三尖瓣修復手術策略ppt課件

1、三尖瓣修復手術戰(zhàn)略Prof.Dr.Rainer G.H. MoosdorfMedical DirectorChairmanDepartment for Cardiovascular SurgeryUniversity Hospital Giessen and MarburgCampus Marburg病理 三尖瓣的臨床重要性常被低估，且臨床相關文獻也很少。 三尖瓣疾病常由其他瓣膜疾病所致。 但是: 二尖瓣或自動脈瓣修復術并不能緩解三尖瓣封鎖不全。 二尖瓣狹窄患者同時進展或未進展三尖瓣手術的結果繼發(fā)性三尖瓣封鎖不全繼發(fā)性三尖瓣封鎖不全 二尖瓣狹窄患者同時進展或未進展三尖瓣手術的結果 二尖瓣狹窄患

2、者同時進展或未進展三尖瓣手術的結果繼發(fā)性三尖瓣封鎖不全病理 瓣環(huán)擴展 (LsVD,肺動脈高壓) 創(chuàng)傷后三尖瓣封鎖不全 類癌綜合癥中的三尖瓣狹窄 感染性心內膜炎 先天性解剖學異常修復手術順應癥 我知道,我不知道! 文獻報導中，很多作者討論了右心室功能妨礙在三尖瓣返流發(fā)生中的作用: 誰是因，誰是果? 同時糾正會影響遠期預后嗎? 二尖瓣狹窄患者同時進展或未進展三尖瓣手術的結果繼發(fā)性三尖瓣封鎖不全 二尖瓣狹窄患者同時進展或未進展三尖瓣手術的結果繼發(fā)性三尖瓣封鎖不全修復手術順應癥 雖然許多問標題前沒有明確的答案，但一致以為最好同時進展三尖瓣修復手術 。 我們以為，中重度三尖瓣返流和瓣環(huán)直徑大于30 mm

3、或直徑指數(shù)大于 20 mm/m 是修復手術順應癥。 二尖瓣狹窄患者同時進展或未進展三尖瓣手術的結果繼發(fā)性三尖瓣封鎖不全 二尖瓣狹窄患者同時進展或未進展三尖瓣手術的結果繼發(fā)性三尖瓣封鎖不全Cardiovascular Surgery 2019; Vol 9, Nr 4: 369-77修復手術術式 雖然一些文獻討論了三尖瓣置換術，大部分作者以為，初次手術首選修補術。 最近的文獻報導主要傾向于運用人工瓣環(huán)的瓣環(huán)成形術，但大多數(shù)研討未能比較其與縫合瓣環(huán)成形術 如 DeVega 成形術)相比的優(yōu)越性.修復手術術式 根據(jù)文獻報導及我們的閱歷, 中度返流和中度瓣環(huán)擴張的患者行簡單的縫合瓣環(huán)成形術即改良DeV

4、ega 成形術。 為了到達良好的預期效果，引薦采用足夠深的縫合，并且兩根縫線相互交叉。手術技巧 三尖瓣瓣環(huán)成形術 縫合DeVega 瓣環(huán)成形術修復手術術式 改良 DeVega 成形術:交叉縫線:修復手術術式 重度三尖瓣返流合并嚴重瓣環(huán)擴張和/或重度肺動脈高壓的病例,應選擇硬質環(huán)! 二尖瓣狹窄患者同時進展或未進展三尖瓣手術的結果繼發(fā)性三尖瓣封鎖不全 二尖瓣狹窄患者同時進展或未進展三尖瓣手術的結果繼發(fā)性三尖瓣封鎖不全 三尖瓣瓣環(huán)成形術手術技術 三尖瓣瓣環(huán)成形術 硬質瓣環(huán)成形術手術技術病理 瓣環(huán)擴展 (LsVD,肺動脈高壓) 創(chuàng)傷后三尖瓣封鎖不全 粘液綜合癥中的三尖瓣狹窄 感染性心內膜炎 先天性解剖

