Fadel Bahaa M, Alsoufi Bahaaldin, Manlhiot Cedric, McCrindle Brian W, Siblini Ghassan, Al-Halees Zohair, Al Sanei Aly, Canver Charles C
King Faisal Heart Institute, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.
J Heart Valve Dis. 2010 Jul;19(4):513-22; discussion 523.
Triple valve surgery (3VS) is required in some cardiac disorders that simultaneously involve the aortic valve (AV), mitral valve (MV), and tricuspid valve (TCV). Herein are reported details of the authors' experience with 3VS, and their attempts to identify those factors associated with a poor clinical outcome.
The medical records of patients who underwent 3VS between 1985 and 2005 were reviewed. A competing-risks methodology was used to determine the time-related prevalence and associated factors for three mutually exclusive end states after 3VS, namely death, valve reoperation, and survival without subsequent valve reoperation.
A total of 206 consecutive patients (124 females, 82 males; median age 34 years; range: 12-82 years) underwent 3VS. The most common underlying pathology for all valves was rheumatic, followed by repair failure and prosthesis dysfunction for AV and MV, and functional regurgitation for TCV. In total, 72 patients (35.0%) had undergone prior valve surgery. At 3VS, the MV and AV were usually replaced (> 70%), whereas the TCV was usually repaired (91%). The operative mortality (prior to hospital discharge) was 11%, and 15-year survival 68%. At 15 years after 3VS, 21% of the patients had died, without subsequent valve reoperation, 50% had undergone valve reoperation, and 30% remained alive without valve reoperation. Baseline factors associated with early mortality after 3VS were older age at operation, TCV replacement, and the use of a mechanical MV during 3VS. A late risk of mortality was associated with poor left ventricular function and renal impairment at the time of the initial 3VS, and MV prosthesis prior to the initial 3VS. Younger age at 3VS and MV repair during the index 3VS were associated with a higher constant risk of valve reoperation, while female gender, MV prosthesis prior to index 3VS, MV replacement with a bioprosthesis during 3VS, and rheumatic TCV disease were associated with an increased late risk of valve reoperation.
Both, primary and reoperative 3VS can be performed with acceptable operative mortality and long-term survival. However, patients continue to be at risk of valve reoperation, which steadily increases over time.
某些同时累及主动脉瓣（AV）、二尖瓣（MV）和三尖瓣（TCV）的心脏疾病需要进行三瓣膜手术（3VS）。本文报告了作者进行3VS的经验细节，以及他们试图确定与不良临床结局相关的因素。
回顾了1985年至2005年间接受3VS患者的病历。采用竞争风险方法来确定3VS后三种相互排斥的终末状态的时间相关患病率及相关因素，这三种终末状态分别为死亡、瓣膜再次手术以及存活且无需后续瓣膜再次手术。
共有206例连续患者（124例女性，82例男性；中位年龄34岁；范围：12 - 82岁）接受了3VS。所有瓣膜最常见的基础病理是风湿性，其次是AV和MV的修复失败及人工瓣膜功能障碍，以及TCV的功能性反流。总共有72例患者（35.0%）曾接受过瓣膜手术。在3VS时，MV和AV通常进行置换（>70%），而TCV通常进行修复（91%）。手术死亡率（出院前）为11%，15年生存率为68%。在3VS后15年，21%的患者死亡，未进行后续瓣膜再次手术，50%的患者进行了瓣膜再次手术，30%存活且未进行瓣膜再次手术。与3VS后早期死亡相关的基线因素包括手术时年龄较大、TCV置换以及在3VS期间使用机械MV。晚期死亡风险与初次3VS时左心室功能差和肾功能损害以及初次3VS前的MV人工瓣膜有关。3VS时年龄较小以及初次3VS期间进行MV修复与瓣膜再次手术的持续高风险相关，而女性性别、初次3VS前的MV人工瓣膜、3VS期间用生物人工瓣膜置换MV以及风湿性TCV疾病与瓣膜再次手术的晚期风险增加有关。
初次和再次3VS均可在可接受的手术死亡率和长期生存率下进行。然而，患者仍有瓣膜再次手术的风险，且该风险会随着时间稳步增加。
