功能性三尖瓣关闭不全的治疗策略
공능성삼첨판관폐불전적치료책략
The therapy policy about functional tricuspid regurgitate
  • 万方数据
    中华胸心血管外科杂志 중화흉심혈관외과잡지
    Chinese Journal of Thoracic and Cardiovascular Surgery
    2015年 10期 585-589 ,共5页

    祝岩%王辉山%金岩

    축암%왕휘산%금암

    三尖瓣闭锁不全%三尖瓣成形术%Kay三尖瓣成形术%MC3三尖瓣成形环 三尖瓣閉鎖不全%三尖瓣成形術%Kay三尖瓣成形術%MC3三尖瓣成形環
    삼첨판폐쇄불전%삼첨판성형술%Kay삼첨판성형술%MC3삼첨판성형배
    Functional tricuspid regurgitate%Tricuspid annuloplasty%Kay's%MC3 ring
    目的 探讨和比较三尖瓣Kay成形术与MC3三尖瓣成形环治疗功能性三尖瓣反流(FTR)的方法和疗效.方法 2010年1月至2014年5月,于我院因合并FTR行左心系统手术同期接受三尖瓣成形手术共759例,男355例,女404例,平均年龄(54.1±8.3)岁.术前NYHA心功能分级:Ⅰ级13例,Ⅱ级177例,Ⅲ级400例,Ⅳ级169例.平均左心室射血分数(LVEF)0.53 ±0.04,平均肺动脉压(62.5±17.6) mmHg(1 mmHg =0.133 kPa).病因包括风心病517例,退行性变209例,心内膜炎33例.行二尖瓣成形术132例,二尖瓣置换术295例,二尖瓣成形与主动脉瓣置换术20例,二尖瓣与主动脉瓣置换术388例.行冠状动脉旁路移植术86例,MazeⅢ型手术23例.术前三尖瓣反流程度Ⅰ级88例,Ⅱ级189例,Ⅲ级352例,Ⅳ级130例.全部患者中2010年1月至2012年5月连续行Kay成形术447例(Kay组),2012年5月至2014年5月连续行Edwards MC3人工瓣环置入312例(MC3组).术前经超声心动图明确三尖瓣反流(TR)程度,测量三尖瓣瓣环直径,肺动脉压力及心功能等指标.两种三尖瓣成形术均在心脏复跳后进行.MC3组根据瓣环大小置入成形环28 mm 79例、30 mm 155例、32 mm66例、34 mm 12例.结果 两组患者均无死亡、不良事件及针对三尖瓣再次手术发生.两组主动脉阻断时间、体外循环时间、术后机械通气辅助时间、ICU滞留时间、平均住院日以及术后并发症发生率差别均无统计学意义(P＞0.05).随访率90.4％(686/759),平均随访时间(39.9±7.7)个月.两组术后随访期间右心室EF值均有不同程度增加,右心室内径逐渐减小.术后3个月两组均无中度以上的TR,1年内Kay组有1例中-重度TR,MC3组为2例(P＞0.05);2年内Kay组出现5例中-重度及以上程度的TR,而MC3组为3例中度TR且无更严重的TR发生(P＜0.05).术后2年以上Kay组出现中-重度及以上程度的TR为12例,MC3组仍为3例.超声心动图测量患者术后3个月、1年、2年的三尖瓣反流量,Kay组与MC3组分别为(3.4±1.4) ml与(6.5±2.1) ml、(7.9±2.5) ml与(2.9±0.9) ml、(3.5±1.3) ml与(3.4±2.1)ml.Kay组术后2年以后为(12.4±4.7) ml,提示二者近期术后效果相似(P＞0.05),远期效果MC3组明显好于Kay组(P＜0.05).结论 Kay成形术近期效果较好,但术后长期反流率偏高,可应用于高龄或预期寿命较短的患者;MC3瓣环可以持久、有效地纠正FTR,特别是小型号的MC3成形环,可以在最大程度上防止术后残余或再次出现TR,适用于年轻患者或对术后预期较高的患者.
    목적 탐토화비교삼첨판Kay성형술여MC3삼첨판성형배치료공능성삼첨판반류(FTR)적방법화료효.방법 2010년1월지2014년5월,우아원인합병FTR행좌심계통수술동기접수삼첨판성형수술공759례,남355례,녀404례,평균년령(54.1±8.3)세.술전NYHA심공능분급:Ⅰ급13례,Ⅱ급177례,Ⅲ급400례,Ⅳ급169례.평균좌심실사혈분수(LVEF)0.53 ±0.04,평균폐동맥압(62.5±17.6) mmHg(1 mmHg =0.133 kPa).병인포괄풍심병517례,퇴행성변209례,심내막염33례.행이첨판성형술132례,이첨판치환술295례,이첨판성형여주동맥판치환술20례,이첨판여주동맥판치환술388례.행관상동맥방로이식술86례,MazeⅢ형수술23례.술전삼첨판반류정도Ⅰ급88례,Ⅱ급189례,Ⅲ급352례,Ⅳ급130례.전부환자중2010년1월지2012년5월련속행Kay성형술447례(Kay조),2012년5월지2014년5월련속행Edwards MC3인공판배치입312례(MC3조).술전경초성심동도명학삼첨판반류(TR)정도,측량삼첨판판배직경,폐동맥압력급심공능등지표.량충삼첨판성형술균재심장복도후진행.MC3조근거판배대소치입성형배28 mm 79례、30 mm 155례、32 mm66례、34 mm 12례.결과 량조환자균무사망、불량사건급침대삼첨판재차수술발생.량조주동맥조단시간、체외순배시간、술후궤계통기보조시간、ICU체류시간、평균주원일이급술후병발증발생솔차별균무통계학의의(P＞0.05).수방솔90.4％(686/759),평균수방시간(39.9±7.7)개월.량조술후수방기간우심실EF치균유불동정도증가,우심실내경축점감소.술후3개월량조균무중도이상적TR,1년내Kay조유1례중-중도TR,MC3조위2례(P＞0.05);2년내Kay조출현5례중-중도급이상정도적TR,이MC3조위3례중도TR차무경엄중적TR발생(P＜0.05).술후2년이상Kay조출현중-중도급이상정도적TR위12례,MC3조잉위3례.초성심동도측량환자술후3개월、1년、2년적삼첨판반류량,Kay조여MC3조분별위(3.4±1.4) ml여(6.5±2.1) ml、(7.9±2.5) ml여(2.9±0.9) ml、(3.5±1.3) ml여(3.4±2.1)ml.Kay조술후2년이후위(12.4±4.7) ml,제시이자근기술후효과상사(P＞0.05),원기효과MC3조명현호우Kay조(P＜0.05).결론 Kay성형술근기효과교호,단술후장기반류솔편고,가응용우고령혹예기수명교단적환자;MC3판배가이지구、유효지규정FTR,특별시소형호적MC3성형배,가이재최대정도상방지술후잔여혹재차출현TR,괄용우년경환자혹대술후예기교고적환자.
