三尖瓣关闭不全的外科处理

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,The closing mechanism of the tricuspid valve mainly depends on right ventricular contractilityLeft-sided valvular lesions may influence tricuspid valve functionPhysiological changes of tricuspid valve ring during cardiac cycle,Mechanisms of significanttricuspid 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 valve?A myriad of possibilities,Valve repair Annuloplasty,Reduction of the annulus without supportAnnular reduction supported by suturesSelective reduction supported by strips or pledgets of synthetic materialAnnular reduction by different types of prosthetic rings,De Vega annuloplasty,Preservation of valvular mechanismIt maintains the physiological flexibility of the annulusNo prosthetic material is requiredNo damage to the conduction tissueIt is easy, fast to perform, cheap,Classical De Vega,Modification of De Vega,Classical De Vega annuloplasty,Why we need Annuloplasty rings,Correction of annular dilatationRemodelling the shape of the annulusImprove coaptation between leaflets during systoleStabilization of repair over time,Annuloplasty rings,Edwards MC3,Standard CarpentierEdwards.,Biodegradable ring,Poly-1,4-dioxanone polymer curved C-shaped ring and suture material extensions at each endIts 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 monthsEasy implantation technique (reduction in the duration of aortic cross clamp and ECC),Tricuspid valve replacement,TVR OR TVP?,Rheumatic heart disease,Patients47Period1977 2010Mean age59.011.4yGenderM19.1% F80.9%Atrial fibrillation80.9%,Two groups according to tricuspid valve surgeryRepair n = 18 (38.3%)Replacement n = 29 (61.7%),TRICUSPID REPAIRDe Vega annuloplasty (8 pts)Duran ring annuloplasty (10 pts)Commissurotomy (2 pts),TRICUSPID REPLACEMENTMechanical valve (14 pts)Bioprosthesis (15 pts),Follow-upComplete follow-up97.8%Mean follow-up16.2 yearsRange1 month 33 years,Late results,Survival,Freedom from reoperation,TVR n = 29Alive 20.7%Class I2Class II3Class III1,Repair n = 18Alive 50.0%Class I3Class II4Class III2,Isolated tricuspid valve surgery with normal functioning left side valve occurs after mitral and/or aortic valve surgeryIsolated tricuspid valve surgery has a high early and late mortality due to cardiac causesTricuspid valve replacement entails a worse result comparing with tricuspid valve repair,Conclusions,Other options,C