Czer L S, Maurer G, Bolger A, DeRobertis M, Kleinman J, Gray R J, Chaux A, Matloff J M
Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, Calif. 90048.
J Thorac Cardiovasc Surg. 1989 Jul;98(1):101-10; discussion 110-1.
Severe tricuspid regurgitation may produce significant morbidity and mortality if not corrected, but commonly used methods of intraoperative assessment may be unreliable. Tricuspid regurgitation was evaluated by a new intraoperative technique, Doppler color flow mapping, in 85 patients before and after cardiopulmonary bypass. Regurgitation grade by intraoperative color Doppler mapping correlated well with right ventricular angiography (kappa value = 0.92, p less than 0.01; n = 8) and with preoperative color Doppler studies (kappa = 0.71, p less than 0.05; n = 51). The right atrial V wave correlated poorly with the severity of tricuspid regurgitation intraoperatively, both before (r = 0.30) and after (r = -0.05, p = no significant difference) cardiopulmonary bypass. Advanced (3+ or 4+) tricuspid regurgitation was found in 40% (21) of 52 patients requiring mitral valve repair or replacement. Tricuspid annuloplasty with a prosthetic ring provided a significant (greater than or equal to 2 grade) reduction in regurgitation severity in 94% (17/18; p less than 0.05). Without repair, tricuspid regurgitation decreased to a similar degree after mitral valve operations in 14% (5/36); only one of the five patients had advanced tricuspid regurgitation prepump. Fluid filling of the arrested right ventricle after the surgical procedure did not predict regurgitation severity (false negative rate 50%, 2/4; false positive rate 22%, 2/9). Regurgitation grade remained unchanged after the initial postpump study, up to 60 weeks postoperatively. In conclusion, color Doppler flow mapping provides more accurate intraoperative assessment of tricuspid regurgitation than the right atrial V wave or fluid filling of the right ventricle. This semiquantitative technique aids in the selection of patients appropriate for surgical repair of the tricuspid valve and is useful in judging the adequacy of tricuspid valve repair before chest closure. Advanced (3+ or 4+) tricuspid regurgitation is a common occurrence in patients undergoing mitral valve repair or replacement and rarely responds to conservative (nonoperative) management. Ring annuloplasty provides a highly effective and durable reduction in tricuspid regurgitation.
严重三尖瓣反流若不纠正，可能导致显著的发病率和死亡率，但常用的术中评估方法可能不可靠。采用一种新的术中技术——多普勒彩色血流图，对85例患者在体外循环前后的三尖瓣反流情况进行了评估。术中彩色多普勒图评估的反流分级与右心室血管造影相关性良好（kappa值 = 0.92，p < 0.01；n = 8），与术前彩色多普勒研究也具有相关性（kappa = 0.71，p < 0.05；n = 51）。术中右心房V波与三尖瓣反流严重程度的相关性较差，体外循环前（r = 0.30）和体外循环后（r = -0.05，p = 无显著差异）均如此。在52例需要二尖瓣修复或置换的患者中，40%（21例）存在重度（3+或4+）三尖瓣反流。使用人工瓣环进行三尖瓣环成形术可使94%（17/18；p < 0.05）的患者反流严重程度显著降低（降低≥2级）。若不进行修复，14%（5/36）的患者在二尖瓣手术后三尖瓣反流程度有相似程度的降低；这5例患者中只有1例术前存在重度三尖瓣反流。手术操作后右心室停跳时的液体充盈情况无法预测反流严重程度（假阴性率50%，2/4；假阳性率22%，2/9）。术后最初的体外循环后检查至术后60周，反流分级保持不变。总之，与右心房V波或右心室液体充盈情况相比，彩色多普勒血流图能更准确地进行术中三尖瓣反流评估。这种半定量技术有助于选择适合进行三尖瓣手术修复的患者，且有助于在关胸之前判断三尖瓣修复是否充分。重度（3+或4+）三尖瓣反流在接受二尖瓣修复或置换的患者中很常见，且很少对保守（非手术）治疗有反应。瓣环成形术能非常有效地持久减轻三尖瓣反流。
