人工瓣环成形术与其联合"缘对缘"瓣膜成形术治疗重度三尖瓣关闭不全

Objective To analyze whether association of edge to edge valve repair to artificial ring annuloplasty would result in better results in patients with severe tricuspid regurgitation (TR).Methods From April,2001 to May,2010,41 patients underwent tricuspid valve repair to treat severe TR were studied.Twenty-one patients were done artificial ring annuloplasty alone (group R) and twenty patients were done artificial ring annuloplasty associated with edge to edge valve repair ( group E).All the patients received echocardiography before surgery,before discharge and in mid and long-term follow-up.The ratio between TR jet area (TRA) and right atrial area (RAA) was used to quantitatively evaluate the seriousness of TR.Movement of tricuspid valve leaflets,tricuspid valve orifice area,pulmonary artery pressure ( PAP),left ventricular ejection fraction ( LVEF) were obserbed to evaluate heart function.Results At discharge in group R,no or trivial TR was presented in 7 patients,mild TR in 12 patients and moderate TR in 2 patient.Bad apposition of the free edges of anterior and septal leaflets was observed in paients with mild and moderate TR.While in group E,no or trivial TR was presented in 13 patients and mild TR in 7 patients.The follow-up ranged from 6 months to 100 months[average (54.8 ±26.7) months].In group R,no or trivial TR was present in 5 patients,mild TR in 11 patients,moderate TR in 4 patients and severe in 1 patient.Bad apposition of the free edges of anterior and septal leaflets was observed in paients with mild to severe TR.Redo tricuspid valve repair was done in one patient in group R for recurrent severe TR and the edge-to-edge valve repair was utilized.In group E,no tricuspid stenosis was found.No or trivial TR was presented in 10 patients,mild TR in 9 patients and moderate TR in 1 patient.The ratio of TRA/RAA of group R was significantly higher than that of group E (0.25 ±0.16 vs.0.13±0.10,P < 0.01).Conclusion Association of edge-to-edge valve technique to artificial ring annuloplasty was safe and effective for treatment of severe tricuspid regurgitation due to bad apposition of free edges of tricuspid leaflets and dilatation of tricuspid annulus,.It could decrease the incidence of residual tricuspid regurgitation and prevent the recurrence of severe tricuspid regurgitation.     

人工瓣环成形术与其联合"缘对缘"瓣膜成形术治疗重度三尖瓣关闭不全

目的 总结人工瓣环成形术与人工瓣环联合"缘对缘"瓣膜成形术的治疗重度三尖瓣反流(TR)的治疗效果.方法 2001年4月至2010年5月间因重度TR行三尖瓣成形术41例,其中单纯人工瓣环成形(R组)21例,人工瓣环联合"缘对缘"瓣膜成形(E组)20例.所有病人均经术前、术后早期(出院时)及术后中长期经胸超声心动图检查,观察三尖瓣瓣叶对合情况,以三尖瓣反流束面积(TRA)/右房面积(RAA)定量测定反流程度,三尖瓣口面积、肺动脉压及心功能测定.结果 出院时R组7例无或微量TR,12例轻度TR,2例中度TR,轻、中度者均有前、隔叶对合不良;E组13例无或微量TR,7例轻度TR.随访6～100个月,平均(54.8±26.7)个月,R组5例无或微量TR,11例轻度TR,4例中度TR、1例重度TR,轻至重度者均有前、隔叶对合不良,1例重度者再次实施"缘对缘"瓣膜成形术;E组无三尖瓣狭窄,10例无或微量TR,9例轻度TR,1例中度TR.人工瓣环成形联合"缘对缘"瓣膜成形术中长期TRA/RAA比值显著低于单纯人工瓣环成形术者(P<0.01).结论 对于三尖瓣瓣缘对合不良及其瓣环扩张引起的重度TR者,人工瓣环成形联合"缘对缘"瓣膜成形技术能够更有效地减少术后三尖瓣残余反流以及TR的复发.

