三尖瓣修復(fù)手術(shù)策略

Prof.Dr.RainerG.H.MoosdorfMedicalDirectorChairmanDepartmentforCardiovascularSurgeryUniversityHospitalGiessenandMarburgCampusMarburg病理繼發(fā)性三尖瓣關(guān)閉不全繼發(fā)性三尖瓣關(guān)閉不全繼發(fā)性三尖瓣關(guān)閉不全病理瓣環(huán)擴大(LsVD,肺動脈高壓)創(chuàng)傷后三尖瓣關(guān)閉不全類癌綜合癥中的三尖瓣狹窄感染性心內(nèi)膜炎先天性解剖學(xué)異常我知道,我不知道!文獻報導(dǎo)中，很多作者討論了右心室功能障礙在三尖瓣返流發(fā)生中的作用:誰是因，誰是果?同時糾正會影響遠期預(yù)后嗎?繼發(fā)性三尖瓣關(guān)閉不全繼發(fā)性三尖瓣關(guān)閉不全繼發(fā)性三尖瓣關(guān)閉不全繼發(fā)性三尖瓣關(guān)閉不全CardiovascularSurgery2001;Vol9,Nr4:369-77交叉縫線: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(yīng)選擇硬質(zhì)環(huán)!繼發(fā)性三尖瓣關(guān)閉不全繼發(fā)性三尖瓣關(guān)閉不全病理瓣環(huán)擴大(LsVD,肺動脈高壓)創(chuàng)傷后三尖瓣關(guān)閉不全粘液綜合癥中的三尖瓣狹窄感染性心內(nèi)膜炎先天性解剖學(xué)異常病理創(chuàng)傷后三尖瓣關(guān)閉不全?Theclovertechnique“Alfierietal.JThoracCardiovascSurg2003;126:75-9病理瓣環(huán)擴大(LsVD,肺動脈高壓)創(chuàng)傷后三尖瓣關(guān)閉不全類癌綜合癥中的三尖瓣狹窄感染性心內(nèi)膜炎先天性解剖學(xué)異常類癌綜合癥的心臟超聲表現(xiàn)病理病理瓣環(huán)擴大(LsVD,肺動脈高壓)創(chuàng)傷后三尖瓣關(guān)閉不全類癌綜合癥中的三尖瓣狹窄感染性心內(nèi)膜炎先天性解剖學(xué)異常病理近年來，三尖瓣感染性心內(nèi)膜炎發(fā)病率增高，主要由異物感染所致(起搏器電極,導(dǎo)管).患者反復(fù)出現(xiàn)肺部感染癥狀，且有時會出現(xiàn)敗血癥。病理三尖瓣感染性心內(nèi)膜炎超聲心動圖表現(xiàn)三尖瓣感染性心內(nèi)膜炎超聲心動圖表現(xiàn)病理病理三尖瓣感染性心內(nèi)膜炎GottardiR.etal.,AnnThoracSurg2007;84:1943-9病理瓣環(huán)擴大(LsVD,肺動脈高壓)創(chuàng)傷后三尖瓣關(guān)閉不全類癌綜合癥中的三尖瓣狹窄感染性心內(nèi)膜炎先天性解剖學(xué)異常病理Ebstein畸形DaSilvaetal.,JThoracCardiovascSurg2007;133:215-23非常感謝大家.我非常樂意回答大家的問題。繼發(fā)性三尖瓣關(guān)閉不全Tricuspidvalve

