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1、三尖瓣修复手术策略,Prof.Dr.Rainer G.H. Moosdorf Medical Director Chairman Department for Cardiovascular Surgery University Hospital Giessen and Marburg Campus Marburg,病理,三尖瓣的临床重要性常被低估，且临床相关文献也很少。 三尖瓣疾病常由其他瓣膜疾病所致。 但是: 二尖瓣或主动脉瓣修复术并不能缓解三尖瓣关闭不全。,二尖瓣狭窄患者同时进行或未进行三尖瓣手术的结果,继发性三尖瓣关闭不全,继发性三尖瓣关闭不全,二尖瓣狭窄患者同时进行或未进行三尖瓣手术的
2、结果,二尖瓣狭窄患者同时进行或未进行三尖瓣手术的结果,继发性三尖瓣关闭不全,病理,瓣环扩大 (LsVD,肺动脉高压) 创伤后三尖瓣关闭不全 类癌综合症中的三尖瓣狭窄 感染性心内膜炎 先天性解剖学异常,修复手术适应症,我知道,我不知道! 文献报导中，很多作者讨论了右心室功能障碍在三尖瓣返流发生中的作用: 谁是因，谁是果? 同时纠正会影响远期预后吗?,二尖瓣狭窄患者同时进行或未进行三尖瓣手术的结果,继发性三尖瓣关闭不全,二尖瓣狭窄患者同时进行或未进行三尖瓣手术的结果,继发性三尖瓣关闭不全,修复手术适应症,尽管许多问题目前没有明确的答案，但一致认为最好同时进行三尖瓣修复手术 。 我们认为，中重度三尖
3、瓣返流和瓣环直径大于30 mm或直径指数大于 20 mm/m 是修复手术适应症。,二尖瓣狭窄患者同时进行或未进行三尖瓣手术的结果,继发性三尖瓣关闭不全,二尖瓣狭窄患者同时进行或未进行三尖瓣手术的结果,继发性三尖瓣关闭不全,Cardiovascular Surgery 2001; Vol 9, Nr 4: 369-77,修复手术术式,尽管一些文献讨论了三尖瓣置换术，大部分作者认为，首次手术首选修补术。 最近的文献报导主要倾向于使用人工瓣环的瓣环成形术，但大多数研究未能比较其与缝合瓣环成形术 （如 DeVega 成形术)相比的优越性.,修复手术术式,根据文献报导及我们的经验, 中度返流和中度瓣环扩
4、张的患者行简单的缝合瓣环成形术即改良DeVega 成形术。 为了达到良好的预期效果，推荐采用足够深的缝合，并且两根缝线互相交叉。,手术技巧,三尖瓣瓣环成形术 缝合DeVega 瓣环成形术,修复手术术式,改良 DeVega 成形术:,交叉缝线 :,修复手术术式,重度三尖瓣返流合并严重瓣环扩张和/或重度肺动脉高压的病例,应选择硬质环!,二尖瓣狭窄患者同时进行或未进行三尖瓣手术的结果,继发性三尖瓣关闭不全,二尖瓣狭窄患者同时进行或未进行三尖瓣手术的结果,继发性三尖瓣关闭不全,三尖瓣瓣环成形术,手术技术,三尖瓣瓣环成形术 硬质瓣环成形术,手术技术,病理,瓣环扩大 (LsVD,肺动脉高压) 创伤后三尖瓣
5、关闭不全 粘液综合症中的三尖瓣狭窄 感染性心内膜炎 先天性解剖学异常,修复手术术式,原则上，三尖瓣创伤后损伤的修复可以根据具体情况采用双瓣叶化、 改良Alfieri 缝合技术（双孔法）或人工腱索. 复杂病例应行瓣膜置换术。,病理,创伤后三尖瓣关闭不全,The clover technique“ Alfieri et al. J Thorac Cardiovasc Surg 2003; 126: 75-9,病理,瓣环扩大 (LsVD,肺动脉高压) 创伤后三尖瓣关闭不全 类癌综合症中的三尖瓣狭窄 感染性心内膜炎 先天性解剖学异常,病理和修复手术术式,类癌综合症患者，右心瓣膜受累尤其是三尖瓣受累，是
6、最常见的并发症 。 瓣叶和腱索增厚，瓣叶活动受限即贴合度受限。 治疗方法为瓣膜置换术。 与文献报导相反的是，年轻患者，我们使用带支架的生物瓣膜。随访12年，长期预后好。,类癌综合症的心脏超声表现,病理,病理,瓣环扩大 (LsVD,肺动脉高压) 创伤后三尖瓣关闭不全 类癌综合症中的三尖瓣狭窄 感染性心内膜炎 先天性解剖学异常,病理,近年来，三尖瓣感染性心内膜炎发病率增高，主要由异物感染所致 (起搏器电极, 导管). 患者反复出现肺部感染症状，且有时会出现败血症。,病理,三尖瓣感染性心内膜炎超声心动图表现,三尖瓣感染性心内膜炎超声心动图表现,病理,修复手术适应症和手术术式,肺部或全身症状出现前应行
7、手术治疗。 体外循环直视手术下取出异物，以防止感染赘生物栓塞。三尖瓣修复是手术的目的。自体心包片可用于进行瓣叶重建。如果可能应尽量避免使用异体组织材料。 起搏器依赖患者，我们倾向于选择心外膜同步起搏器植入，以防止心内植入物与重建瓣膜接触 。,病理,三尖瓣感染性心内膜炎,Gottardi R. et al., Ann Thorac Surg 2007; 84: 1943-9,病理,瓣环扩大 (LsVD,肺动脉高压) 创伤后三尖瓣关闭不全 类癌综合症中的三尖瓣狭窄 感染性心内膜炎 先天性解剖学异常,病理和修复手术类型,Ebsteins 畸形: 三尖瓣环向右心室下移，并伴有不同程度的瓣叶畸形。 应同
8、时修复三尖瓣和房室结构关系。不同临床中心根据各自的特点选择不同的手术方式。,病理,Ebstein 畸形,Da Silva et al., J Thorac Cardiovasc Surg 2007; 133: 215-23,非常感谢大家.我非常乐意回答大家的问题。,二尖瓣狭窄患者同时进行或未进行三尖瓣手术的结局,继发性三尖瓣关闭不全,Tricuspid valve repair strategies,Prof.Dr.Rainer G.H. Moosdorf Medical Director Chairman Department for Cardiovascular Surgery Unive
9、rsity Hospital Giessen and Marburg Campus Marburg,Pathologies,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 aorti
10、c- valve does not necessarily lead to an improvement of the tricuspid insufficiency.,Outcome of patients after MVS with or without concommittant TV-surgery,Outcome of secondary TVI,Outcome of secondary TVI,Outcome of patients after MVR with and without concommittant TV-surgery,Outcome of patients af
11、ter MVS with or without concommittant TV-surgery,Outcome of secondary TVI,Pathologies,Annulodilatation (LsVD,PHt) Posttraumatic TI Tricuspid stenosis in Carcinoid syndrome Endocarditis Congenital malformations,Indications for repair,I know, I dont know! In a literature review, many authors discuss t
12、he role of right ventricular dysfunction in the devellopment of tricuspid 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-surgery,Outcome of secondary TVI,Outcome of patien
13、ts after MVS with or without concommittant TV-surgery,Outcome of secondary TVI,Indications 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 tr
14、icuspid valve regurgitation and an annular diameter of 30 mm respectively an indexed diameter of 20 mm/m an indication for repair.,Outcome of patients after MVS with or without concommittant TV-surgery,Outcome of secondary TVI,Outcome of patients after MVS with or without concommittant TV-surgery,Ou
