左心瓣膜术后继发性三尖瓣反流再次行三尖瓣置换术的临床分析  

Clinical analysis on tricuspid valve replacement for secondary tricuspid regurgitation late after left-sided valve surgery

作　　者：李伟[1] 顾伟礼[1] 张卫[1] 方亮[1] 

机构地区：[1]上海交通大学附属胸科医院心外科,上海200030

出　　处：《上海交通大学学报（医学版）》2017年第7期987-992,共6页Journal of Shanghai Jiao tong University:Medical Science

基　　金：上海市胸科医院科技发展基金项目(YZ14-01)~~

摘　　要：目的·分析左心瓣膜术后三尖瓣置换术的围术期及中期结果,探讨继发性三尖瓣反流发病机制以及手术危险因素。方法·回顾性分析85例左心瓣膜术后行三尖瓣置换术患者的围术期临床资料及中期随访结果。根据人工瓣膜种类分2组,其中生物瓣组50例,机械瓣组35例;根据手术径路分2组,其中右前外侧切口组51例,正中切口组34例。结果·住院死亡7例(8.2%),其中住院早期死亡(术后30 d内)5例(5.9%),住院晚期死亡(术后30 d后)2例(2.4%),死亡原因均为术后严重右心功能衰竭及低心排血量。生物瓣组死亡率(4/50)与机械瓣组(3/35)比较,差异无统计学意义(χ~2=0.009,P=1.000);正中切口组死亡率(6/34)与右前外侧切口组(1/51)比较,差异有统计学意义(χ2=6.642,P=0.015)。随访74例(94.9%),随访时间(31.5±23.1)个月;中期死亡4例(5.4%),均为机械瓣组患者,其中心源性死亡3例,肠癌晚期死亡1例。随访的70例存活患者中,纽约心脏病学会(NYHA)心功能分级Ⅰ~Ⅱ级,无发生抗凝意外及再次行三尖瓣置换手术者。结论·左心瓣膜术后继发性三尖瓣反流应密切随访,及时合理的三尖瓣置换术可以取得良好的围术期及中期临床疗效;孤立性三尖瓣置换术首选右前外侧切口。Objective · To analyse the outcomes of tricuspid valve replacement （TVR） for secondary tricuspid regurgitation （STR） late after left-sided valve surgery during perioperative period and mid-term follow-up, investigate mechanisms of STR and surgical risk factors. Methods · A total of 85 consecutive patients who underwent the TVR surgery were analyzed. The perioperative and mid-term clinical outcomes were retrospectively investigated. The data were divided into bioprosthesis group （n=50） and mechanical prosthesis group （n=35） according to the prosthesis used, and divided into right anterolateral thoracotomy（RALT） group （n=51） and sternotomy（S） group （n=34） according to the surgical incision. Results · In-hospital mortality was 8.2% （7/85）. There was no significant difference in the mortality with different choice of bioprosthetic or mechanical valve （4/50 vs 3/35, χ2=0.009,P=1.000）; while there was significant difference between S group and RALT group （6/34 vs 1/51,χ2=6.642, P=0.015）. Seven cases all died of right heart failure and severe low cardiac output syndrome. Five （5.9%） cases died in perioperative within 30 in-hospital days and 2 （2.4%） cases died after 30 in-hospital days. Seventy-four cases were followed up. With the follow-up of （31.5±23.1） months, there were 4 case of late deaths（5.4%）, all of whom were mechanical prosthesis, of whom 3 died in cardiac related death and 1 died in later period bowel cancer. Seventy cases survived in New York Heart Association （NYHA） class I-II with no coagulated accident and redo-TVR. Conclusion · The perioperative and mid-term clinical outcomes are satisfied in timely and reasonable TVR with the standard follow-up for STR late after left-sided valve surgery. Right anterolateral incision is recommend for isolated TVR.

关 键 词：左心瓣膜手术 心脏瓣膜病 三尖瓣置换术 生物瓣 机械瓣 

分 类 号：R654.2[医药卫生—外科学]