左心瓣膜置换术后孤立性三尖瓣关闭不全的外科治疗

目的 探讨左心瓣膜置换术后的患者远期发生孤立性三尖瓣关闭不全 （TR） 再次手术治疗的危险因素和远期效果。 方法 回顾性分析2000年1月至2013年6月广东省心血管病研究所左心瓣膜置换术后发生远期孤立性重度TR行再次手术65例患者的临床资料，其中男12例，女53例；年龄37～72 （52.3±8.0） 岁，其中合并心房颤动 （AF） 59例。功能性TR 61例，风湿性TR 4例。术前心功能Ⅱ级6例，Ⅲ级40例，Ⅳ级19例。两次手术的间隔时间1～26 （11.2±4.7） 年。行三尖瓣置换术 （TVR） 55例，三尖瓣成形术 （TVP） 10例。 结果 全组患者住院死亡11例 （16.9%）。单因素分析结果显示：男性、术前右心室内径、血浆白蛋白 （ALB）、结合胆红素 （DBil）、体外循环 （CPB） 时间及术前心功能Ⅳ级与手术死亡显著相关；而术前心胸比率 （C/T）、TR面积、左心室射血分数 （LVEF）、肺动脉收缩压 （PAs）、术前血红蛋白 （HGB）、肌酐 （Cr）、总胆红素 （TBil）、丙氨酸氨基转移酶 （ALT） 及两次手术间隔时间均与手术死亡无明显相关性。多因素logistic回归分析结果显示，与手术早期死亡相关的独立危险因素为术前心功能Ⅳ级 （OR=7.23，95% CI：1.57-33.25，P=0.01）。54例生存患者中共有50例获得随访，随访率为92.6%，随访时间1～160 （47.2±43.3） 个月。随访期间死亡5例，其中行TVR患者死于心力衰竭3例、主动脉瓣梗阻1例；TVP1例患者死于心跳骤停。行TVR患者1年和5年生存率分别为95%±3%和89%±7%；行TVP患者1年和5年生存率分别为100%和80%±18%（P=0.92）。Cox回归分析结果显示，与术后远期死亡相关的独立危险因素为术前血肌酐值（HR=1.10，95% CI：1.03-1.17，P＜0.01）。 结论 左心瓣膜置换术后发生远期孤立性三尖瓣关闭不全行再次手术的死亡率与术前患者全身状况和心功能独立相关，外科手术治疗应在严重心力衰竭发生之前进行。术后5年生存率较好，术后远期死亡主要与术前肌酐水平相关。

Surgical Treatment for Isolated Tricuspid Regurgitation after Left-Sided Valve Replacement

Objective To analyze risk factors and long-term outcomes of surgical treatment for isolated tricuspid regurgitation （TR） after left-sided valve replacement. Methods We retrospectively analyzed clinical data of 65 patients who underwent surgical treatment for severe isolated TR after left-sided valve replacement in Guangdong CardiovascularInstitute from January 2000 to June 2013. There were 12 male and 53 female patients with their age of 37-72 （52.3±8.0） years. Fifty-nine patients had atrial fibrillation （AF）. There were 61 patients with functional TR and 4 patients with rheumaticTR. Six patients were in New York Heart Association （NYHA） functional class Ⅱ,40 patients were in NYHA class Ⅲ,and19 patients were in NYHA class Ⅳ.The duration between the first and second cardiac operation was 1-26 （11.2±4.7） years.Fifty-five patients received tricuspid valve replacement （TVR） and 10 patients received tricuspid valvuloplasty （TVP）.Results Eleven patients （16.9%） died postoperatively. Univariate analysis showed that male gender,right ventricularinternal dimension,preoperative serum albumin level （ALB）,direct bilirubin （DBil） level,cardiopulmonary bypass （CPB） time and preoperative NYHA functional class Ⅳ were significantly correlated with postoperative death. Preoperative cardio-thoracic ratio（C/T）,TR area,left ventricular ejection fraction （LVEF）,pulmonary arterial systolic pressure （PAs）,preo-perative hemoglobin（HGB） level,creatinine （Cr） level,total bilirubin （TBil） level,alanine aminotransferase （ALT） leveland the duration between the first and second cardiac operation were not significantly related with surgical mortality.Multivariate logistic regression analysis showed that preoperative NYHA functional class Ⅳ was an independent risk factorof in-hospital death （OR=7.23,95% CI：1.57-33.25,P=0.01）. Among the 54 survivors,50 patients （92.6%） were followed up for 1-160（47.2±43.3） months. Five patients died during follow-up including 3 TVR patients with heart failure,1 TVR patient with aortic valve obstruction and 1 TVP patient with sudden cardiac arrest. One-year and 5-year survival rates of TVR patients were 95%±3% and 89%±7% respectively,and 1-year and 5-year survival rates of TVP patients were 100% and 80%±18% respectively（P=0.92）. Cox regression analysis showed that preoperative Cr level was an independent risk factor of long-term mortality （HR=1.10,95% CI：1.03-1.17,P〈0.01）. Conclusion In-hospital mortality of patients with isolated TR after left-sided valve replacement who undergo surgical treatment is significantly related with preoperative overall condition and heart function. Surgical therapy should be performed before severe heart failure occurs. Postoperative 5-year survival rate is good,and long-term mortality is related with preoperative Cr level.