应用全方向M型超声心动图术中监测评价二尖瓣狭窄患者右心功能变化

目的 探讨在心脏手术中应用全方向M型超声心动图（omni-directional M-mode echocardiograph,OME）评价右心功能的价值. 方法 二尖瓣狭窄行二尖瓣置换术患者55例,术前将患者分为轻度肺动脉高压组38例（Ⅰ组）和中、重度肺动脉高压组17例（Ⅱ组）.术中经食道超声心动图（transesophageal echocardiography,TEE）监测,应用OME及定量组织速度成像技术分别测量术前、术后三尖瓣环收缩期峰值速度（peak systolic velocity of tricuspid annulus,Sa）. 结果 术后Sa大部分位点较术前增加（Ⅰ组的间隔、前壁,Ⅱ组的各位点,P＜0.05）;Sa与肺动脉收缩压（pulmonary arterial systolic pressure,PASP）成负相关（r=-0.85,P＜0.01）;两种技术测值差异无统计学意义（P＞0.05）,相关性良好（P＜0.01）. 结论 全方向OME在术中监测评价二尖瓣置换术后右心功能具有一定指导意义.     

应用彩色多普勒对二尖瓣置换术后三尖瓣功能的远期随访

目的应用彩色多普勒超声评价二尖瓣置换术后远期三尖瓣功能及形态变化。方法对接受二尖瓣置换术的903例病人术后三尖瓣功能进行了2～9年,平均(3.6±2.4)年的跟踪观察。所有病例术前均有不同程度的三尖瓣环扩大或关闭不全,其中未行三尖瓣成形术者201例;行Kay或改良DeVega成形术者686例;三尖瓣成形术同时加成形环者16例。结果未行三尖瓣成形术者术后2～3年有46例出现三尖瓣重度关闭不全;行Kay或改良DeVega成形术者,术后3～5年150例出现中重度三尖瓣关闭不全;三尖瓣成形术同时加成形环者仅1例术后2年出现三尖瓣轻-中度关闭不全。结论二尖瓣置换术后远期三尖瓣功能性关闭不全与三尖瓣环扩大、右心功能损害和严重肺动脉高压有关,三尖瓣环扩大是其重要的原因。对二尖瓣置换术者,手术中一旦发现有三尖瓣环扩大,即使无三尖瓣关闭不全,亦应行三尖瓣成形术,重度三尖瓣关闭不全、瓣环明显扩大者最好在环缩术的同时加成形环。     

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.     

左心瓣膜置换术后远期三尖瓣关闭不全的外科处理

目的探讨左心瓣膜置换术后远期三尖瓣关闭不全(TR)发生的可能机制以及外科治疗方法的选择和结果.方法 56例左心瓣膜置换术后远期发生TR行再次瓣膜手术的病人,10例人工瓣膜功能正常(A组)者中行二尖瓣置换(MVR)4例,主动脉瓣、二尖瓣双瓣置换(DVR)6例;46例人工瓣膜功能障碍(B组)者中MVR 36例,主动脉瓣置换(AVR)4例, DVR 6例.在A、B两组中,46例第1次手时三尖瓣未见明显异常,10例第1次手术时已行DeVega三尖瓣成形(TVP),第2次手术时发现缝线断裂3例,缝线撕脱7例.56例TR病人再次手术时9例行三尖瓣替换(TVR),其中6例三尖瓣呈风湿性改变;47例行TVP.结果 TVP和TVR各死亡1例,病死率3.6%.54例获随访,随访时间6～132个月,平均(79.4±34.8)个月.8例TVR病人术后心功能恢复良好,46例TVP者40例为轻度TR,5例出现中度TR,仍需强心、利尿药维持,1例再次出现重度TR.结论左心瓣膜置换术后远期TR可能与持续肺动脉高压、右心室不可逆损害、三尖瓣风湿性病变、左心功能的恢复情况以及持续心房纤颤有关.重度功能性TR和三尖瓣风湿性病变者行TVR的疗效可靠.随访发现部分TVP病人功能性TR仍有逐渐加重趋势.     

