左心瓣膜置换术后三尖瓣反流的再手术治疗  

Re-operation of tricuspid regurgitation(TR) in patients undergone left-sided valve replacement

作　　者：严宇[1] 何德沛[1] 杨庆军[1] 赵次洪[1] 申林[1] 陈灏 罗永金[1] 吴洪坤[1] 余杨[1] 

机构地区：[1]重庆市中山医院心脏外科,400013

出　　处：《重庆医学》2008年第3期303-304,共2页Chongqing medicine

摘　　要：目的探讨左心瓣膜置换术后，三尖瓣关闭不全（TR）的因素及手术效果。方法总结本院2001年6月～2006年12月期间，5例左心瓣膜置换手术术后发生重度TR，行再次三尖瓣成形术（TVP）及三尖瓣置换术（TVR）。男2例，女3例，年龄41～60岁，二尖瓣置换术1例，双瓣置换术4例，5例均因第1次手术时伴三尖瓣反流同时行TVP术。术后1～3年发生重度TR，肝大、腹水、右心衰，心功能4级。5例患者左心人工瓣功能良好，其中1例伴二尖瓣瓣周漏。结果5例均再次手术，1例除三尖瓣环扩大外，瓣叶钙化，萎缩缺如，考虑为风湿性器质性病变，行TVR。3例原Devega成形术缝线割裂瓣环，缝线游离，瓣环扩大，经再次Kay法成形，并对其中1例伴二尖瓣瓣周漏同时修补。以上4例TR得以纠正，术后情况良好。另1例左心瓣膜功能正常，重度TR，行TVR术后肺动脉高压不减，右室进行性扩大，术后3周死于右心功能衰竭。结论左心瓣膜置换术后远期发生TR可能与以下因素有关：（1）风湿性病变继续发展，侵犯三尖瓣叶；（2）左心瓣膜病变未纠正，瓣膜过小或发生瓣周漏；（3）原TVP失败，特别是Devega成形术，缝线切割瓣环或断裂使环缩失败；（4）左心瓣膜术后，由于肺动脉器质性病变发生持续性肺动脉高压，或心房纤颤等原因，导致右房右室变大致TR发生。对重度TR，出现右心衰竭，内科治疗无效者，应再次行三尖瓣手术，特别是伴左心瓣膜功能障碍的患者应积极处理。首选TVP，如有瓣叶病损应行TVR。Objective To discuss the cause of tricuspid regurgitation（TR） in patients undergone left-sided valve replacement and the outcome of this operation. Methods From June 2001 to December 2006,severe TR had been occured in 5 patients who had undergone left-sided valve replacement operation,and all of them were performed tricuspid valvuloplasty（TVP） or tricuspid valve replacement（TVR） operation. 2 males and 3 females, the age was in range from 41 years to 60 years, 1 patient had been performed mitral valve replacement,4 patients had been performed double cardiac valve replacement, all of them had been performed tricuspid valvuloplasty at fist cardiac operation for TR. The severe TR had been occurred in postoperative 1-3years,with hepatomegaly,ascites and right heart failure, they were in New York Heart Association（NYHA） functional class Ⅳ. The function of prosthetic valves in these patients were well,but paravalvular leak were occured in 1 patients. Results These patients underwent re-operation, 1 patient with rheumatic heart disease was performed TVR for tricuspid annular dilatation and valve calcification. 3 patients underwent Kay annuloplasty again,because the suture of the first DeVega annuloplasty had cut tricuspid valve,one of the 3 patients was repaired a mitral valve paravalvular leakage simultaneously. The tricuspid regurgitation had been corrected in the 4 patients. Only one patient with serious TR was dead for severe right heart failure after three weeks undergone TVR. Conclusion The reasons of long-term tricuspid regurgitation（TR） in patients undergone left-sided valve replacement may listed as follows： 1：The tricuspid valve have been destroyed by rheumatic heart disease. 2：The left-sided valve disease did not be corrected, the valve too small or paravalvular leakage. 3：The first TVP was failures, especially the suture of DeVega annuloplasty had ruptured tricuspid valve or had been broken. 4 ： After undergone left-sided valve replacement, the patients developed persistent pul

关 键 词：瓣膜置换 三尖瓣反流 三尖瓣成形 心力衰竭 

分 类 号：R654.2[医药卫生—外科学]