三尖瓣置换术临床经验分析  

Clinical experience and analysis of tricuspid valve replacement

作　　者：曾文辉 朱家全[1] 鲍春荣[1] 丁芳宝[1] 梅举[1] ZENG Wen-hui;ZHU Jia-quan;BAO Chun-rong;DING Fang-bao;MEI Ju(Department of Cardiothoracic Surgery,Shanghai Xinhua Hospital,Shanghai Jiaotong University,School of Medicine,Shanghai 200092,China)

机构地区：[1]上海交通大学医学院附属新华医院心胸外科,上海市200092

出　　处：《中国心血管病研究》2019年第5期446-450,共5页Chinese Journal of Cardiovascular Research

基　　金：国家自然科学基金(81600219);新华医院临床重点基金(15LC03).

摘　　要：目的总结三尖瓣置换术的临床治疗经验,比较正中开胸与右侧小切口手术方式在三尖瓣置换中的近远期效果,以利提高手术疗效。方法回顾性分析2007年6月至2018年6月在上海交通大学医学院附属新华医院心胸外科行三尖瓣置换术的28例患者临床资料。结果本研究中男性16例(57.1%),年龄(40.4±17.6)岁。病因以三尖瓣下移畸形(Ebstein畸形)(15例,53.6%)为主。本组患者采用胸骨正中切口组20例(71.4%)、右胸小切口组8例(28.6%);共置换21例机械瓣及7例生物瓣。与正中切口组相比,右胸小切口组患者平均年龄更大(P=0.036),心脏手术史比例更高(P=0.014),术中心脏不停跳比例更高(P<0.001),同期试行其他心内手术较少(P=0.025);而两组在体外循环时间、瓣膜类型选择、术后呼吸机辅助呼吸时间及总住院时间等方面在切口部位的选择上无明显差异。住院期间3例死亡,无永久起搏器置入。术后随访2月至11年,1例早期死亡,1例患者术后6年因双叶机械瓣卡瓣再次置换,1例生物瓣中量反流,其余机械瓣或三尖瓣生物瓣功能良好。结论严格掌握手术适应证,注意维护围术期右心功能,避免损伤传导束,三尖瓣置换术可获得良好的手术和近中期结果,右前外侧切口可作为经典正中胸骨切口的补充,尤其适用于既往心脏手术史患者;三尖瓣术后远期仍需严密随访。Objective To summarize the clinical experiences of tricuspid replacement and compare the outcomes between sternotomy and right anterior thoracotomy approaches,therefore,improve the surgical results.Methods Twenty-eight surgical patients of tricuspid replaccment in our hospital from Jun 2007 to Jun 2018 were retrospectively reviewed.Results There were 16 males(57.1%)and the mean age were(40.4±17.6)years.The main indication of tricuspid valve replacement was Ebstein's anomaly(15 cases,53.6%).Twenty patients(71.4%)underwent median steniotomy,while the other 8 patients(28.6%)right mini-thoracotomy.Totally,21 mechanical and 7 biological prothesis were implanted.Compared with sternotomy group.patients in right mini-thoracotomy group were older(P=0.036),had more previous cardiac surgeries(P=0.014)and higher ratio of beating heart surgery and less simultaneous intracardiac procedures.However,no significant difference was found in term of cardiopulmonary bypass time,types of valve prothesis,postoperative ventilation time and length of postoperative stay.There were 3 deaths and no pacemaker implantation.The patients were followed 2 months to 11 years.There was one more early death,one rcopcration because of malfunctioned mechanical valve and one moderate regurgitation of biological valve.Conclusion By selecting appropriate patients,optimizing peri-operative right ventricular function and avoiding injury of conduction system,tricuspid valve replacement would yield favorable early and midterm outcomes.Surgery through right thoracotomy is an alternative therapy additional to surgery from sternotomy,especially in those who had previous cardiac surgeries.Close follow-up is needed after tricuspid valve replacement.

关 键 词：心脏瓣膜病 二尖瓣置换 EBSTEIN畸形 

分 类 号：R654.2[医药卫生—外科学]