Pulmonary annuloplasty in functional pulmonary regurgitation associated with mitral stenosis: a case report

In order to prevent disadvantage of pulmonary regurgitation (PR) on cardiac function, pulmonary annuloplasty (PAP) was performed in a 58-year-old female. She suffered from severe mitral stenosis with right heart failure, and was in a state of cardiac cachexia. She was associated with PR due to pulmonary annular dilatation secondary to severe pulmonary hypertension. She underwent mitral valve replacement, tricuspid annuloplasty and PAP around the pulmonary annulus using a Teflon tape. No PR was observed by postoperative angiograms, and the operative method was proved to be effective on the treatment for PR. The PAP is recommended for patients with functional PR secondary to severe pulmonary hypertension.     

Starnes procedure in a neonate with pulmonary atresia and intact ventricular septum

We describe the case of 7-day-old neonate with pulmonary atresia, intact ventricular septum, and severe tricuspid valve (TV) dysplasia who underwent a Starnes right ventricular exclusion procedure (RVEP). The patient had severe tricuspid stenosis and regurgitation and right ventricular dysfunction after perforation and balloon dilation of the pulmonary valve.     

Pulmonary atresia and intact ventricular septum. Definitive repair in the neonatal period

Pulmonary atresia with an intact ventricular septum and a small right ventricle is associated with high mortality and lacks a consensus surgical approach. The results of operations in eight of eleven patients with either pulmonary atresia and an intact ventricular septum or critical pulmonary stenosis, hypoplastic right ventricle, and intact ventricular septum, who were operated on between 1983 and 1989, are presented. Definitive correction was performed via a right ventricular transannular patch with prolonged postoperative prostaglandin E1 infusion. Limiting conditions in using this approach were (1) severely hypoplastic right ventricle, (2) massive tricuspid regurgitation, or (3) right ventricle-dependent coronary artery blood supply. Eleven neonates had the aforementioned diagnoses; eight underwent definitive repair, five successfully. Successful outcome, up to 5 postoperative years, was achieved if the tricuspid valve diameter was greater than or equal to 0.75 cm, or if the tricuspid/mitral valve ratio was greater than or equal to 0.70. Other significant predictors of success were a tripartite right ventricle (p less than 0.006), lack of sinusoids (p less than 0.05), the ratio of the right ventricular internal and external diameters greater than or equal to 0.73 (p less than 0.05), and some contractility (p less than 0.04). Thus we choose a right ventricular transannular patch with long-term prostaglandin E1 infusion for patients with pulmonary atresia and intact ventricular septum if (1) they have a tricuspid valve diameter of 0.75 cm or 70% of the mitral valve size, (2) they have a tripartite right ventricle, (3) they exhibit some right ventricular contractility, (4) they do not have marked tricuspid valve insufficiency, and (5) the coronary arteries do not fill primarily from sinusoids.     

