左心瓣膜置换术后孤立性三尖瓣关闭不全的外科治疗及危险因素

目的 明确左心瓣膜置换术后出现远期孤立性三尖瓣关闭不全（tricuspid regurgitation,TR）的外科治疗效果和危险因素.方法 分析2000年1月至2010年12月广东省人民医院因左心瓣膜术后发生远期孤立性重度TR而接受三尖瓣外科治疗的41例患者的资料.三尖瓣成形（tricuspid valve repair,TVP）7例,三尖瓣置换（tricuspid valve replacement,TVR）34例,比较两组的近、远期结果.并比较存活组与术后早期死亡组及术后远期死亡组的临床资料,分析手术早期及远期死亡的危险因素.结果 随访时间（6.3±3.4）年,随访率97％,死亡14例（34.1％）.TVP组术后死于右心功能衰竭1例（14.3％）,无远期死亡；因再发重度TR于术后3.5年行TVR1例.TVR组手术死亡8例,远期死亡5例,死亡率38.2％.因右心功能衰竭死亡9例,感染性心内膜炎、脑出血、猝死、结肠癌术后肝转移死亡各1例.TVP组死亡率有高于TVR组的趋势（P=0.43）.手术早期死亡组三尖瓣反流面积、肌酐值明显高于与存活组,差异有统计学意义（P＜0.05）；而术后远期死亡组右心室大小、肌酐值明显高于存活组,差异有统计学意义（P＜0.05）.结论 左心瓣膜置换术后远期孤立性TR的再次手术死亡率高,选择TVP将有助于降低死亡率.三尖瓣反流程度重、术前肌酐值升高是手术早期死亡的危险因素;右心室大小和术前肌酐值升高是术后远期死亡的危险因素.

Outcomes and risk factors of surgical treatment in patients with isolated tricuspid regurgitation following left cardiac valve replacement

Objectives To investigate the outcomes and the risk factors of surgical treatment of severe isolated tricuspid regurgitation（TR） after left cardiac valve replacement.Methods From January 2000 to December 2010,41 patients underwent surgical corrections due to severe isolated TR after left cardiac valve replacement at Guangdong Cardiovascular Institute.Tricuspid valve repair （TVP） was performed in 7,and tricuspid valve replacement （TVR） in 34.Follow-up data were obtained from patients＇ visits to the outpatient clinic,telephone or mail contacts.Early and long term outcomes were compared between TVP group and TVR group.In addition,patients were divided into survival group and died group,and the patients of died group were divided into two subgroups：early died group and late died group.The age,interval time between the initial and second surgery,the results of pre-and post-operative echocardiography,laboratory test were compared between survival patients and died patients to find out the risk predictors of early and late mortality in TVR and TVP patients after left cardiac valve replacement.Results Follow-up was 97% complete,one patients was missed,with a mean follow-up period of （6.3±3.4） years （range,2 to 12years）.Fourteen patients died in hospital or during the follow-up period with a 34.1% mortality rate.Out of 7 patients in TVP group,1 patient died of right heart failure in hospital after second surgery with a 14.3% mortality rate,no late death; 1 patient underwent TVR in 3.5 years after the second surgery due to reoccur severely tricuspid regurgitation.There were 8 hospital deaths and 5 late deaths in TVR group with 38.2% mortality rate; the causes of mortality included right heart failure in 9,endocarditis in 1,cerebral hemorrhage in 1,sudden death in 1,and hepatic metastasis of colonic cancer in 1.Higher mortality rate was associated with TVR when compared with that of TVP,although there was no statistic significance.There were significant differences between survival group and early died group in tricuspid regurgitation area,creatinine value P〈0.05.The diameter of right ventricle and the value of creatinine of late died group were higher than those of survival group （P〈0.05）.Conclusions Surgical treatment of isolated TR after left cardiac valve replacement is associated with high rate of mortality.TVP contributed to improve the results of surgery.The severity of tricuspid regurgitation and elevated creatinine value are risk factors associated with early death,and the late death is linked to diameter of right ventricle and creatinine value.