尖瓣關(guān)閉不全的外科處理ppt課件

1、三尖瓣封鎖不全的外科處置三尖瓣封鎖不全的外科處置LU Shuyang；The tricuspid valve:a neglected valvular lesion；History 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 routin

2、e valve repair for functional tricuspid regurgitation. late 1960s by Carpentier et al annuloplasty at the initial mitral valve operation in the 1970s；Tricuspid anatomy；Tricuspid physiologylThe closing mechanism of the tricuspid valve mainly depends on right ventricular contractilitylLeft-sided valvu

3、lar lesions may influence tricuspid valve functionlPhysiological changes of tricuspid valve ring during cardiac cycle ；Mechanisms of significanttricuspid regurgitation；Stages of primary and functional TR(Stage A-B) ；Stages of primary and functional TR(Stage C-D) ；Indications of TR Surgery2021 AHA/AC

4、C Guideline；Indications of TR Surgery2021 AHA/ACC Guideline；Valve 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 r

5、ings；De Vega annuloplasty1. 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 Vega；Classical De Vega annulopl

6、asty；Why we need Annuloplasty ringslCorrection of annular dilatationlRemodelling the shape of the annuluslImprove coaptation between leaflets during systolelStabilization of repair over time；Annuloplasty ringsEdwards MC3Standard CarpentierEdwards.；Biodegradable ringlPoly-1,4-dioxanone polymer curved

7、 C-shaped ring and suture material 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 end

8、ocarditis) No need for anticoagulation during the first three postoperative months Easy implantation technique (reduction in the duration of aortic cross clamp and ECC)；Tricuspid valve replacement；TVR OR TVP?；Rheumatic heart diseasePatients47Period1977 2021Mean age59.011.4yGenderM19.1% F80.9%Atrial

9、fibrillation80.9%；Two groups according 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 area24.14.425.73.5；TVReplacementTVrepairAtrial

10、fibrillation27 (93.1%)14 (77.8%)Cardiac index2.00.72.10.3PA sistolic pressure43.313.742.711.3Pulmonary capillary pressure26.52.421.74.2Left ventricular EF57.810.154.311.7Mean TV regurgitation3.573.55；TVReplacementTVrepairPrevious TV surgery Repair7 (24.1%)2 (11.1%) Replacement 4 (13.8%)-Previous CPB

11、 operations One11 (37.9%)6 (33.3%) Two9 (31.0%)2 (11.1%) Three2 (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 p

12、ts)Bioprosthesis (15 pts)；Follow-upComplete follow-up97.8%Mean follow-up16.2 yearsRange1 month 33 years；TVReplacementTVrepairCPB time79.942.875.745.7Ischemic time21.823.164.548.8Mortality8 (27.6%)- Cardiac6 Bleeding1 Neurologic1；TVReplacementTVrepairLate mortality15 (51.7%)9 (50.0%) Cardiac23 Valvul

13、ar11 Unknown71 Reoperation12 Thromboembolism1 Hemorrhage1 Malignacy1 Others non cardiac21Late results；Survival；Freedom from reoperation；TVR n = 29Alive 20.7%Class I2Class II3Class III1Repair n = 18Alive 50.0%Class I3Class II4Class III2；1.Isolated tricuspid valve surgery with normal functioning left side valve occurs after mitral and/or aortic valve surgery2.Isolated tricuspid valve surgery has a high early and late mortality due to cardiac causes3.Tricuspid valve replacement entails a worse result comparing with tricu