改良三尖瓣环成形技术治疗功能性重度三尖瓣反流

目的 总结采用改进瓣环成形技术加用人工毡条加固的方法进行三尖瓣成形的手术效果。方法 2008年1月至2010年6月，76例平均年龄53.3岁。合并左心瓣膜疾病的重度三尖瓣关闭不全患者接受手术。其他病变包括：二尖瓣病变52例，主动脉瓣病变5例，二尖瓣、主动脉瓣双瓣病变19例，左房血栓22例，房颤73例。心功Ⅱ级6例，Ⅲ级47例，Ⅳ级23例。行二尖瓣置换52例，主动脉瓣置换5例，二尖瓣及主动脉瓣置换19例，左房血栓清除22例，左房折叠21例，左心耳缝合68例。左心病变处理完，心脏复跳后进行三尖瓣成形。先对隔前交界进行折叠环缩，用3-0带垫片双头针prolene线，在交界区作水平褥式缝合并打结。进出针均在瓣环上，缝合距离隔瓣5～6 mm，前瓣10 ～ 12 mm。然后按类似DeVega成形方法对后瓣瓣环区域重建，从前后交界前叶侧开始，顺时针方向缝至隔后交界隔叶侧，于三尖瓣瓣口中置入27 ～ 29 mm测瓣器行打结，再取3～5 mm宽毡条用两根2-0 prolene线间断缝合，对已环缩后瓣部分进行加固。生理盐水注射若无明显反流，完成手术。术后1周进行心脏超声心动图检查。患者出院后每6个月进行复查。结果 全组患者无死亡。术后中心静脉压明显降低，由术前16 mm Hg(1 mm Hg =0.133 kPa)降至术后8 mm Hg(P =0.0021)；肺动脉收缩压由术前59 mm Hg降至术后24 h的41 mm Hg，P=0.038。术后7天超声心动图检查56例三尖瓣无反流，18例三尖瓣微量或少量反流，2例三尖瓣中量反流，无残余中度以上三尖瓣关闭不全发生。右房室直径较术前明显变小。左室射血分数提高，但与术前差异无统计学意义。所有患者心功能均明显改善，术前右心功能不全体征均明显缓解或消失。术后随访1～36个月，除1例三尖瓣反流由出院时轻度变成中度外，其余均无明显变化。患者复查时均无明显肝淤血或双下肢水肿。结论 采用改进的瓣环成形方法，合理地保留了重建后三尖瓣的外形，使不均匀扩张的三尖瓣的各个部分都得到改善，继而增加了三尖瓣前叶和隔叶在收缩期的对合面积。既保留了自体三尖瓣环的弹性，也减小了远期因缝线松脱断裂导致关闭不全复发的危险性。

A modified tricuspid annuloplasty for functional severe tricuspid regurgitation

Objective To retrospectively analyze clinical data of patients who has left-side valvular disease combined with severe tricuspid regurgitation and evaluate the effect of our modified tricuspid annuloplasty with enforcement of artificial felt strip.Methods 76 patients who had left-side valvular disease combined with severe tricuspid regurgitation received operations between Jan.2008 and Jun.2010.The average age of the patients was 53.5 years old (32 male and 44 female).Besides the severe tricuspid regurgitation, other combined cardiac impairments included mitral valvar disease (52 cases), aortic valvar disease(5 cases), double valvar disease(19 cases) and left atrial thrombosis(22 cases).6 patients had grade II cardiac function according to the NYHA criteria, while 47 and 23 were in grade III and IV, respectively.Other signs included cyanosis(5cases), jaundice(11 cases), neck vein engorgement(48 cases) , ascites(22 cases), hepatomegaly(41 cases) and pitting edema in the lower limbs(68 cases).The concomitant operative procedures included mitral valve replacement in 52 patients,aortic valve replacement in 5 patients, double valve replacement in 19 patients, removal of left atrial thrombus in 22 patients,left atrium folding in 21 patients and left atrium appendage suture in 68 patients.Left-sided valve disease were corrected first,TAP was performed on the beating heart after the heart had been defibrillated.The anteroseptal commissure was plicated first.A double-armed 3-0 pledgeted suture was taken through the base of the septal leaflet, 5-6 mm from the commissure, extending along the annulus, and out from the point in the anterior annulus 10-12 mm from the anteroseptal commissure.Both ends of the suture was tied until the two Teflon pledgets approximated each other near the commissure.Then a semicircular De Vega type of plicating with a 3-0 prolene was taken, starting just from the anterior annulus near the anteroposterior commissure, and extending clockwise to a point just cephalad to the posteroseptal commissure.The suture was tied with positioning a 27-29 mm valve siser across the tricuspid valve.At last, a 3-5 mm width felt strip was prepared and was sutured to the plicated posterior annulus region with interrupted mattress sutures of 2 to 3 2-0 prolene.A favorable result was considered when TR was not marked by saline injection.Echocardiography was routinely examined one week postoperatively and patients were followed up 6 month after discharge.Results There is no death in all patients.The CVP diminished significantly from 16mmHg preoperatively to 8mmHg postoperatively (P = 0.0021).The systomic pulmonary pressure diminished from 59 mmHg preoperatively to 41 mmHg postoperatively (P = 0.038).Echo one week postoperative showed no tricuspid regurgitation in 56 patients and mild in 18 patients, while 2 had moderate tricuspid regurgitation.The diameter of right atrium diminished significantly postoperatively, too.The ejection fraction was improved even though there was not significant difference as compared with preoperative data.The cardiac function of all patients improved and the signs of right heart failure were alleviated or disappeared.Follow up 1 to 36 months showed no change of the regurgitation except for one become moderate from mild when discharged.No hepatic congestion or edema was observed in all patients.Conclusion These new modifications make the technique more selective in the remodeling of the tricuspid annulus.It could achieve better coaptation of the anterior leaflet with the others, successful annular reduction, better maintenance of the contractile property of the tricuspid ring, better distribution of pursing force in the more dilated region.It could prevent the tear of the endocardium in the posteroseptal region in the long period of time postoperatively.