    Objective To assess and compare the the results of tricuspid annuloplasty performed with the Edwards MC3 and Kay methode.Methods From January 2010 to May 2014, 759 patients with function tricuspid regurgitation(FTR) secondary to left-sided valve disease received tricuspid annuloplasty.Cardiac ultrasound Heartbeat diagram were made to confirm the degree of tricuspid regurgitation, the diameter of tricuspid annulus, the pressure of pulmonary artery and the heart function both in the left and the right, and so on.Of them, 355 cases of male, female 404 cases, at the mean age of(54.1 ± 8.3) years old, with the heart function classical(NYHA) : Ⅰ 13, Ⅱ 177, Ⅲ 400, Ⅳ 169, the mean left ventricles ejection fraction(LVEF) was 0.53 ±0.04, the mean pulmonary artery pressure was(62.5 ± 17.6) mmHg(1 mmHg =0.133 kPa).The diagnosis include rheumatic heart disease 517 cases, degenerative disease 209 cases and infective endocarditis 33 cases.The operation include mitral annuloplasty 132 case, mitral replacement 295 cases, mitral annuloplasty and aortic replacement 20 cases, mitral and aortic replacement 388 cases, CABG 86 cases and Maze Ⅲ methode 23 cases.The degree of tricuspid regurgitation before the operation were class Ⅰ 88, Ⅱ 189, Ⅲ 352 and V 130.From January 2010 to May 2012, 447 cases received Kay' s methods and 312 cases received MC3 annuloplasty ring during May 2012 to May 2014.In the MC3, We use the rings in 28mm size were 79 cases, 30 mm 155 cases, 32 mm 66 cases and 34 mm 12 cases.Results There were no death, reoperation and adverse events in both groups.There were no diffent in the aorta block time, the circulation bypass time, the time of mechanical ventilation, stay in ICU and in the hospital(P ＞ 0.05).All the patient were followed up regularity.The rat of follow up was 90.4％ (686/759), and the mean time of follow up was(39.9 ± 7.7) month.The patients' s EF increased, inner diameter of the right ventricle decreased in both group.There were no severe TR in the patients in the Kay group within 3 months, and 1 case of severe TR 1 year later, as 5 cases at 2 years and 12 cases after 2 years.The regurgitation volume of tricuspid was (3.4 ± 1.4) ml at the moment of 3 month, (6.5 ± 2.1) ml at 1 year, (7.9 ± 2.5) ml at 2 years and (12.4 ± 4.7)ml 2 years later.In the MC3 group, there were no severe TR in the patients during all the stage of fellow-up.There were on regurgitation in the patient within 3 months, 1 case of Class Ⅲ of TR at 1 year and 3 cases of Class Ⅲ at 2 years, without worse TR happen.At the same stage as in MC3 group, the regurgitation volume was(2.9 ±0.9) ml,(3.5 ±1.3) ml and(3.4 ±2.1) ml.The result in MC3 group was similar with Kay group(P ＞0.05) in short term, but much better in the long-term(P ＜ 0.05).Conclusion The Kay methode has good early result, but not the same good in the long-term, which can be applied in the elder persons or the patient without long Life expectancy.And the MC3 ring can correct the FTR enduringly and effectually, specifically the size in small one which behaves perfectly.The MC3 ring should be used in the young patient or the patient wants more.
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