Abstract：

Objective To analyze whether association of edge to edge valve repair to artificial ring annuloplasty would result in better results in patients with severe tricuspid regurgitation (TR).Methods From April,2001 to May,2010,41 patients underwent tricuspid valve repair to treat severe TR were studied.Twenty-one patients were done artificial ring annuloplasty alone (group R) and twenty patients were done artificial ring annuloplasty associated with edge to edge valve repair ( group E).All the patients received echocardiography before surgery,before discharge and in mid and long-term follow-up.The ratio between TR jet area (TRA) and right atrial area (RAA) was used to quantitatively evaluate the seriousness of TR.Movement of tricuspid valve leaflets,tricuspid valve orifice area,pulmonary artery pressure ( PAP),left ventricular ejection fraction ( LVEF) were obserbed to evaluate heart function.Results At discharge in group R,no or trivial TR was presented in 7 patients,mild TR in 12 patients and moderate TR in 2 patient.Bad apposition of the free edges of anterior and septal leaflets was observed in paients with mild and moderate TR.While in group E,no or trivial TR was presented in 13 patients and mild TR in 7 patients.The follow-up ranged from 6 months to 100 months[average (54.8 ±26.7) months].In group R,no or trivial TR was present in 5 patients,mild TR in 11 patients,moderate TR in 4 patients and severe in 1 patient.Bad apposition of the free edges of anterior and septal leaflets was observed in paients with mild to severe TR.Redo tricuspid valve repair was done in one patient in group R for recurrent severe TR and the edge-to-edge valve repair was utilized.In group E,no tricuspid stenosis was found.No or trivial TR was presented in 10 patients,mild TR in 9 patients and moderate TR in 1 patient.The ratio of TRA/RAA of group R was significantly higher than that of group E (0.25 ±0.16 vs.0.13±0.10,P < 0.01).Conclusion Association of edge-to-edge valve technique to artificial ring annuloplasty was safe and effective for treatment of severe tricuspid regurgitation due to bad apposition of free edges of tricuspid leaflets and dilatation of tricuspid annulus,.It could decrease the incidence of residual tricuspid regurgitation and prevent the recurrence of severe tricuspid regurgitation.     

慢性中重度缺血陛二尖瓣关闭不全的外科治疗及中期随访

Objective To compare the results of mitral valve reconstruction and replacement as treatments for moderate to severe ischemic mitral regurgitation(IMR), and report the mid-term outcome. Methods From June 2002 to May 2008, 83 pa-tients with moderate IMR(35 cases) and severe IMR (48 cases) underwent coronary artery bypass grafting(CABG) combined with mitral valvuloplasty (MVP) (n = 43) or mitral valve replacement (MVR) (n = 40). There were 49 males and 34 females with a mean age of (59.3±7.5) years(51 -77years). The procedures of MVP included annuloplasty with a Dacron or autologous per-icardium ring in 21cases, commissural annuloplasty in 9, quadrangular resection of the posterior leaflet in 9 and using St. Jude mitral annuloplasty ring in 4. In the cases underwent MVR, 28 patients received mechanical prostheses and 12 received biopros-theses. Results 30-day mortality rate was 2.3% for MVP and 5.0% for MVR (P >0.05). The 30-day complication rate was similar for the 2 groups but mechanical ventilation time was longer for MVR patients. Mild MR ocurred in 6 patients with MVP (P <0.05). Sevonty-six patients were followed by outpatient department visit or telephone for (20.2 ± 4.9) months (3 - 60 months). During the follow-up period, 7 patients with MVP had mild insufficiency but free off etber complications. All the valve prothesis functioned well. However, 3 cases had thromboembolic complications and 7 late deaths were recorded in MVR group. Five-year complication-free survival rate was 90% for MVP group and 61% for MVR. Conclusion MVP resulted in excellent durability and provided significant mid-term survival benefit over MVR. MVP should be the first choice for patients with chronic IMR.     

慢性中重度缺血陛二尖瓣关闭不全的外科治疗及中期随访

Objective To compare the results of mitral valve reconstruction and replacement as treatments for moderate to severe ischemic mitral regurgitation(IMR), and report the mid-term outcome. Methods From June 2002 to May 2008, 83 pa-tients with moderate IMR(35 cases) and severe IMR (48 cases) underwent coronary artery bypass grafting(CABG) combined with mitral valvuloplasty (MVP) (n = 43) or mitral valve replacement (MVR) (n = 40). There were 49 males and 34 females with a mean age of (59.3±7.5) years(51 -77years). The procedures of MVP included annuloplasty with a Dacron or autologous per-icardium ring in 21cases, commissural annuloplasty in 9, quadrangular resection of the posterior leaflet in 9 and using St. Jude mitral annuloplasty ring in 4. In the cases underwent MVR, 28 patients received mechanical prostheses and 12 received biopros-theses. Results 30-day mortality rate was 2.3% for MVP and 5.0% for MVR (P >0.05). The 30-day complication rate was similar for the 2 groups but mechanical ventilation time was longer for MVR patients. Mild MR ocurred in 6 patients with MVP (P <0.05). Sevonty-six patients were followed by outpatient department visit or telephone for (20.2 ± 4.9) months (3 - 60 months). During the follow-up period, 7 patients with MVP had mild insufficiency but free off etber complications. All the valve prothesis functioned well. However, 3 cases had thromboembolic complications and 7 late deaths were recorded in MVR group. Five-year complication-free survival rate was 90% for MVP group and 61% for MVR. Conclusion MVP resulted in excellent durability and provided significant mid-term survival benefit over MVR. MVP should be the first choice for patients with chronic IMR.     

