三尖瓣关闭不全的外科处理课件

三尖瓣关闭不全的外科处理 LU Shuyang The tricuspid valve: a neglected valvular lesion History mitral valve replacement alone leads to resolution of severe functional tricuspid regurgitation and therefore tricuspid valve surgery was not indicated. （mid-1960s by Braunwald et al） the opposing view of routine valve repair for functional tricuspid regurgitation.（ late 1960s by Carpentier et al ） annuloplasty at the initial mitral valve operation in the 1970s Tricuspid anatomy Tricuspid physiology lThe closing mechanism of the tricuspid valve mainly depends on right ventricular contractility lLeft-sided valvular lesions may influence tricuspid valve function Physiological changes of tricuspid valve ring during cardiac cycle Mechanisms of significant tricuspid regurgitation Stages of primary and functional TR (Stage A-B) Stages of primary and functional TR (Stage C-D) Indications of TR Surgery 2014 AHA/ACC Guideline Indications of TR Surgery 2014 AHA/ACC Guideline How to deal with the tricuspid How to deal with the tricuspid valve?valve? A myriad of possibilitiesA myriad of possibilities Valve repair Annuloplasty 1. Reduction of the annulus without support 2. Annular reduction supported by sutures 3. Selective reduction supported by strips or pledgets of synthetic material 4. Annular reduction by different types of prosthetic rings De Vega annuloplasty 1. Preservation of valvular mechanism 2. It maintains the physiological flexibility of the annulus 3. No prosthetic material is required 4. No damage to the conduction tissue 5. It is easy, fast to perform, cheap Classical De VegaModification of De Vega Classical De Vega annuloplasty Why we need Annuloplasty rings lCorrection of annular dilatation lRemodelling the shape of the annulus lImprove coaptation between leaflets during systole lStabilization of repair over time Annuloplasty rings Edwards MC3 Standard CarpentierEdwards. Biodegradable ring lPoly-1,4-dioxanone polymer curved C-shaped ring and suture material extensions at each end lIts specific molecular weight provides structural memory to protect it from subsequent deformity Biodegradable ring Preservation of the potential for growth of the mitral annulus (pediatric population) No synthetic material (less risk of endocarditis) No need for anticoagulation during the first three postoperative months Easy implantation technique (reduction in the duration of aortic cross clamp and ECC) Tricuspid valve replacement TVR OR TVP? Rheumatic heart disease Patients47 Period1977 2010 Mean age59.011.4y Gender M19.1% F80.9% Atrial fibrillation80.9% Two groups according to tricuspid valve surgery Repair n = 18 (38.3%) Replacement n = 29 (61.7%) TVReplacementTVrepair Age59.913.662.35.5 Range21 7653 - 76 Female 23 (79.3%)15 (83.3%) Weight59.611.566.510.3 Height157.36.5160.97.4 Body surface area24.14.425.73.5 TVReplacementTVrepair Atrial fibrillation27 (93.1%)14 (77.8%) Cardiac index2.00.72.10.3 PA sistolic pressure43.313.742.711.3 Pulmonary capillary pressure 26.52.421.74.2 Left ventricular EF57.810.154.311.7 Mean TV regurgitation3.573.55 TVReplacementTVrepair Previous TV surgery Repair7 (24.1%)2 (11.1%) Replacement 4 (13.8%)- Previous CPB operations One11 (37.9%)6 (33.3%) Two9 (31.0%)2 (11.1%) Three2 (6.9%)- TVReplacementTVrepair NYHA class III7 (24.1%)12 (66.7%) NYHA class IV19 (65.5%)4 (22.2%) TRICUSPID REPAIR De Vega annuloplasty (8 pts) Duran ring annuloplasty (10 pts) Commissurotomy (2 pts) TRICUSPID REPLACEMENT Mechanical valve (14 pts) Bioprosthesis (15 pts) Follow-up Complete follow-up97.8% Mean follow-up16.2 years Range1 month 33 years TVReplacementTVrepair CPB time79.942.875.745.7 Ischemic time21.823.164.548.8 Mortality8 (27.6%)- Cardiac6 Bleeding1 Neurologic1 TVReplacementTVrepair Late mortality15 (51.7%)9 (50.0%) Cardiac23 Valvular11 Unknown71 Reoperation12 Thromboembolism1 Hemorrhage1 Malignacy1 Others non cardiac21 Late results Survival Freedom from reoperation TVR n = 29 Alive 20.7% Class I2 Class II3 Class III1 Repair n = 18 Alive 50.0% Class I3 Class II4 Class III2 1.Isolated tricuspid valve surgery with normal functioning left side valve occurs after mitral and/or aortic valve surgery 2.Isolated tricuspid valve surgery has a high early and late mortality due to cardiac causes 3.Tricuspid valve replacement entails a worse result comparing w