继发性三尖瓣反流的术中量化干预指征

发布时间：2018-07-14 11:42

【摘要】：第一部分以术中三尖瓣瓣环周长指数作为同期三尖瓣成形术的手术标准的探讨 目的：中度以下三尖瓣反流（tricuspid regurgitation，，TR）患者，以三尖瓣瓣环扩张作为预防性三尖瓣成形的手术指征已被欧美指南所正式推荐。然而定义三尖瓣瓣环扩张目前缺乏理想的标准。本课题组拟在术中直接测量三尖瓣瓣环周长并量化评估三尖瓣环扩张程度，初步探索该方法的可行性及提出对于继发性三尖瓣反流量化的术中手术标准。 方法：本研究选取了2010年10月至2011年10月在北京安贞医院九病房因单纯的二尖瓣病变或二尖瓣合并主动脉瓣病变，行二尖瓣置换术或主动脉瓣及二尖瓣双瓣置换术的患者，其中三尖瓣反流程度小于或等于2+及超声测量三尖瓣瓣环“正常”直径的患者最终纳入本次研究。这些患者均仅行单纯的左心瓣膜病变手术，并在术中测量了三尖瓣瓣环周长。术后通过超声心动图对患者进行TR程度的随访监测。定义终点事件为随访期三尖瓣反流程度与术前相比超过两级或最后达到3+/4+TR级别。 结果：在一年的入组期内，最终有127名患者列入了本次研究。其中，男性49例，女性78例；年龄53.3±10.9岁。有超过半数的患者合并有心房颤动，且大多数患者左心瓣膜的病因为风湿性。围术期死亡患者1例。术后平均随访30.2±11.8月，有23例（18.7%）最终达到终点事件。通过单因素分析，得出术前合并房颤、左房直径和术中测量的三尖瓣瓣环周长指数（tricuspid annularcircumference index， TACI）可以预测术后三尖瓣反流的加重；将这三个指标带入多因素分析，仅有TACI为术后TR加重的独立预测因素（OR,1.586;95%CI1.303to1.929; p0.001）。通过绘制受试者工作特征曲线，最终得出TACI需干预的截点值为83mm/m2，而此时的敏感度和特异度均表现出极佳的参考价值，分别为95.7%和87%。 结论：以三尖瓣塞规测量三尖瓣瓣环周长是术中定量评估三尖瓣瓣环扩张程度的一种较为理想的方法。在左心瓣膜病变患者中，三尖瓣瓣环周长指数大于83mm/m2可考虑作为术中同期行三尖瓣成形的一个参考指征。传统的二维超声心动图会很大程度上低估三尖瓣瓣环扩张程度，特别是非显著性三尖瓣反流患者，而术中直接测量评估三尖瓣瓣环大小应该作为一必要的补充，在术中常规进行。 第二部分以术中三尖瓣瓣环周长指数作为同期三尖瓣成形术的手术标准的验证 目的：以三尖瓣塞规测量三尖瓣瓣环周长是术中定量评估三尖瓣瓣环扩张程度的一种较为理想的方法。在本研究中，旨在通过再次的前瞻性临床随机对照研究，进一步验证以三尖瓣瓣环周长指数作为术中定量干预指征的可行性及可靠性。 方法：本研究连续入选从2012年10月至2013年11月，安贞医院心外科九病房单纯二尖瓣或二尖瓣合并主动脉瓣病变，同时合并2+TR及超声提示三尖瓣径线＜21cm/m2的需手术者。对纳入研究的患者随机分为左心瓣膜手术同期行三尖瓣成形术（tricuspid valve plasty, TVP组），另一组只做单纯左心瓣膜手术（non-tricuspid valve plasty, NTVP组）。术前及术后评估是基于二维超声心动图对TR程度的评估。统计分析TVP组与NTVP组术后及随访期三尖瓣关闭不全程度是否有差异；再进一步根据三尖瓣瓣环周长指数（tricuspid annularcircumference index，TACI）大于等于或小于83mm/m2将TVP组和NTVP组再分别细分为两亚组，统计分析两组术后及随访三尖瓣关闭不全程度是否有差异。 结果：最后纳入符合标准的左心瓣膜病变合并2+TR患者170例，根据研究方案随机将患者分为TVP组（n=86）和NTVP组（n=84）。按照术中测量的TACI值，进一步在TVP和NTVP中分别划分成两组。四个亚组间的患者年龄、性别、合并房颤率、左心瓣膜病变病因、单纯二尖瓣手术/双瓣手术构成比，及超声指标差异均无统计学意义(p0.05)。围术期无患者死亡。出现术后并发症患者39例（22.8%）。随访过程中无死亡患者。随访期超声心动图检查率达98.2%（166/169）。平均随访时间为20.2±10.2月。TVP组患者出院时TR程度明显低于术前程度，并在随访期保持稳定。根据TACI值将TVP组分为Group1和Group2两亚组，术后及随访期的TR程度均明显降低，并保持稳定。NTVP组患者出院时复查三尖瓣反流程度较术前亦有明显减低，但在经过平均20.2月随访，该组患者TR程度出现了恶化（p=0.009）。根据TACI值将NTVP组分为Group3和Group4。两亚组患者出院时TR程度均较术前有明显改善，但在随访期，Group3患者的TR程度尚能保持稳定（p=0.530），而Group4的患者TR程度出现了显著进展（p=0.004）。在TACI≥83mm/m2的患者中，两组术前基线资料无统计学差异，但出院及随访期，Group2TR程度显著低于Group4（p0.001），且在短期随访内，未预防性成形组有4例患者进展为显著的三尖瓣反流（TR≥3+）。 结论：在术中以三尖瓣塞规测量三尖瓣瓣环周长的方法来定量评估三尖瓣瓣环扩张程度具有简便易行、操作简单、重复性强的特点。在左心瓣膜病变手术中，三尖瓣瓣环周长指数≥83mm/m2可作为2+TR患者术中同期行预防性三尖瓣成形术的手术指征。
[Abstract]:The first part discusses the operation standard of tricuspid valve annulus circumference index as the same period of tricuspid annuloplasty .