Outcome of surgical treatment of post-traumatic tricuspid insufficiency

Objective: To investigate the optimal time and procedure of surgical treatment of traumatic tricuspid insufficiency. Methods: From May 1984 to September 2004, eight patients underwent operation for traumatic tricuspid valve insufficiency. All patients, male, aged from 7 to 67 years [median: 38 years, mean: (38.5±18.1) years]. The intervals between trauma and operation ranged from 1 month to 20 years [median: 19 months, mean: (52.5± 80.3) months)]. In seven patients, tricuspid insufficiency was attributed to blunt chest trauma including vehicle accident in three patients and the other patient is a stab wound. Diagnosis was confirmed by echocardiography. Pre-operative cardiac functions in patients were classified as New York Heart Association ( NYHA ) classes Ⅱ-Ⅳ. During operation, the anterior leaflet of the tricuspid valve was completely or partially flailed as a result of chordal rupture in all patients. Chordal rupture of septal leaflet was found in one patient. Anterior leaflet was perforated in two patients. Septal leaflet was retracted and adherent to ventricular septum in two patients. Valve repair was intended for all patients. Finally, valve repair was performed successfully in 3 patients and tricuspid replacement was performed in 5 patients. Results: No early or late death occurred. With a follow-up through clinical manifestation and echocardiography for 7-129 months [median; 39 months, mean: (53.4±42.8) months], all patients were classified as NYHA class I, without any changes. Conclusions : The satisfactory treatment of traumatic tricuspid insufficiency can be obtained by surgical treatment. Earlier surgery may increase the feasibility of tricuspid valve repair and prevent the deterioration of right ventricular function.     

心脏瓣膜术后心室辅助治疗

Objective An increasing number of patients requiring ventricular assist devices (VAD) have had previous valvular corrections,including valve repair,and valve replacement with mechanical or bioprosthetic valves.The operative and peri-operative management of these patients has been varied.Methods A retrospective study of VADs between Jan 1994 and June 2008 revealed 10 patients with previous prosthetic valves requiring management during and after VAD placement.Three patients were supported post-cardiotomy after valve surgery.Two patients were supported due to cardiogenic shock postopera-tively.Four patients were supported as a bridge to transplantation.One patient was supported as a destination therapy.Results The mitral valve was left untreated during VAD implantation regardless of valve repair or replacement.For aortic valves,the mechanical aortic valve was replaced with tissue valve in two patients and left untreated in one case.One patient had tricuspid valve repair previously and was left untouched.All patients with prosthetic valves in aortic,mitral and tricuspid position during VAD support received anticoagulation therapy.There were 4 deaths,and 4 went on to transplantation.One patient weaned from VAD and discharge from hospital.One patient received HeartMate Ⅰ as destination therapy.The most common causes of death were multisystem organ failure and sepsis.One patient had a thromboembolic event.Conclusion The survival rate of 60% is encouraging when compared to overall survival rates.The most common cause of death was multisystem organ failure.Patients with prosthetic valves may be safely managed during VAD support.     