De Vega tricuspid annuloplasty for tricuspid regurgitation in children

BACKGROUND: Significant tricuspid valve regurgitation (TR) occurs with other congenital heart defects, typically after repair of right-sided obstructive lesions. Since 1991, we applied the De Vega tricuspid annuloplasty technique for TR in children. METHODS: Forty-one children, aged 5 months to 22.7 years (mean, 9.9 years) underwent 42 De Vega tricuspid annuloplasties for moderate or severe TR during correction of other heart defects. One child had a De Vega during primary ventricular septal defect repair. The remaining patients had prior repair of tetralogy of Fallot or pulmonary atresia, or both (19 patients), double-outlet right ventricle (6 patients), pulmonary stenosis (4 patients), pulmonary atresia and intact ventricular septum (3 patients), complete atrioventricular septal defect (3 patients), and other diagnoses (6 patients). At the time of the De Vega, 37 patients (88%) had pulmonary valve replacement or right ventricular to pulmonary artery conduit replacement. Other procedures included aortic or mitral repair or replacement (6 patients), atrial septal defect and ventricular septal defect closure (5 patients), pulmonary arterioplasty (6 patients), and tracheoplasty (1 patient). RESULTS: There were no deaths at follow-up of 3.4 +/- 2.1 years; 1 child required cardiac transplantation 17 months postoperatively. Early postrepair echocardiography quantified TR as absent or mild (34 patients; 81%), mild-to-moderate (4 patients), moderate (3 patients), and severe (1 patient). The most recent echocardiogram showed moderate TR in 11 patients and severe TR in 2 patients (both with recurrent right ventricular hypertension). One child required tricuspid valve replacement 3 years later and 1 child had redo De Vega at the time of conduit re-replacement. No other child has symptomatic TR, significant tricuspid stenosis, or De Vega-related pacemaker implantation. CONCLUSIONS: The De Vega tricuspid annuloplasty safely provides excellent relief of TR, usually in children undergoing pulmonary valve replacement or conduit replacement. Although echocardiographic TR tends to increase with time (especially with right ventricular hypertension), it rarely requires reintervention or causes symptoms.     

Prostaglandin E1. A new therapy for refractory right heart failure and pulmonary hypertension after mitral valve replacement

Patients undergoing mitral valve replacement, particularly those with severe pulmonary hypertension and/or congestive heart failure, may develop life-threatening right heart failure in the immediate postbypass period. We have observed that such patients have intense pulmonary vasoconstriction. The markedly increased pulmonary impedance may aggravate the right heart failure and prevent recovery of right ventricular function in this setting. Therefore, we studied the effects of high-dose prostaglandin E1 (30 to 150 ng/kg/min), a potent pulmonary vasodilator, in combination with massive infusion of norepinephrine (up to 1 microgram/kg/min) into the left atrium in five consecutive patients with refractory right heart failure and pulmonary hypertension after mitral valve replacement. This pharmacologic approach takes advantage of the pulmonary vasodilating effects of prostaglandin E1, while offsetting associated systemic vasodilation and resulting hypotension. All five patients had rapid pulmonary vasodilator responses followed by marked improvement in right ventricular function. All survived the operation and none had right ventricular infarction or chronic right heart failure postoperatively.     

Cardiac Myxoma

Ten patients with cardiac myxoma were reviewed. They ranged from 23 months to 60 years old. Echocardiography was the most helpful noninvasive diagnostic technique. The tumor was demonstrated by angiocardiography, left atrial myxomas frequently migrating to the left ventricle in diastole. Hemodynamically, left atrial myxomas were associated with moderately severe pulmonary hypertension and simulated mitral stenosis or insufficiency and right atrial myxomas, with right atrial hypertension. There were 7 myxomas in the left atrium, 2 in the right atrium, and 1 in the right ventricle.Eight patients underwent open-heart operation with removal of the myxoma, 1 had concomitant tricuspid valve replacement, and 1 had biopsy of the right ventricle only. The other patient was a Jehovah's Witness and refused operation. One patient died of cardiac arrest intraoperatively, and another died of a bilateral cerebral infarct. One patient had recurrence requiring reoperation. Postoperative hemodynamic and clinical improvement was more striking in patients with a left atrial myxoma presumably due to a normal mitral valve in contradistinction to the tricuspid valve.     