Objective : To study the feasibility of the method and to propose a surgical standard for secondary tricuspid regurgitation .

Methods : In October 2010 to October 2011 , the patients who underwent mitral valve replacement or mitral valve double - valve replacement underwent mitral valve replacement or mitral valve double - valve replacement in nine wards of Beijing Anzhen Hospital . Among them , the tricuspid regurgitation was less than or equal to 2 + and the ultrasonic measurement of tricuspid valve annulus ' normal ' diameter was eventually included in this study .

Results : In the enrollment period of one year , 127 patients were included in the study , including 49 males and 78 females .
There were more than half of patients aged 53 . 3 卤 10.9 years old . More than half of patients had atrial fibrillation , and most patients died of heart valves due to rheumatic heart disease . The mean follow - up was 30 . 2 卤 11 . 8 months . 23 ( 18.7 % ) had end - point events . By single factor analysis , the tricuspid annular circumference index ( TACI ) was obtained for preoperative combined atrial fibrillation , left atrial diameter and intraoperative measurement .
These three indexes were brought into multi - factor analysis , with only TACI as an independent predictor of postoperative TR weighting ( OR , 1.586 ; 95 % CI 1.303to1.929 ; p0.001 ) . By plotting the working characteristic curve of the subject , it is concluded that the intercept value of the intervention of TACI is 83 mm / m2 , and the sensitivity and specificity at this time show excellent reference value , which is 95.7 % and 87 % , respectively .

Conclusion : The tricuspid valve annulus circumference is an ideal method to quantitatively assess the degree of tricuspid valve annulus dilation . In patients with left heart valve disease , tricuspid valve annulus circumference index is more than 83 mm / m2 . The traditional two - dimensional echocardiography can significantly underestimate the degree of tricuspid valve annulus dilation , especially the non - significant tricuspid regurgitation .

The second part is verified by the operation standard of tricuspid valve annulus circumference index as the same period of tricuspid annuloplasty .

Objective : To evaluate the feasibility and reliability of tricuspid valve annulus circumference index ( tricuspid valve annulus circumference index ) as a quantitative intervention index during operation in this study .

Methods : The study was performed continuously from October 2012 to November 2013 , while the patients with mitral or mitral valve combined with 2 + TR and ultrasound showed that the tricuspid valve diameter was less than 21cm / m2 . Patients included in the study were randomly divided into tricuspid valve plasty ( TVP group ) and tricuspid valve plasty ( NTVP group ) . Preoperative and postoperative assessments were based on two - dimensional echocardiography to assess the degree of TR . Statistical analysis showed that the degree of tricuspid insufficiency was different between the TVP group and the NTVP group and the follow - up period .
The TVP group and NTVP group were subdivided into two subgroups according to tricuspid annular circumference index ( TACI ) greater than or less than 83 mm / m2 .

Results : There were 170 patients with left heart valve lesion and 2 + TR patients who met the criteria . The patients were randomly divided into TVP group ( n = 86 ) and NTVP group ( n = 84 ) .

Conclusion : The tricuspid valve annulus circumference index is simple and easy to operate in operation , and the tricuspid valve annulus circumference index 鈮

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