis with pulmonary stenosis, three had severe tricuspid regurgitation who applied tricuspid valve replacement. Mortality was high in the critical AS, severe MR and TVR groups. Patients who survived the surgery and had no complications showed satisfiable results.     

Prosthetic replacement of tricuspid valve: bioprosthetic or mechanical

BACKGROUND: Tricuspid valve replacement is one of the most challenging operations in cardiac surgery. Selection of the suitable prosthesis is still debatable. METHODS: In our institution, between January 1980 and December 2000, 129 tricuspid valve replacements were performed in 122 patients (14.7%). Bioprosthetic valves were used in 32 patients, whereas 97 patients had mechanical valve implantation. Twenty-two percent of replacements were done on men. Mean age was 35.27+/-11.56 years. In all patients, initially an annuloplasty technique was tried. Tricuspid valve replacement was performed when annuloplasty was not sufficient. In most of the cases, tricuspid valve interventions were done under cardiopulmonary bypass and on a beating heart. RESULTS: Early mortality was 24.5%. Patients were followed for 2 to 228 months. Seven patients underwent reoperation because of tricuspid valve dysfunction (7.6%). Nine patients died during the follow-up period. Late mortality was 9.7%. Actuarial estimates of survival in 20 years of follow-up for all tricuspid prosthetic valves, mechanical valves, and bioprosthetic valves were 65.1%+/-9.3%, 68.3%+/-10.6%, and 54.8%+/-12.1%, respectively. For the bioprosthetic valve group, freedom from structural valve degeneration was 90%+/-5.5%; for the mechanical valve group, freedom from deterioration, endocarditis, and leakage was 97.8%+/-4.2%, and freedom from thromboembolism was 92.6%+/-6.9%. CONCLUSIONS: We found that there was no statistically significant difference between the two groups in terms of early mortality, re-replacement, and midterm mortality (p > 0.05). Nevertheless, we recommend low profile modern bileaflet mechanical valves for prosthetic replacement of the tricuspid valve, due to their favorable hemodynamic characteristics and durability.     

Sutureless aortic valve replacement with concomitant valvular surgery

Objectives

Sutureless aortic valve replacement (SU-AVR) is an alternative technique to standard aortic valve replacement. We evaluated our experience with the Perceval SU-AVR with concomitant mitral valve surgery, with or without tricuspid valve surgery, and aimed to discuss the technical considerations.

Valve replacement in the right side of the heart in children: long-term follow-up

Twenty-five patients (16 male, 9 female) underwent right-sided valve replacement (10 pulmonary valve replacement, 14 tricuspid valve replacement, 3 tricuspid plus pulmonary valve replacement, and 2 replacements of a single atrioventricular valve) at the University of Nebraska Medical Center from June 1977 to December 1986. Twenty-one patients (84%) are long-term survivors with 2,035 months follow-up (range, 41 to 143 months; mean, 96.9 months). Twenty-three Carpentier-Edwards bioprosthetic valves, one Ionescu-Shiley bioprosthetic valve, and nine St. Jude Medical valves were inserted. Follow-up of 17 patients with a Carpentier-Edwards valve ranged from 5 years 9 months to 11 years 9 months (mean, 8 years 11 months). To date there has been one reoperation after 3 years 4 months in this group. One patient who received an Ionescu-Shiley bioprosthesis required re-replacement at 20 months after operation. Three of 4 patients who received St. Jude mechanical valves and are long-term survivors have required replacement after 36 to 56 months. We conclude that the Carpentier-Edwards bioprosthetic valve is a viable option in the right side of the heart in the young age group when annular size is adequate to accommodate an appropriate bioprosthesis.