5、學異常修復手術術式 原那么上，三尖瓣創(chuàng)傷后損傷的修復可以根據(jù)詳細情況采用雙瓣葉化、 改良Alfieri 縫合技術雙孔法或人工腱索. 復雜病例應行瓣膜置換術。病理 創(chuàng)傷后三尖瓣封鎖不全The clover technique“Alfieri et al. J Thorac CardiovascSurg 2019; 126: 75-9病理 瓣環(huán)擴展 (LsVD,肺動脈高壓) 創(chuàng)傷后三尖瓣封鎖不全 類癌綜合癥中的三尖瓣狹窄 感染性心內膜炎 先天性解剖學異常病理和修復手術術式 類癌綜合癥患者，右心瓣膜受累尤其是三尖瓣受累，是最常見的并發(fā)癥 。 瓣葉和腱索增厚，瓣葉活動受限即貼合度受限。 治療方法為瓣膜

6、置換術。 與文獻報導相反的是，年輕患者，我們運用帶支架的生物瓣膜。隨訪12年，長期預后好。 類癌綜合癥的心臟超聲表現(xiàn)病理病理 瓣環(huán)擴展 (LsVD,肺動脈高壓) 創(chuàng)傷后三尖瓣封鎖不全 類癌綜合癥中的三尖瓣狹窄 感染性心內膜炎 先天性解剖學異常病理 近年來，三尖瓣感染性心內膜炎發(fā)病率增高，主要由異物感染所致 (起搏器電極, 導管). 患者反復出現(xiàn)肺部感染病癥，且有時會出現(xiàn)敗血癥。病理 三尖瓣感染性心內膜炎超聲心動圖表現(xiàn) 三尖瓣感染性心內膜炎超聲心動圖表現(xiàn)病理修復手術順應癥和手術術式 肺部或全身病癥出現(xiàn)前應行手術治療。 體外循環(huán)直視手術下取出異物，以防止感染贅生物栓塞。三尖瓣修復是手術的目的。自體

7、心包片可用于進展瓣葉重建。假設能夠應盡量防止運用異體組織資料。 起搏器依賴患者，我們傾向于選擇心外膜同步起搏器植入，以防止心內植入物與重建瓣膜接觸 。病理 三尖瓣感染性心內膜炎Gottardi R. et al., Ann Thorac Surg 2019; 84: 1943-9病理 瓣環(huán)擴展 (LsVD,肺動脈高壓) 創(chuàng)傷后三尖瓣封鎖不全 類癌綜合癥中的三尖瓣狹窄 感染性心內膜炎 先天性解剖學異常病理和修復手術類型 Ebsteins 畸形: 三尖瓣環(huán)向右心室下移，并伴有不同程度的瓣葉畸形。 應同時修復三尖瓣和房室構造關系。不同臨床中心根據(jù)各自的特點選擇不同的手術方式。病理 Ebstein 畸

8、形Da Silva et al., J Thorac Cardiovasc Surg 2019; 133: 215-23非常贊賞大家.我非常樂意回答大家的問題。 二尖瓣狹窄患者同時進展或未進展三尖瓣手術的結局繼發(fā)性三尖瓣封鎖不全Tricuspid valve repair strategiesProf.Dr.Rainer G.H. MoosdorfMedical DirectorChairmanDepartment for Cardiovascular SurgeryUniversity Hospital Giessen and MarburgCampus MarburgPathologies

9、 The tricuspid valve is underestimated in its clinical importance and also under-represented in literature. Tricuspid valve disease is mainly seen as a consequence of other valvular dysfunctions. But: The correction of the mitral- or aortic- valve does not necessarily lead to an improvement of the t

10、ricuspid insufficiency. Outcome of patients after MVS with or without concommittant TV-surgeryOutcome of secondary TVIOutcome of secondary TVI Outcome of patients after MVR with and without concommittant TV-surgery Outcome of patients after MVS with or without concommittant TV-surgeryOutcome of seco

11、ndary TVIPathologies Annulodilatation (LsVD,PHt) Posttraumatic TI Tricuspid stenosis in Carcinoid syndrome Endocarditis Congenital malformationsIndications for repair I know, I dont know! In a literature review, many authors discuss the role of right ventricular dysfunction in the devellopment of tr

