腔静脉内阻断技术在单纯性三尖瓣微创手术中的应用

目的总结采用带球囊插管行腔静脉内阻断技术在再次单纯性三尖瓣微创手术中的应用经验。方法对2002年至2012年在我院运用腔静脉内阻断技术在体外循环心脏不停跳下实施再次三尖瓣微创手术治疗心脏术后远期单纯性三尖瓣重度关闭不全46例进行回顾性总结和分析。胸部cT显示胸骨后及心包均存在严重粘连。术中行股动脉插管，经右胸前外侧第4肋间切口进胸，经右房上、下切口分别插入上、下腔静脉引流腔静脉，食管超声确定插管的位置，无菌生理盐水注入球囊阻断腔静脉，切开右房行三尖瓣手术。结果46例患者均顺利实施三尖瓣手术，无体外循环意外发生，其中三尖瓣置换术34例，三尖瓣成形术12例。手术时间（161~52）min，建立体外循环时间（55~15）rain，体外循环时间（58~23）min；术后胸液引流量（275~108）ml；术后平均住院时间（8~7）do全组患者均成功治愈出院。随访6-120个月，死亡2例，其中1例因肺血管破裂大咯血死亡，另1例死于心力衰竭。三尖瓣置换者无瓣周漏出现；三尖瓣成形者中，1例于术后5年出现感染性心内膜炎合并三尖瓣重度关闭，1例随访为中度关闭不全。结论采用带球囊插管腔内阻断技术阻断上、下腔静脉，可安全、有效、可靠地应用于再次单纯性三尖瓣微创手术，使手术的复杂程度明显简化。

Application of vena cava intraluminal occlusion technique in minimally invasive isolated tricuspid valve surgery

Objective To summarize the experiences of appling vena cava intraluminal occlusion tech- nique in minimally invasive repeated isolated tricuspid valve surgery. Methods Consecutive patients （n=46） with isolated significant late tricuspid regurgitation （TR） after previous cardiac surgery received minimally invasive re- peated tricuspid valve surgery in beating heart without crossclamping ascending aorta from 2002 to 2012. Computed tomography showed that severe adhesions exited in the pericardium and the posterior of the sternum. It was difficult to carry out the conventional median thoracotomy and segregate the vena cava. Cardiopulmonary bypass was initiated by cannulating the right femoral artery for arterial access. A right anterolateral thoracotomy incision was made over the fourth intercostal space. Under transoesophageal echocardiographic guidance, the balloon cannulas were insterted through the surface of the right atrium for the venous drainage both of the superior vena cava （SVC） and the inferior vena cava （IVC） respectively. The balloon of the cannula was inflated to obtain the occlusion of SVC and IVC when the nasopharyngeal temperature was about 32 ~C-55 ~C. After the endovascular occlusion of both the caval veins,the right atrium was opened and the tricuspid valve surgery was performed. Results The tricuspid valve was re- paired in 12 patients and replaced in 34 patients. There was not cardiopulmonary bypass accident during the opera- tion. The time of operation was （161＋52） min. The time of building cardiopulmonary bypass（CPB） was （55＋15） rain and the time of CPB was （58＋23） min. The postoperative drainage was （275＋108） ml, and the postoperative inhospi- tal time was （8＋7） days. There was no death in hospital. During the follow-up, 2 patients died. One died of pul- monary vascular rupture, and the other died of heart failure. There was no paravalvular leakage occurs in tricuspid valve replacement （TVR）. Echocardiography showed that one patient who had tricuspid valve plasty （TVP） had se- vere TR due to infective endocarditis, and another patient who had TVP had moderate TR. Conclusion Appling of vena cava intraluminal occlusion technique in minimally invasive repeated isolated tricuspid valve surgery is safe, effective and reliable. It could significantly simplified the complexity of the surgery.