三尖瓣关闭不全外科处理课件.pptx

1、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 ShuyangThe tricuspid valve:a neglected valvular lesionHistory 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

2、valve repair for functional tricuspid regurgitation.（late 1960s by Carpentier et al）annuloplasty at the initial mitral valve operation in the 1970sTricuspid anatomyTricuspid physiologylThe closing mechanism of the tricuspid valve mainly depends on right ventricular contractilitylLeft-sided valvular

3、lesions may influence tricuspid valve function Physiological changes of tricuspid valve ring during cardiac cycle Mechanisms of significanttricuspid regurgitationStages of primary and functional TR(Stage A-B)Stages of primary and functional TR(Stage C-D)Indications of TR Surgery2014 AHA/ACC Guidelin

4、eIndications of TR Surgery2014 AHA/ACC GuidelineValve repair Annuloplasty1.Reduction of the annulus without support2.Annular reduction supported by sutures3.Selective reduction supported by strips or pledgets of synthetic material4.Annular reduction by different types of prosthetic ringsDe Vega annu

5、loplasty1.Preservation of valvular mechanism2.It maintains the physiological flexibility of the annulus3.No prosthetic material is required4.No damage to the conduction tissue5.It is easy,fast to perform,cheapClassical De VegaModification of De VegaClassical De Vega annuloplastyWhy we need Annulopla

6、sty ringslCorrection of annular dilatationlRemodelling the shape of the annuluslImprove coaptation between leaflets during systolelStabilization of repair over timeAnnuloplasty ringsEdwards MC3Standard CarpentierEdwards.Biodegradable ringlPoly-1,4-dioxanone polymer curved C-shaped ring and suture ma

7、terial extensions at each endlIts 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 anticoagul

8、ation during the first three postoperative months Easy implantation technique(reduction in the duration of aortic cross clamp and ECC)Tricuspid valve replacementTVR OR TVP?Rheumatic heart diseasePatients47Period1977 2010Mean age59.011.4yGenderM19.1%F80.9%Atrial fibrillation80.9%Two groups according

9、to tricuspid valve surgeryRepair n=18 (38.3%)Replacement n=29 (61.7%)TVReplacementTVrepairAge59.913.662.35.5Range21 7653-76Female 23(79.3%)15(83.3%)Weight59.611.566.510.3Height157.36.5160.97.4Body surface area24.14.425.73.5TVReplacementTVrepairAtrial fibrillation27(93.1%)14(77.8%)Cardiac index2.00.7

10、2.10.3PA sistolic pressure43.313.742.711.3Pulmonary capillary pressure26.52.421.74.2Left ventricular EF57.810.154.311.7Mean TV regurgitation3.573.55TVReplacementTVrepairPrevious 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%)Three

11、2(6.9%)-TVReplacementTVrepairNYHA class III7(24.1%)12(66.7%)NYHA class IV19(65.5%)4(22.2%)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.

12、2 yearsRange1 month 33 yearsTVReplacementTVrepairCPB time79.942.875.745.7Ischemic time21.823.164.548.8Mortality8(27.6%)-Cardiac6 Bleeding1 Neurologic1TVReplacementTVrepairLate mortality15(51.7%)9(50.0%)Cardiac23 Valvular11 Unknown71 Reoperation12 Thromboembolism1 Hemorrhage1 Malignacy1 Others non ca

13、rdiac21Late resultsSurvivalFreedom from reoperationTVR n=29Alive 20.7%Class I2Class II3Class III1Repair n=18Alive 50.0%Class I3Class II4Class III21.Isolated tricuspid valve surgery with normal functioning left side valve occurs after mitral and/or aortic valve surgery2.Isolated tricuspid valve surge

14、ry has a high early and late mortality due to cardiac causes3.Tricuspid valve replacement entails a worse result comparing with tricuspid valve repairConclusionsOther optionsConclusions The tricuspid valve is still challenging There is variability in approach and techniques Specific subsets of patients are at high risk of morbidity and mortality