A study of isolated tricuspid valve surgery late after left heart valve operation

Management of severe tricuspid regurgitation late after left heart valve operation is controversial. There has been reluctance to the operation due to the high risk of repeat operation, coexistent right ventricular dysfunction and pulmonary hypertension. We investigated 6 cases of isolated tricuspid valve surgery (tricuspid valve replacement: 2, tricuspid valve plasty: 4) late after left heart valve operation. Before operation, these patients showed poor general condition (4 cases were NYHA III or IV) but good left ventricular function [mean ejection fraction (EF) 66 +/- 9.6%]. Hospital mortality was 0% and the mean mid-term actual event-free survival over 2 +/- 1.8 years was 80%. Most of patients demonstrated NYHA I and improvement of hepatomegaly after operation. There were many complications in 2 cases that had been performed previous operation more than 20 years before. In summary, the patient who complained symptoms due to right heart ventricular failure and showed good left ventricular function after left heart valve surgery should be considered to undergo tricuspid valve operation before the occurrence of other complications.     

Mid-term results of tricuspid annuloplasty using the MC3 ring for secondary tricuspid valve regurgitation

We investigated mid-term outcomes after ring annuloplasty with the MC3 ring and aimed to identify factors associated with recurrent tricuspid regurgitation (TR). From October 2006 to October 2010, 136 patients (male:female 80:56, with a mean age 64.7±11.8 years) underwent tricuspid valve (TV) annuloplasty for functional TR. The indications for TV annuloplasty were (1) severe TR, or (2) mild or moderate TR with pulmonary hypertension (systolic pulmonary artery pressure >50 mmHg) or tricuspid annular (TA) dilatation, in patients undergoing mitral valve (MV) surgery. The average follow-up period was 1.5±0.8 years. The overall survival rates were 97.1±0.15%, 93.4 ± 0.02% and 90.7 ± 0.28% at three months, one year and four years, respectively. Freedom from recurrent moderate TR was 98.5±0.01, 95.6 ± 0.17% and 90.6 ± 0.03% at three months, one year and four years, respectively. Multivariate analysis revealed that residual TR was significantly associated with preoperative severe TR, left ventricular end-diastolic dimension >70 mm, right ventricular dimension >40 mm, dilated cardiomyopathy (DCM) and left ventriculoplasty. This MC3 ring corrects TR effectively, and provided good results. We must point out, however, that additional or alternative surgical options should still be considered for high-risk of repair failure, such as those with DCM or high pulmonary hypertension.     

二尖瓣置换术后远期功能性三尖瓣关闭不全的外科治疗

目的：报告二尖瓣置换（ＭＶＲ）术后远期三尖瓣关闭不全（ＴＲ）外科治疗的结果及作用,方法：３７例ＭＶＲ术后中重度ＩＲ病人,其中人工二尖瓣为生物瓣者１３,机械瓣２４例,有１１例行内科保守治疗,２６例行外科手术治疗,手术类型,ＭＶＲ加三尖瓣置换２例,ＭＶＲ加三法瓣成形１１例,三尖瓣置换３例,三尖瓣成型１０例,三尖瓣成形术包括改良Ｋay形成形１２例,改良ＤeVega成形术７例,加成形环的三尖瓣成形术２例,结果：１１例内科治疗者,７个月－７．５年后７６例死亡,病死率为５４．５％,26例手术治疗者,术后早期病死２例,病死率为７．７％,随访个月－１０．５年,晚期死亡例,仍中度ＴＲ２例,结论：ＭＶＲ术后远期ＴＲ的产生与不可逆的左心损害或（和）严重肺动脉高压有关,对重度ＴＲ伴有临床症状、左心功能基本正常者,行三尖瓣成形或三尖瓣置换术可取得良好的效果。     

Surgical strategy for tricuspid valve disease

The most common cause of tricuspid valve dysfunction is functional tricuspid regurgitation (TR) secondary to mitral valve disease. Annuloplasty is feasible in most patients with functional TR, and valve repair can also be performed in most patients with tricuspid valve dysfunction of other etiologies. Valve replacement is considered to be indicated only for those patients whose tricuspid valves have severe organic change or have been damaged by infective endocarditis. Although good long-term results of tricuspid valve replacement using bioprostheses have been reported, a bileaflet mechanical prosthesis may be an acceptable alternative in those patients who undergo concomitant valve replacement with a mechanical prosthesis in the mitral or aortic position or who may have persisting pulmonary hypertension after surgery.     