限制性二尖瓣环成形联合冠状动脉旁路移植术治疗缺血性二尖瓣反流

Objective To retrospectively summarize and analyze the short and mid term follow-up outcomes of combined coronary artery bypass grafting ( CABG) and restrictive mitral annuloplasty in curing ischemic cardiomyopathy and ischemic mitral regurgitation (IMR) , and to study its effect on reverse left ventricular remodeling. Methods From January 2000 to June 2008,111 patients of coronary artery disease with morderate to severe IMR underwent combined CABG and restrictive mitral annuloplasty, downsizing by 1-2 ring sizes. There were 81 male and 30 female patients. The age ranged from 36 to 83 years with a mean of (63 ± 18) years. Preoperative transthoracic echocardiography showed minimal to moderate IMR in 7 cases, moderate to severe in 65 cases and severe in 39 cases. The left artrial diameter (LAD) was (58 ±6) mm, left ventricular end-diastolic diameter (LVEDD) was (61 ±8) mm, left ventricular ejection fraction (LVEF) was 46% ±6%. Serial studies were performed to assess the survival rate, the extent of mitral regurgitation (MR), LVEF, the leaflet coaptation height, LAD, LVEDD, New York Heart Association (NYHA) functional class. Results Hospital mortality was 2.7% (3 cases). Each case received an undersized ring. Intraoperative transesophageal echocardiography showed that no regurgitation in 69 cases,minimal in 34 cases, minimal to moderate in 5 cases, moderate to severe in 3 cases which received mitral valve replacement. The 3-, 12- and 24-month survival rate was 96. 2% , 93. 5% and 89. 7% respectively.Mitral regurgitation grade decreased after the operative prodecures (P ＜0. 01). LVEF increased from (46 ± 6) % to (53 ±6) % (24 months follow-up) (F＜0. 01). LAD decreased from (58 ±6) mm to (46 ±6)mm(24 months follow-up) (P ＜0. 01). LVEDD decreased from (61 ±8) mm to (48 ± 10) mm (24 months follow-up) (P ＜ 0. 01 ) . There was no significant decline of LVEDD in 18 cases ( 16. 2% ) whose preoperative mean LVEDD was (69 ±9) mm. NYHA functional class improved after operative procedures ( P ＜ 0. 01) . At 24 months follow-up, 2 cases received valvular replacement Conclusions Combined CABG and restrictive mitral annuloplasty is a feasible and effective treatment for IMR, the short and mid term outcomes are satisfactory, and a significant reduction of LVEDD and an increase of LVEF due to reverse ventricular remodeling were observed.     

限制性二尖瓣环成形联合冠状动脉旁路移植术治疗缺血性二尖瓣反流

Objective To retrospectively summarize and analyze the short and mid term follow-up outcomes of combined coronary artery bypass grafting ( CABG) and restrictive mitral annuloplasty in curing ischemic cardiomyopathy and ischemic mitral regurgitation (IMR) , and to study its effect on reverse left ventricular remodeling. Methods From January 2000 to June 2008,111 patients of coronary artery disease with morderate to severe IMR underwent combined CABG and restrictive mitral annuloplasty, downsizing by 1-2 ring sizes. There were 81 male and 30 female patients. The age ranged from 36 to 83 years with a mean of (63 ± 18) years. Preoperative transthoracic echocardiography showed minimal to moderate IMR in 7 cases, moderate to severe in 65 cases and severe in 39 cases. The left artrial diameter (LAD) was (58 ±6) mm, left ventricular end-diastolic diameter (LVEDD) was (61 ±8) mm, left ventricular ejection fraction (LVEF) was 46% ±6%. Serial studies were performed to assess the survival rate, the extent of mitral regurgitation (MR), LVEF, the leaflet coaptation height, LAD, LVEDD, New York Heart Association (NYHA) functional class. Results Hospital mortality was 2.7% (3 cases). Each case received an undersized ring. Intraoperative transesophageal echocardiography showed that no regurgitation in 69 cases,minimal in 34 cases, minimal to moderate in 5 cases, moderate to severe in 3 cases which received mitral valve replacement. The 3-, 12- and 24-month survival rate was 96. 2% , 93. 5% and 89. 7% respectively.Mitral regurgitation grade decreased after the operative prodecures (P ＜0. 01). LVEF increased from (46 ± 6) % to (53 ±6) % (24 months follow-up) (F＜0. 01). LAD decreased from (58 ±6) mm to (46 ±6)mm(24 months follow-up) (P ＜0. 01). LVEDD decreased from (61 ±8) mm to (48 ± 10) mm (24 months follow-up) (P ＜ 0. 01 ) . There was no significant decline of LVEDD in 18 cases ( 16. 2% ) whose preoperative mean LVEDD was (69 ±9) mm. NYHA functional class improved after operative procedures ( P ＜ 0. 01) . At 24 months follow-up, 2 cases received valvular replacement Conclusions Combined CABG and restrictive mitral annuloplasty is a feasible and effective treatment for IMR, the short and mid term outcomes are satisfactory, and a significant reduction of LVEDD and an increase of LVEF due to reverse ventricular remodeling were observed.     

