Gravel Guillaume Marquis, Bouchard Denis, Perrault Louis P, Pagé Pierre, Carrier Michel, Cartier Raymond, Jeanmart Hugues, Pellerin Michel
Department of Surgery, Montreal Heart Institute and University of Montreal, Montreal, Canada.
J Heart Valve Dis. 2011 Jan;20(1):75-82.
Triple-valve disease is a challenge that surgeons face periodically, yet the clinical benefits of triple-valve surgery, in relation to the high operative risk, are not well known. The study aims were to describe the early and late mortality associated with triple-valve surgery, to assess the risk factors, and describe the long-term outcomes.
A retrospective analysis of 178 consecutive triple-valve surgeries performed at the Montreal Heart Institute between 1977 and 2008 was performed. The median follow up was 5.0 years (inter-quartile range: 1.6 to 9.4 years).
Among 170 patients (122 females, 48 males; mean age 60 +/- 11 years), the preoperative NYHA functional class was > or = III/IV in 93% of cases; 61% of the patients had undergone previous cardiac surgery. The operative mortality was 12% between 1999 and 2008, and 25% between 1977 and 1998 (p = 0.033). Independent risk factors between 1999 and 2008 period included tricuspid regurgitation severity (OR = 13.71; p = 0.03) and the presence of a right intraventricular pacemaker lead (OR = 11.25; p = 0.039). Survival rates at five and 10 years were 61 +/- 4% and 38 +/- 5%, respectively. A lower left ventricular ejection fraction at discharge was associated with a poor late survival, independent of patient age and gender (OR = 0.95; p = 0.035). Twenty-three patients (18%) required reoperation during the follow up period, at which time the NYHA functional class was improved compared to baseline (p < 0.001).
Although triple-valve surgery is associated with substantial operative mortality, this situation has improved significantly over the years. Currently, survivors experience a significant improvement in their cardiac functional capacity, justifying the continued use of triple-valve procedures, though preferably earlier during the course of the disease.
三尖瓣疾病是外科医生时常面临的一项挑战，然而三尖瓣手术的临床益处与高手术风险之间的关系尚不明确。本研究的目的是描述三尖瓣手术相关的早期和晚期死亡率，评估风险因素，并描述长期预后。
对1977年至2008年在蒙特利尔心脏研究所连续进行的178例三尖瓣手术进行回顾性分析。中位随访时间为5.0年（四分位间距：1.6至9.4年）。
在170例患者（122例女性，48例男性；平均年龄60±11岁）中，93%的病例术前纽约心脏协会（NYHA）心功能分级≥Ⅲ/Ⅳ级；61%的患者曾接受过心脏手术。1999年至2008年期间手术死亡率为12%，1977年至1998年期间为25%（p = 0.033）。1999年至2008年期间的独立风险因素包括三尖瓣反流严重程度（比值比[OR]=13.71；p = 0.03）和右心室内起搏器导线的存在（OR = 11.25；p = 0.039）。5年和10年生存率分别为61±4%和38±5%。出院时较低的左心室射血分数与较差的晚期生存率相关，与患者年龄和性别无关（OR = 0.95；p = 0.035）。23例患者（18%）在随访期间需要再次手术，此时纽约心脏协会心功能分级较基线有所改善（p < 0.001）。
尽管三尖瓣手术伴有较高的手术死亡率，但多年来这种情况已显著改善。目前，幸存者的心脏功能能力有显著改善，这证明三尖瓣手术仍可继续使用，尽管最好在疾病进程中尽早进行。