Tricuspid annuloplasty and right ventricular function in mitral valve disease

From 1985 to 1987, we examined relationship between the lesion of tricuspid valve and right ventricular function in 31 patients (male: 9, female: 22) with mitral valve disease. The median age at operation was 52 years (range 37-69 years). Group I consisted of 17 patients (MS: 10, MSR: 5, MR: 2) accompanied with tricuspid regurgitation (TR) and Group II 14 patients (MS: 12, MSR: 2) without TR. In all cases of Group I tricuspid annuloplasty (TAP) were performed correctly. De Vega methods were done in 12 cases and Carpentier rings were used in 5 cases. Cardiac catheterization was done before and after operation. And right ventricular volume was measured by right ventricular angiography. In both groups pulmonary capillary wedge pressure, pulmonary artery pressure and cardiac index were improved postoperatively. Pulmonary artery resistance (PAR) and total pulmonary resistance (TPR) in Group I were significantly higher before operation but there were no difference between two groups postoperatively. Right ventricular end-diastolic volume index (RVEDVI) and right ventricular end-systolic volume index (RVESVI) in Group I were significantly improved postoperatively, but in Group II these were within normal range both pre- and postoperatively. Preoperative PAR was correlated inversely with postoperative right ventricular ejection fraction (RVEF). It means that patients with severe pulmonary vascular lesion had postoperative lower right ventricular function. In both groups, RVESVI was in inverse correlation with RVEF pre- and postoperatively. In both groups, there was an inverse correlation between the per cent change of RVESVI and that of RVEF. This means that RVESVI influenced right ventricular pump function.     

Staged Fontan procedure for mitral atresia associated with severe tricuspid regurgitation, pulmonary hypertension, and pulmonary artery distortion

Optimal initial palliation and a subsequent staged approach is mandatory for high-risk Fontan candidates. We describe the case of mitral atresia with severe tricuspid regurgitation and pulmonary hypertension successfully managed by repeated palliation from the neonatal period and 2-stage Fontan surgery. A 1-month-old boy diagnosed with mitral atresia and double-outlet right ventricle underwent pulmonary artery banding at 1 month of age, followed by repeated pulmonary artery banding accompanied by tricuspid annuloplasty and atrial septal defect enlargement at 6 months. Because of the presence of pulmonary artery distortion, right ventricular dysfunction, and borderline pulmonary vascular resistance, a hemi-Fontan procedure was conducted with extended pulmonary artery plasty when the boy was 3 years and 8 months old. Cardiac catheterization done 3 months after showed improvement in risk factors, and the final Fontan operation (total cavopulmonary connection) was successfully done in conjunction with repeated tricuspid annuloplasty when the boy was 4 years and 5 months old. The patient remains in excellent clinical condition at the last follow-up 5 years after the final Fontan procedure with sinus rhythm and good ventricular function.     

Incidental diagnosis of an ostium-secundum-type interatrial communication during coronary surgery

Preoperative assessment of a 73-year-old woman scheduled for coronary revascularization revealed signs of severe disease in three coronary vessels, mild mitral valve insufficiency, moderate tricuspid insufficiency and moderate-to-severe pulmonary hypertension, with preserved left ventricular function. During surgery pulmonary artery catheter measurements confirmed pulmonary hypertension and the presence of very high cardiac output, leading to suspicion of atrial septal defect. Peripheral vein and right atrial blood samples revealed a sudden increase of 23 mm Hg in PO2 and of 22% in oxygen saturation. Finding the opening in the wall of the right atrium gave diagnostic confirmation of an ostium secundum defect 3 cm in diameter. The defect was closed and the coronary vessel bypasses were created. Upon weaning from extracorporeal circulation, the sudden oximetric increase was seen to have disappeared and pulmonary artery pressures had decreased. Postoperative course was satisfactory, with normal sinus rhythms alternating with episodes of atrial fibrillation. We stress the importance of invasive hemodynamic monitoring and transesophageal echography during heart surgery to confirm diagnoses that have not been established during preoperative assessment.     