15、tcome of secondary TVI,Cardiovascular Surgery 2001; Vol 9, Nr 4: 369-77,Type 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 propa
16、bly prefer ring annuloplasties, the majority of studies does not show a superiority 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 mod
17、erate regurgitation and moderately dilated annuli. Deep enough stitches, alternating between the two suture lines, are mandatory for a satisfactory longterm result.,Operative techniques,Tricuspid valve annuloplasty DeVega suture annuloplasty,Type of repair,Modified DeVega Plasty:,Alternating Sutures
18、:,Type of repair,In case of severe tricuspid regurgitation, associated with severe 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-surgery,Outcome of secondary TVI,Ou
19、tcome of patients after MVS with or without concommittant TV-surgery,Outcome of secondary TVI,Tricuspid valve annuloplasty,Operative techniques,Tricuspid valve annuloplasty Rigid ring annuloplasty,Operative Techniques,Pathologies,Annulodilatation (LsVD,PHt) Posttraumatic TI Tricuspid stenosis in Car
20、cinoid syndrome Endocarditis Congenital malformations,Type of repair,Principally, posttraumatic 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
21、 necessary.,Pathologies,Posttraumatic tricuspid insufficiency,The clover technique“ Alfieri et al. J Thorac Cardiovasc Surg 2003; 126: 75-9,Pathologies,Annulodilatation (LsVD,PHt) Posttraumatic TI Tricuspid stenosis in Carcinoid syndrome Endocarditis Congenital malformations,Pathology and type of re
22、pair,In patients with Carcinoid syndrome, involvement of the right sided heart valves, especially 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 contra
23、st to some recommendations in literature, we also use stented biological valves in younger patients with this disease and have observed promising longterm observations up to 12 years.,Echo-findings in Carcinoid syndrome,Pathologies,Pathologies,Annulodilatation (LsVD,PHt) Posttraumatic TI Tricuspid s
24、tenosis in Carcinoid syndrome Endocarditis Congenital malformations,Pathology,Tricuspid valve 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 s
25、ometimes by a septic syndrome.,Pathology,Echo-findings in tricuspid valve endocarditis,Echo-findings in tricuspid valve endocarditis,Pathology,Indication and type of repair,Surgery should be performed early before pulmonary or even general complications have occured. The foreign bodies have to be re
26、moved under direct vision in ECC to avoid further embolization of infective vegetations. A repair 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 pati
27、ents, we prefer a simultaneous epicardial implantation to avoid any further endocardial implants in contact with the reconstruced valve.,Pathologies,Tricuspid valve endocarditis,Gottardi R. et al., Ann Thorac Surg 2007; 84: 1943-9,Pathologies,Annulodilatation (LsVD,PHt) Posttraumatic TI Tricuspid st
28、enosis in Carcinoid syndrome Endocarditis Congenital malformations,Pathology and type of repair,Ebsteins anomaly: It is characterized by a displacement of the tricuspid valve towards the right ventricle, associated with different degrees of leaflet malformations. Simultaneous correction of the valve
29、 and the atrio-ventricular relation should be aimed at. Different types of repair have been proposed and should be reserved to specialized centers.,Pathologies,Ebsteins anomaly,Da Silva et al., J Thorac Cardiovasc Surg 2007; 133: 215-23,Thank You very much for Your attention. I would be happy to answer Your questions,Outcome of patients after MVS with or without concommittant TV-surgery,Outcome of secondary TVI,