不同三尖瓣修复技术的临床效果分析

【摘要】BackgroundandAim:Ithasbeenwidelyacknowledged,thattricuspidvalverepairisnotsolelydone,anditisdonealongwithaccompanyingrepairprocedures.Tricuspidvalvediseasehasadirectimpactontheseverityofthedisease.Identifyingtheriskofthediseaseorseverityofvalvelesionswhichisrelatedtotheoutcomeofthepatient,andincreaseinlifespanhasanimportantroleinsurgicalpractice.Moreover,locationandsizeofthelesionplaysakeyroleinthemanagementofthevalvetoattainthebestsurgicalapproach.Severalliteraturehasshown,thatpatientsundergoingconcomitantsurgicalprocedureshasalessimpactontricuspidvalvethanmitralandaorticvalves,alsodescribedasaforgottenvalve.[14,15,16]Logically,thepatientsbecomeasymptomaticduringtheearlyonsetofdiseaseastheseverityofthediseaseprogresssymptomswillappear,andthedoctorsalsoanonymoustoitssignsandsymptomsso,thisdiseaseishiddenuntilthediseaseapproachesinitsseverestages.Andthesediseasesalsogetlessimportanceorattentionthanleftsidedheartdiseases.Diseaseclassificationisdependsonthepathologyofthevalve.Inheart,tricuspidvalveplaysakeyroleindistributingthedeoxygenatedbloodtolungs.Thetricuspidvalvehasthreeleafletsorcuspswhichaccesstheregulationofbloodflowandmaintainthewayofsystemiccirculation.Iftricuspidvalvedamages,thedeoxygenatedbloodregressingbacktotherightatriumwhichaltersinpressureandinfluencespulmonarycirculationandsystemiccirculation.Notonlywiththis,tricuspidvalveshowsmajorconsequenceswhilethepatientishavingleft-sidedheartdisorders.Theorificeoftricuspidvalveisroughandtriangular,andisalsolargerthanthemitralvalve.Chordaetendineaeoriginatesfrompapillarymuscles,whichattachestothecuspsofthevalve.Duringsystole,rightventriclecontracts,andthetricuspidvalvecloses,papillarymusclescomeinactiontopullthechordaetendineaeandprohibittheleafletstofluctuatebackintotherightatriumand,thedeoxygenatedbloodispumpedtothelungsthroughthepulmonaryartery.Theheartgeneratesitsownbeat,andregulatedbytheelectricalactivityoftheimpulseswithcoordinationoftheatrialandventricularcontractions.ThepurposeofthestudyistofindouttheoutcomesofTricuspidValveRepairwhounderwentdifferentsurgicalmanagementtechniquesandtheoutcomeofthepatientsbyfollowingtheappliedtricuspidvalvetechnique.AsthevalveannulustensionissmallerintheTricuspidValvethanthatofmitralvalve,thecoordinationbetweenrightventriclewallandtricuspidvalvealtersandinteractsinaweakmanner,whentheannulusdilatationandpapillarymuscledisplacementtakesplace,tensionintheannulusrisestoneutralizetheactionofthedilatation.Nowadays,specialistshasenteredacommondamageofTVcarriedoutbyprimaryorsecondarydiseases.Selectgraspthetimingofsurgery,surgicaltechniquesandpostoperativecarehaveanimportantinfluenceonthecourseoftreatmenttoattainsurgicalresults.Surgeonsareunawareofthediseaseduringearlystagesofthedisease,whenthediseaseisdiagnosedtocorrectthedisorderstherearevariousproceduresavailable.Commonlyusedprocedureistraditionalprocedureoropenheartsurgery.Notonlythis,thereareothernon-surgicaltechniquesalsoperformeddependontheseverityofthedisease.Extensivelydoublevalvereplacementisperformed,whereastricuspidvalvereplacementisanaberrantprocedurelogicallytricuspidvalverepairissusceptibletorepairandinTVRmortalityratesarehigh.PersistingTricuspidRegurgitationaftertherepairofothervalveproceduresisassociatedwithrecurrentseverepulmonaryhypertensionormitro-aorticdisease,whichcausestheprogressionofrightventricularfailureandannulardilatation.Asithasconsidered,severityofthetricuspidvalvediseasedependsonAnnularDilatation.IfTVisuntreatedduringthemitralvalverepair,therewillbeanegativeimpressionofsignificantresidualtricuspidregurgitationontheoperativeoutcomesandsurvivalofthepatient,becausereoperationsmaycausehighmortalityrates.SurgicalmanagementofTRisoftendifficult,especiallywhenitpersistsafterapreviousvalverepairprocedure.Inseveretricuspidvalvediseases,normallysurgicalmanagementofthelesionistoodifficulttorepair.Repairwillbedoneinpatientshavingmildormoderatelesions,replacementwhichisarareprocedurewillbesuggestedwhentheleafletsdiminishes,andduringfusionofthechordae.MaterialandMethods:Tosummarizetheclinicalexperienceof55patientswhounderwentTricuspidValveRepairfrom2011-2012associatedwiththeconcomitantsurgicalprocedureswiththemeanageofthepatients45.5±14.6years.Thestudywasdesignedtotestthehypothesis,thattricuspidproceduresandleft-sidedheartsurgicalproceduresgivenbyanymeanswouldreducetheincidenceofpostoperativeinfectiouscomplications,ifthetricuspidlesionisobservedintraoperatively.Thesecondaryobjective,wastoevaluatetheeffectofRingAnnuloplastymethodonoverallmorbidityandmortalitycomparedwithothertricuspidrepairtechniques.Allarederived,accordingtotheseverityofregurgitationareaandNewYorkHeartAssociationClasses.Intraoperativeregurgitationareascrutinizedbyexecutingthesalineinjectiontest.Bythetransthoracicechocardiographicfindings,accordingtotheDopplerfindingsonthefour-chamberviewfromthecardiacapexdescribestheseverityofTR.Alltricuspidvalvesurgicalproceduresaredonealongwithmitralandaorticrepair/replacement,septaldefectpatchrepairandalsomoreoverwithotherdisorders.Basedonthedegreeofannulardilationandseverityofregurgitation,tricuspidsurgeryisperformedin52patientsandinthe3patientstricuspidregurgitationisdisappearedwhileperformingtheleftchamberaberrancies.Allproceduresareopen-heartsurgicalprocedureassociatedwithcardiopulmonarybypasstomaintainthecirculationandelectrolytebalance,alsoforthestabilityofbrain,lungsandkidney.SelectedpatientsincludingtricuspidrepairtechniquesareRingAnnuloplastyisperformedin28(14.5±8.23),Annuloplastyin9(5.0±2.74),KayAnnuloplastymethodin4(2.5±1.29),DeVegaAnnuloplastymethodin2(1.5±0.71),andValvuloplastyin9(5.0±2.74).Pulmonaryhypertensionin29patients(15.0±8.51).Surgicalandnon-surgicalcomplicationsfromsurgerytohospitaldischarge,weredocumentedprospectivelyandstaticallyanalyzed.Result:Thefollow-upperiodis36months.Openheartsurgerywasperformedin55patientsandrelievedinallpatients.Among55patients,noneofwhompresentedwithstenosisofthetricuspidvalve,allareexistedwithtricuspidvalveregurgitationorinsufficiency,whichwasdiagnosedpreoperativelyin53patientsandintraoperativelyin2patientswhiledoinginjectiontestduringassociatedprocedures.Thereisnotricuspidreplacementprocedureinthisstudy.Tricuspidvalverepairsurgerywasperformedin52patients(P=0.458).Concomitantproceduresconsistedofmitralvalvesurgeryin24patients(43.6%),doublevalvesurgeryin12patient’s(21.8%),AorticSurgeryin1patient(1.8%)Atrialseptaldefectrepairin10patient’s(18.1%),ventricularseptaldefectrepairin6patient’s(10.9%),andleftatrialtumorexcisionin11patient’s(20%),CABGin2patient’s(3.6%),TricuspidEbstein’smalformationcorrectionsurgeryin1patient(1.8%).Differenttechniqueswereperformed,RingAnnuloplastymethodwasusedin28patients(50.1%),Annuloplastyin9patients(16.3%),KayAnnuloplastymethodin4patients(7.3%),DeVegaAnnuloplastymethodin2patients(3.6%),Valvuloplastyin9patients(16.4%),andallpatientswererelievedanddischarged(P=0.000<0.05).Itwasobservedthatintraoperativecomplaintsin4patients(7.3%),postoperativecomplaintsin41patients(74.5%)andallarerelieved.Pulmonaryhypertensionoccurredin29patientsandrelieved.Withthehelpofadvancedultrafiltrationtechnology,surgeonscanperformeasilyinordertoachievethesatisfiedoutcomeinpatientsbyreducingtheburdenonheartandlungmechanismandmetabolism.Duringfollow-up,mostlikelyafter3months,threepatientsexperiencedshortnessofbreathandchesttightnessforaparticularperiodofoccurrence.Allofthe3patientshavegoodresultandrecoveredfromthesignsandsymptoms.AllpatientsCardiacfunctionareatNYHAclassI-II.Theoveralltricuspidsurgicaloutcomerateswere100%alongwithassociatedprocedures.So,thereisasignificantbenefitintricuspidvalvediseaseoutcomewhileimplementingtheconcomitantprocedures.Conclusions:Total55tricuspidvalverepairsurgerywereperformedconsistedofconcomitantprocedures.Itwasobservedthattricuspidvalverepairwithdifferenttechniqueswereperformedbasedontheconditionofthevalvediseasesandpathology.Ourstudyconcludestricuspidrepairtechniquesshowsthegoodoutcomerateswhileperformedwithconcomitantprocedures.Anannuloplastyringwasusedparticularlyinsevereannulardilationorseveretricuspidregurgitationtopreventanannulardilationandtricuspidregurgitation.Anannuloplastysuturewasusedinmoderateannulardilationormoderatetricuspidregurgitationtoreduceannulardilationandregurgitation.KayAnnuloplastymethodperformedintricuspidvalvedisorderlocalizedtotheposteriorleaflet,tocompleteposteriorleafletexcisionandplicationoftheinvolvedportionoftheannulus.TheDeVegasutureAnnuloplastymethodwasusedtoplicationoftheannulussurroundingtheanteriorandposteriorleafletstorepairtheannulardilationandtricuspidregurgitation.Valvuloplastywasusedtoopenthevalvebyshapingorincisiononthelocationwherethevalvecuspsmeettogetherorthickened.Abnormalfunctionorcoaptationofthetricuspidvalveduetodilatationoftheannulusmayleadtoregurgitation.Rightventricularmyocardiumandleafletsinfluencesthemechanismofannuluswhichplaysthekeyroleintheannulardilatation.Mostpatientswithtricuspidvalveinsufficiencyorstenosissufferfromconcomitantmitralandaorticvalvulardiseases.Theleafletforceortensionexertedontheannulusassignstheannulardilatation.Leftsidedheartdisorderswithenlargementofchamberandregurgitationcanresultinrightventricularchamberenlargement,pressureoverload,andTricuspidannulardilationwhichresultsinTricuspidRegurgitation.Tricuspidvalveregurgitationissecondarytorightventricularenlargementandelevatedpulmonarypressures.TRmostcommonlycausedbyPulmonaryHypertension,inwhichPASPisastrongindicatorofTRseverity.Ebstein’sanomalyisararecongenitalcardiacdefectinwhichdeformityanddisplacementoftricuspidvalveleafletstakesplacebyseparatingtherightsidedheartchambersi.e.,ventriclefromatriumleadingtoseveretricuspidinsufficiency,rightatrialdilationandavariabledegreeofrightventriculardysfunction.Itspathologydefinesconductionabnormalities,ventricularandatrialtachyarrhythmia.Valverepairorreplacementistotallydependsonthevalvelesion.TVrepairiscommonlyindicatedforsevereTRwhoareundergoingMVsurgery,concomitantTVrepairwith>4cm2ofannulusdiameterormoderateTR.Repairisalsoindicatedformildormoderatelesions,whereasduringdiminishedleaflet,degenerativediseasesandfusionofchordaeorendocarditisreplacementwillbethebetterchoice.Iftricuspidlesionsareignoredatthetimeofleft-sidedheartdiseasetreatment,significantTRnegativelyimpactstheperioperativeoutcomes,functionalclassandsurvivalbecauseredooperationsforrecurrentTRshowshighmortalityrates.Withouttreatment,TRbecomesworsedaybydayleadstovariousseveresymptoms,biventricularheartfailureandslowlycausedeath.Duringtheearlyonsetofthedisease,patientsremaincompleteasymptomaticorexperiencefatigueandshortnessofbreathbeforedevelopingunconcealedsignsofRight-sideheartfailure.AsthediseaseprogresseswithsevererightsideheartfailureresultsinsevereTR,patientspresentwithweightlossandcachexia,cyanosisandjaundicewhereasAscites,peripheraledemaandanasarcamayalsobepresent.DuringAnnuloplasty,mostlyRingwillbetheidealrepairmethodbecauseitachievesannulusstabilityforalongperiodoftime,andlowincidenceofgrade3or4whereasitisrelativelyfastandinexpensiveprocedure.Whenringsarenotavailable,modifiedDeVegaTechniquewillbethesuitableoptionbyplacingthepledgetsineachbiteofthesuturefromanteroseptalcommissuretothesamelevelofcoronarysinus.Whileperformingtheconcomitantprocedures,therewillbeagoodoutcome,ifthetricuspidvalvelesionsareidentifiedintra-operatively,becauseifthelesionisignoredduringsurgery,thevalvewillmayormaynotdilateprogressivelyandincreasestherightventricularpressureresultsinenlargementoftherightventricle.Themaingoalistoexecutetheappropriatesurgicalapproachtorestorethefunctionofthetricuspidvalveandimprovethelifespanofthepatient.
【作者】NeerajKumarRam；
【导师】BaiSongLin；
【作者基本信息】吉林大学，Cardio-VascularSurgery，2014，硕士
【关键词】Tricuspidvalve；Tricuspidregurgitation；Tricuspidrepair；Annulus；Dilation；RingAnnuloplasty；DeVegaAnnuloplasty；KayAnnuloplasty；Valvuloplasty；

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