repairstrategiesProf.Dr.RainerG.H.MoosdorfMedicalDirectorChairmanDepartmentforCardiovascularSurgeryUniversityHospitalGiessenandMarburgCampusMarburgPathologiesThetricuspidvalveisunderestimatedinitsclinicalimportanceandalsounder-representedinliterature.Tricuspidvalvediseaseismainlyseenasaconsequenceofothervalvulardysfunctions.But:Thecorrectionofthemitral-oraortic-valvedoesnotnecessarilyleadtoanimprovementofthetricuspidinsufficiency.OutcomeofpatientsafterMVSwithorwithoutconcommittantTV-surgeryOutcomeofsecondaryTVIOutcomeofsecondaryTVIOutcomeofpatientsafterMVRwithandwithoutconcommittantTV-surgeryOutcomeofpatientsafterMVSwithorwithoutconcommittantTV-surgeryOutcomeofsecondaryTVIPathologiesAnnulodilatation(LsVD,PHt)PosttraumaticTITricuspidstenosisinCarcinoidsyndromeEndocarditisCongenitalmalformationsIndicationsforrepairIknow,Idon′tknow!Inaliteraturereview,manyauthorsdiscusstheroleofrightventriculardysfunctioninthedevellopmentoftricuspidregurgitation:Whatisfirstandwhatcomessecond?Doessimultaneouscorrectioninfluencethelongtermresults?OutcomeofpatientsafterMVSwithorwithoutconcommittantTV-surgeryOutcomeofsecondaryTVIOutcomeofpatientsafterMVSwithorwithoutconcommittantTV-surgeryOutcomeofsecondaryTVIIndicationsforrepairWhereasmanyquestionsarenotdefinitivelyanswered,thereisgeneralagreement,thatconcommittantsurgeryofthetricuspidvalveshouldbepreferred.Accordinglyweconsidermoderatetoseveretricuspidvalveregurgitationandanannulardiameterof>30mmrespectivelyanindexeddiameterof>20mm/m2anindicationforrepair.OutcomeofpatientsafterMVSwithorwithoutconcommittantTV-surgeryOutcomeofsecondaryTVIOutcomeofpatientsafterMVSwithorwithoutconcommittantTV-surgeryOutcomeofsecondaryTVICardiovascularSurgery2001;Vol9,Nr4:369-77TypeofrepairAlthoughtricuspidvalvereplacementisalsodiscussedinsomearticles,thereisanagreementamongmostauthors,thatrepairisthefirstchoiceatleastinprimaryinterventions.Whilerecentpublicationspropablypreferringannuloplasties,themajorityofstudiesdoesnotshowasuperioritycomparedtosutureannuloplasties(i.e.DeVegaplasty).TypeofrepairAccordingtoliteratureandbasedonownexperiences,wepreferasimplesutureannuloplastyintermsofamodifiedDeVegaplastyincasesofmoderateregurgitationandmoderatelydilatedannuli.Deepenoughstitches,alternatingbetweenthetwosuturelines,aremandatoryforasatisfactorylongtermresult.OperativetechniquesTricuspidvalveannuloplastyDeVegasutureannuloplastyTypeofrepairModifiedDeVegaPlasty:AlternatingSutures:TypeofrepairIncaseofseveretricuspidregurgitation,associatedwithsevereannulardilatationand/orsignificantpulmonaryhypertension,theimplatationofarigidringisourmethodofchoice!OutcomeofpatientsafterMVSwithorwithoutconcommittantTV-surgeryOutcomeofsecondaryTVIOutcomeofpatientsafterMVSwithorwithoutconcommittantTV-surgeryOutcomeofsecondaryTVITricuspidvalveannuloplastyOperativetechniquesTricuspidvalveannuloplastyRigidringannuloplastyOperativeTechniquesPathologiesAnnulodilatation(LsVD,PHt)PosttraumaticTITricuspidstenosisinCarcinoidsyndromeEndocarditisCongenitalmalformationsTypeofrepairPrincipally,posttraumaticrupturesofthetricuspidvalvemayalsoberepairedbyindividualtechniquesincludingbicuspida-lization,modifiedAlfieristitchandartificialchords.Incomplexcases,avalvereplacementmaybecomenecessary.PathologiesPosttraumatictricuspidinsufficiency?Theclovertechnique“Alfierietal.JThoracCardiovascSurg2003;126:75-9PathologiesAnnulodilatation(LsVD,PHt)PosttraumaticTITricuspidstenosisinCarcinoidsyndromeEndocarditisCongenitalmalformationsPathologyandtypeofrepairInpatientswithCarcinoidsyndrome,involvementoftherightsidedheartvalves,especiallythetricuspidvalve,isacommoncomplication.Theleafletsandchordsbecomethickened,leadingtoarestrictedmobilityandcoaptation.Thetherapyofchoiceisthereplacementofthevalve.Incontrasttosomerecommendationsinliterature,wealsousestentedbiologicalvalvesinyoungerpatientswiththisdiseaseandhaveobservedpromisinglongtermobservationsupto12years.

Echo-findingsinCarcinoidsyndromePathologiesPathologiesAnnulodilatation(LsVD,PHt)PosttraumaticTITricuspidstenosisinCarcinoidsyndromeEndocarditisCongenitalmalformationsPathologyTricuspidvalveendocarditishasbecomemorefrequentinrecentyears,mainlycausedbytheinfectionofforeignbodies(pacemakerleads,portcatheters).Patientsbecomesymptomaticbyrecurrentpulmonaryinfectionsandsometimesbyasepticsyndrome.PathologyEcho-findingsintricuspidvalveendocarditisEcho-findingsintricuspidvalveendocarditisPathologyIndicationandtypeofrepairSurgeryshouldbeperformedearlybeforepulmonaryorevengeneralcomplicationshaveoccured.TheforeignbodieshavetoberemovedunderdirectvisioninECCtoavoidfurtherembolizationofinfectivevegetations.Arepairofthetricuspidvalveshouldbeaimedatinallcases.Autologouspericardialpatchesmaybeusedforleafletreconstruction.Foreignmaterialshouldbeavoidedifpossible.Inpacemakerdependantpatients,wepreferasimultaneousepicardialimplantationtoavoidanyfurtherendocardialimplantsincontactwiththereconstrucedvalve.PathologiesTricuspidvalveendocarditisGottardiR.etal.,AnnThoracSurg2007;84:1943-9PathologiesAnnulodilatation(LsVD,PHt)PosttraumaticTITr