University General Hospital of Valencia, Valencia, Spain.
Eur J Cardiothorac Surg. 2011 Jun;39(6):866-74; discussion 874. doi: 10.1016/j.ejcts.2010.11.014. Epub 2010 Dec 16.
Development of late significant tricuspid regurgitation (TR) after successful mitral valve replacement (MVR) is not infrequent. The impact of different aetiologies or diverse surgical procedures has not been adequately investigated. We studied the influence of subvalvular preservation techniques during MVR on the incidence of late TR.
A total of 801 patients with grade ≤ 2+/4+ preoperative TR underwent MVR without associated tricuspid procedures from January 1994 to August 2008. In 595 patients, only posterior mitral leaflet preservation was performed (group A). In the remaining 206 patients, both anterior and posterior leaflets were retained (group B). Postoperative development of significant TR was defined as a TR increase by more than one grade from preoperative or final TR grade ≥ 3+/4+ at follow-up.
The global incidence of postoperative significant TR was 8.6%, with higher incidence in females (9.4% vs 6.7%, p=0.12), rheumatic disease (9.7% vs 6.5%, p=0.07), patients with previous AF (11.8% vs 3.8%, p<0.001) and, especially, in group A (10.8% vs 2.4%, p<0.001). The Maze procedure was protective in patients with AF (the incidence with and without associated Maze was 6.7% vs 13.2%, p=0.04). Preoperative left-atrial diameters were higher in patients with postoperative development of TR (56 ± 9 mm vs 51 ± 12 mm, p=0.01). Group A (p=0.04) and preoperative atrial fibrillation (p=0.001) were significant predictors of late postoperative TR. Late functional TR decreased free survival from chronic heart failure.
Several clinical and operative factors are associated with the development of significant TR after MVR. Although early surgical intervention for TR may be recommended in selected patients, complete subvalvular preservation of the mitral valve and routine surgical ablation of atrial fibrillation can significantly reduce its incidence.
成功二尖瓣置换（MVR）后出现晚期三尖瓣重度反流（TR）并不少见。不同病因或不同手术方法的影响尚未得到充分研究。我们研究了 MVR 时瓣下保留技术对晚期 TR 发生率的影响。
1994 年 1 月至 2008 年 8 月，共有 801 例术前 TR 分级≤2+/4+的患者接受了 MVR，且未行三尖瓣手术。在 595 例患者中，仅保留后叶二尖瓣（A 组）。在其余 206 例患者中，前后叶均保留（B 组）。术后出现重度 TR 定义为术前或最终 TR 分级≥3+/4+的患者 TR 分级增加≥1 级。
术后重度 TR 的总发生率为 8.6%，女性发生率较高（9.4%比 6.7%，p=0.12）、风湿性疾病（9.7%比 6.5%，p=0.07）、既往有房颤（AF）的患者（11.8%比 3.8%，p<0.001），特别是 A 组（10.8%比 2.4%，p<0.001）。AF 患者行迷宫手术是保护性的（伴或不伴迷宫手术的发生率分别为 6.7%和 13.2%，p=0.04）。TR 术后发生的患者左心房直径较高（56±9mm 比 51±12mm，p=0.01）。A 组（p=0.04）和术前房颤（p=0.001）是晚期术后 TR 的显著预测因素。晚期功能性 TR 降低了慢性心力衰竭的无复发生存率。
一些临床和手术因素与 MVR 后出现重度 TR 有关。虽然可能推荐对有选择的患者进行早期手术干预，但完全瓣下保留二尖瓣和常规手术消融房颤可显著降低其发生率。