Non-penetrating traumatic tricuspid regurgitation after mitral valve replacement

A case of traumatic rupture of the tricuspid chordae tendineae with severe regurgitation in a patient who previously had mitral valve replacement is presented. In this case, it is strongly suggested that a firm pericardial adhesion of the anterior right ventricular wall became a factor of the disruption of the tricuspid valve under a slight precordial blow.     

Severe tricuspid regurgitation late after aortic and mitral double valve replacement; report of a case

A 59-year-old man had undergone aortic and mitral valve replacement (DVR) for rheumatic aortic and mitral valve stenosis 15 years ago. At that time, echocardiography did not detect tricuspid regurgitation (TR), and catheterization data showed right atrial pressure v wave of 8 mmHg and pulmonary artery pressure of 27/12 (17) mmHg. One year after DVR, hepatomegaly and jugular venous dilatation appeared, and after 5 years edema of both legs became apparent. After 7 years, chest X-ray showed an increase of cardio-thoracic ratio, and for the first time, echocardiography detected mild TR. Fifteen years after DVR, severe general fatigue, shortness of breath and hepatomegaly could not be controlled with medication. Catheterization data showed right atrial pressure v wave of 23 mmHg and pulmonary artery pressure of 28/13 (17) mmHg. Right ventriculography showed progression of severe TR. Tricuspid valve replacement (TVR) was performed using a St. Jude Medical 31 M mechanical valve under natural cooling and heart beating. The tricuspid valve was only slightly thickened and no subvalvular abnormalities were seen other than a severely dilated tricuspid annulus. Postoperative course was uneventful and he was discharged 44 days after the TVR. He is currently doing well 6 years after the TVR. All terms, he did not have pulmonary hypertension or left-side heart problems. We suspect that the cause of TR was not secondary, and was included in the category of isolated TR. If the left heart is completely treated, as in this case, it is important to follow-up for signs of right heart failure, before TR is detected.     

Surgical management of tricuspid regurgitation in patients undergoing mitral valve surgery--analysis of the amount of tricuspid valve annular dilatation]

As a means to determine whether correction for tricuspid regurgitation (TR) in mitral valve surgery is necessary, pulsed Doppler echocardiography was used to study 61 patients (age 49.5 +/- 9.5 years) who underwent mitral valve surgery. Early postoperative tricuspid regurgitation (average 9 +/- 3 postoperative days) was evaluated by a comparison with tricuspid valve annular dilatation and systolic annular shortening in preoperative right ventriculography. Kishimoto's method was used to measure the angiographic maximal early systolic (TVD) and minimal end-systolic diameters where as the shortening of the tricuspid annulus (STA) was expressed as a percent reduction in the maximal diameter by Ubago's methods. Patients were categorized into two groups, i.e., a group having had tricuspid annuloplasty (TAP group n = 23), and a NON-TAP group (n = 38). Preoperative right ventricular volume and hemodynamic indicator were studied with respect to both the TVD and the STA. Results are as follows: 1) The TVD significantly correlated with the end-diastolic right ventricular volume index (EDVI), regurgitant fraction of the tricuspid valve (RF), end-systolic right ventricular volume index (ESVI), pulmonary vascular resistance (PVR), mean pulmonary artery pressure (PAm), mean right atrial pressure (RAm), and right ventricular end-diastolic pressure (RVEDP) (p less than 0.01). 2) The STA was significantly correlated with EDVI, RF, ESVI, RAm and RVEDP (p less than 0.01). In the NON-TAP group, the TVD was significantly larger in patients with residual TR (average 32.5 mm/m2) than in patients having postoperative disappearance of TR (average 25.7 mm/m2) (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)