尖瓣关闭不全的外科处理

三尖瓣关闭不全的外科处理LUShuyangThetricuspidvalve:aneglectedvalvularlesionHistorymitralvalvereplacementaloneleadstoresolutionofseverefunctionaltricuspidregurgitationandthereforetricuspidvalvesurgerywasnotindicated.（mid-1960sbyBraunwaldetal）theopposingviewofroutinevalverepairforfunctionaltricuspidregurgitation.（late1960sbyCarpentieretal）annuloplastyattheinitialmitralvalveoperationinthe1970sTricuspidanatomyTricuspidphysiologyTheclosingmechanismofthetricuspidvalvemainlydependsonrightventricularcontractilityLeft-sidedvalvularlesionsmayinfluencetricuspidvalvefunctionPhysiologicalchangesoftricuspidvalveringduringcardiaccycleMechanismsofsignificanttricuspidregurgitationStagesofprimaryandfunctionalTR(StageA-B)StagesofprimaryandfunctionalTR(StageC-D)IndicationsofTRSurgery2014AHA/ACCGuidelineIndicationsofTRSurgery2014AHA/ACCGuidelineHowtodealwiththetricuspidvalve?AmyriadofpossibilitiesValverepair–AnnuloplastyReductionoftheannuluswithoutsupportAnnularreductionsupportedbysuturesSelectivereductionsupportedbystripsorpledgetsofsyntheticmaterialAnnularreductionbydifferenttypesofprostheticringsDeVegaannuloplastyPreservationofvalvularmechanismItmaintainsthephysiologicalflexibilityoftheannulusNoprostheticmaterialisrequiredNodamagetotheconductiontissueItiseasy,fasttoperform,cheapClassicalDeVegaModificationofDeVegaClassicalDeVegaannuloplastyWhyweneedAnnuloplastyringsCorrectionofannulardilatationRemodellingtheshapeoftheannulusImprovecoaptationbetweenleafletsduringsystoleStabilizationofrepairovertimeAnnuloplastyringsEdwardsMC3StandardCarpentier–Edwards.BiodegradableringPoly-1,4-dioxanonepolymercurvedC-shapedringandsuturematerialextensionsateachendItsspecificmolecularweightprovidesstructuralmemorytoprotectitfromsubsequentdeformityBiodegradableringPreservationofthepotentialforgrowthofthemitralannulus(pediatricpopulation)Nosyntheticmaterial(lessriskofendocarditis)NoneedforanticoagulationduringthefirstthreepostoperativemonthsEasyimplantationtechnique(reductioninthedurationofaorticcrossclampandECC)TricuspidvalvereplacementTVRORTVP?RheumaticheartdiseasePatients47Period1977–2010Meanage59.0±11.4yGenderM19.1%F80.9%Atrialfibrillation80.9%TwogroupsaccordingtotricuspidvalvesurgeryRepairn=18(38.3%)Replacementn=29(61.7%)TVReplacementTVrepairAge59.9±13.662.3±5.5Range21–7653-76Female23(79.3%)15(83.3%)Weight59.6±11.566.5±10.3Height157.3±6.5160.9±7.4Bodysurfacearea24.1±4.425.7±3.5TVReplacementTVrepairAtrialfibrillation27(93.1%)14(77.8%)Cardiacindex2.0±0.72.1±0.3PAsistolicpressure43.3±13.742.7±11.3Pulmonarycapillarypressure26.5±2.421.7±4.2LeftventricularEF57.8±10.154.3±11.7MeanTVregurgitation3.573.55TVReplacementTVrepairPreviousTVsurgeryRepair7(24.1%)2(11.1%)Replacement4(13.8%)-PreviousCPBoperationsOne11(37.9%)6(33.3%)Two9(31.0%)2(11.1%)Three2(6.9%)-TVReplacementTVrepairNYHAclassIII7(24.1%)12(66.7%)NYHAclassIV19(65.5%)4(22.2%)TRICUSPIDREPAIRDeVegaannuloplasty(8pts)Duranringannuloplasty(10pts)Commissurotomy(2pts)TRICUSPIDREPLACEMENTMechanicalvalve(14pts)Bioprosthesis(15pts)Follow-upCompletefollow-up97.8%Meanfollow-up16.2yearsRange1month–33yearsTVReplacementTVrepairCPBtime79.9±42.875.7±45.7Ischemictime21.8±23.164.5±48.8Mortality8(27.6%)-Cardiac6Bleeding1Neurologic1TVReplacementTVrepairLatemortality15(51.7%)9(50.0%)Cardiac23Valvular11Unknown71Reoperation12Thromboembolism1Hemorrhage1Malignacy1Othersnoncardiac21LateresultsSurvivalFreedomfromreoperationTVRn=29Alive20.7%ClassI2ClassII3ClassIII1Repairn=18Alive50.0%ClassI3ClassII4ClassIII2Isolatedtricuspidvalvesurgerywithnormalfunctioningleftsidevalveoccursaftermitraland/oraorticvalvesurgeryIsolatedtricuspidvalvesurgeryhasahighearlyandlatemortalityduetocardiaccausesTricuspidvalvereplacemententailsaworseresultcomparingwithtricuspidvalverepairConclusionsOtheroptionsConclusionsThetricuspidvalveisstillchallengingThereisvariabilityinapproachandtechniquesSpecificsubsetsofpatientsareathighriskofmorbidityandmortality