12、icuspid regurgitation: What is first and what comes second? Does simultaneous correction influence the longterm results? Outcome of patients after MVS with or without concommittant TV-surgeryOutcome of secondary TVI Outcome of patients after MVS with or without concommittant TV-surgeryOutcome of sec

13、ondary TVIIndications for repair Whereas many questions are not definitively answered, there is general agreement, that concommittant surgery of the tricuspid valve should be preferred. Accordingly we consider moderate to severe tricuspid valve regurgitation and an annular diameter of 30 mm respecti

14、vely an indexed diameter of 20 mm/m an indication for repair. Outcome of patients after MVS with or without concommittant TV-surgeryOutcome of secondary TVI Outcome of patients after MVS with or without concommittant TV-surgeryOutcome of secondary TVICardiovascular Surgery 2019; Vol 9, Nr 4: 369-77T

15、ype of repair Although tricuspid valve replacement is also discussed in some articles, there is an agreement among most authors, that repair is the first choice at least in primary interventions. While recent publications propably prefer ring annuloplasties, the majority of studies does not show a s

16、uperiority compared to suture annuloplasties (i.e. DeVega plasty).Type of repair According to literature and based on own experiences, we prefer a simple suture annuloplasty in terms of a modified DeVega plasty in cases of moderate regurgitation and moderately dilated annuli. Deep enough stitches, a

17、lternating between the two suture lines, are mandatory for a satisfactory longterm result.Operative techniques Tricuspid valve annuloplasty DeVega suture annuloplastyType of repair Modified DeVega Plasty:AlternatingSutures:Type of repair In case of severe tricuspid regurgitation, associated with sev

18、ere annular dilatation and/or significant pulmonary hypertension, the implatation of a rigid ring is our method of choice! Outcome of patients after MVS with or without concommittant TV-surgeryOutcome of secondary TVI Outcome of patients after MVS with or without concommittant TV-surgeryOutcome of s

19、econdary TVI Tricuspid valve annuloplastyOperative techniques Tricuspid valve annuloplasty Rigid ring annuloplastyOperative TechniquesPathologies Annulodilatation (LsVD,PHt) Posttraumatic TI Tricuspid stenosis in Carcinoid syndrome Endocarditis Congenital malformationsType of repair Principally, pos

20、ttraumatic ruptures of the tricuspid valve may also be repaired by individual techniques including bicuspida- lization, modified Alfieri stitch and artificial chords. In complex cases, a valve replacement may become necessary.Pathologies Posttraumatic tricuspid insufficiencyThe clover technique“Alfi

21、eri et al. J Thorac CardiovascSurg 2019; 126: 75-9Pathologies Annulodilatation (LsVD,PHt) Posttraumatic TI Tricuspid stenosis in Carcinoid syndrome Endocarditis Congenital malformationsPathology and type of repair In patients with Carcinoid syndrome, involvement of the right sided heart valves, espe

22、cially the tricuspid valve, is a common complication. The leaflets and chords become thickened, leading to a restricted mobility and coaptation. The therapy of choice is the replacement of the valve. In contrast to some recommendations in literature, we also use stented biological valves in younger

23、patients with this disease and have observed promising longterm observations up to 12 years. Echo-findings in Carcinoid syndromePathologiesPathologies Annulodilatation (LsVD,PHt) Posttraumatic TI Tricuspid stenosis in Carcinoid syndrome Endocarditis Congenital malformationsPathology Tricuspid valve

24、endocarditis has become more frequent in recent years, mainly caused by the infection of foreign bodies (pacemaker leads, port catheters). Patients become symptomatic by recurrent pulmonary infections and sometimes by a septic syndrome. Pathology Echo-findings in tricuspid valve endocarditis Echo-fi

25、ndings in tricuspid valve endocarditisPathologyIndication and type of repair Surgery should be performed early before pulmonary or even general complications have occured. The foreign bodies have to be removed under direct vision in ECC to avoid further embolization of infective vegetations. A repai

26、r of the tricuspid valve should be aimed at in all cases. Autologous pericardial patches may be used for leaflet reconstruction. Foreign material should be avoided if possible. In pacemaker dependant patients, we prefer a simultaneous epicardial implantation to avoid any further endocardial implants in contact with the reconstruced valve