限制性二尖瓣环成形联合冠状动脉旁路移植术治疗缺血性二尖瓣反流

Objective To retrospectively summarize and analyze the short and mid term follow-up outcomes of combined coronary artery bypass grafting ( CABG) and restrictive mitral annuloplasty in curing ischemic cardiomyopathy and ischemic mitral regurgitation (IMR) , and to study its effect on reverse left ventricular remodeling. Methods From January 2000 to June 2008,111 patients of coronary artery disease with morderate to severe IMR underwent combined CABG and restrictive mitral annuloplasty, downsizing by 1-2 ring sizes. There were 81 male and 30 female patients. The age ranged from 36 to 83 years with a mean of (63 ± 18) years. Preoperative transthoracic echocardiography showed minimal to moderate IMR in 7 cases, moderate to severe in 65 cases and severe in 39 cases. The left artrial diameter (LAD) was (58 ±6) mm, left ventricular end-diastolic diameter (LVEDD) was (61 ±8) mm, left ventricular ejection fraction (LVEF) was 46% ±6%. Serial studies were performed to assess the survival rate, the extent of mitral regurgitation (MR), LVEF, the leaflet coaptation height, LAD, LVEDD, New York Heart Association (NYHA) functional class. Results Hospital mortality was 2.7% (3 cases). Each case received an undersized ring. Intraoperative transesophageal echocardiography showed that no regurgitation in 69 cases,minimal in 34 cases, minimal to moderate in 5 cases, moderate to severe in 3 cases which received mitral valve replacement. The 3-, 12- and 24-month survival rate was 96. 2% , 93. 5% and 89. 7% respectively.Mitral regurgitation grade decreased after the operative prodecures (P ＜0. 01). LVEF increased from (46 ± 6) % to (53 ±6) % (24 months follow-up) (F＜0. 01). LAD decreased from (58 ±6) mm to (46 ±6)mm(24 months follow-up) (P ＜0. 01). LVEDD decreased from (61 ±8) mm to (48 ± 10) mm (24 months follow-up) (P ＜ 0. 01 ) . There was no significant decline of LVEDD in 18 cases ( 16. 2% ) whose preoperative mean LVEDD was (69 ±9) mm. NYHA functional class improved after operative procedures ( P ＜ 0. 01) . At 24 months follow-up, 2 cases received valvular replacement Conclusions Combined CABG and restrictive mitral annuloplasty is a feasible and effective treatment for IMR, the short and mid term outcomes are satisfactory, and a significant reduction of LVEDD and an increase of LVEF due to reverse ventricular remodeling were observed.     

改良腱索转移法治疗二尖瓣前叶脱垂(附16例临床分析)

Objective To introduce an operative technique for prolapse of the anterior leaflet of mitral valve. Methods From January 2002 through May 2005, chordal transfer and "edge-to-edge" technique was performed in 16 cases with serious mitral valve re- gurgitation due to prolapse of the anterior leaflet. The etiology was chordal rupture in 12 cases and chordtal elongation in 4. The mean regurgitation area yam (14.76±3.28) cn2. Left ventricular ejection fraction (LVEF) was 33% - 69% before operation. Among those patients, 5 were in NYHA function class Ⅲ and 11 in class Ⅳ. Operations were performed under general anesthesia and car- diopulmonary bypass. First, "edge to edge" technique was performed. The free edge of the prolapsed anterior leaflet was sutyred to corresponding posterior leaflet. Then quadrangular resection was performed to transfer segment of posterior leaflet with its attached chordae. At last, the posterior leaflet was approximated after quadrangular resetion. Echocardiography was performed in each patient before discharge and at the times of follow-up. Results All patients survived the operation. One patient nequired mitral valve re- placement due to anterior leaflet perforation 3 days after the operatiom. The rest were free from reoperation. At the time d follow-up, all these patients were in NYHA functional class Ⅰ. Echocardiography showed neither stenosis nor significant regurgitation of the mitral valve. The cross-sectional area of the mitral valve was 3.3 -4.8 cm2[mean(3.78±0.52)cm2]. The mean regurgitation area was (0.45±0.22) cm2. Both dimension of left atrium and left vantricule reduced significantly. The diameter of left atrium was (48.26± 11.12) mm pre-operation vs. (37.57±9.56) mm post-operation (P=0.028). The ead-diastolic diameter of the left ventricule was (61.43±8.24)mm pre-operation vs (42.35±10.79) mm post-operation (P = 0.008). Conctusion Chordal transfer and "edge- to-edge" technique provides good results for repair of anterior leaflet prolapse of mitral valve.