Monaco Fabrizio, Di Prima Ambra L, De Luca Monica, Barucco Gaia, Zangrillo Alberto
Department of Cardiothoracic and Vascular Surgery, San Raffaele Hospital, Milan, Italy -
Department of Cardiothoracic and Vascular Surgery, San Raffaele Hospital, Milan, Italy.
Minerva Cardioangiol. 2018 Dec;66(6):691-699. doi: 10.23736/S0026-4725.18.04699-6. Epub 2018 Apr 11.
Tricuspid regurgitation (TR) is a common valvular lesion which may affect morbidity and mortality. It can be related to an intrinsic abnormality of the tricuspid valve leaflets (organic) or secondary to annular dilatation (functional). Often organic and functional TR coexist in the same patient. A long-standing TR is associated with ascites, congestive hepatopathy, peripheral edema, renal failure, and abdominal fullness which significantly affect the outcome. In particular, the perioperative course may be complicated due to both the presence of comorbidities and the development of a severe postoperative right ventricle (RV) dysfunction. In fact, the TR may conceal a preoperative RV dysfunction due to a backflow in in the right atrium, which becomes overt only after the tricuspid valve (TV) repair/replacement (afterload mismatch). In light of this, an appropriate medical treatment before surgery may improve the performance of the RV, maximizing the result of the elective surgical therapy. The perioperative optimization should reduce the right atrial and ventricle overload, decrease the pulmonary vascular resistances, improve RV contractility and treat aggressively the arrhythmias. In doing so, the following rules should be considered: careful fluid administration, β1-agonists favored over α-agonists to treat hemodynamic instability, and maintenance of a normal-to-elevated heart rate. Since the TV repair/replacement needs mechanical ventilation in both open and percutaneous surgery, a careful volume and pharmacological management should be adopted to counteract the detrimental effect of the mechanical ventilation on the top of an already dysfunctional RV. In fact, in the context of RV failure the cardiac output is strictly dependent on the preload and the increase of the intrathoracic pressure, reducing the venous return, may lead to acute heart failure. The intraoperative administration of volume and vasoactive drugs, titrated on the basis of the transesophageal echocardiography, permit to support the RV intraoperatively. Paracorporeal mechanical hemodynamic support should be always available as "bail out" in the event of intractable RV failure. In conclusion the patients undergoing TV surgery are complex and only a detailed anesthesiologic and surgical workup may decrease the perioperative mortality and morbidity.
三尖瓣反流（TR）是一种常见的瓣膜病变，可能影响发病率和死亡率。它可能与三尖瓣小叶的内在异常（器质性）有关，或继发于瓣环扩张（功能性）。通常，器质性和功能性TR在同一患者中并存。长期的TR与腹水、充血性肝病、外周水肿、肾衰竭和腹部胀满有关，这些会显著影响预后。特别是，围手术期过程可能因合并症的存在以及严重的术后右心室（RV）功能障碍的发生而变得复杂。事实上，TR可能由于右心房的反流而掩盖术前RV功能障碍，这种功能障碍仅在三尖瓣（TV）修复/置换后（后负荷不匹配）才会显现出来。鉴于此，术前适当的药物治疗可能会改善RV的功能，使择期手术治疗的效果最大化。围手术期的优化应减少右心房和心室的负荷，降低肺血管阻力，改善RV收缩力，并积极治疗心律失常。在这样做时，应考虑以下原则：谨慎输液，在治疗血流动力学不稳定时，β1激动剂优于α激动剂，维持心率正常至升高。由于TV修复/置换在开放手术和经皮手术中都需要机械通气，因此应采用谨慎的容量和药物管理，以抵消机械通气对本已功能失调的RV的不利影响。事实上，在RV衰竭的情况下，心输出量严格依赖于前负荷，而胸内压的增加会减少静脉回流，可能导致急性心力衰竭。术中根据经食管超声心动图调整容量和血管活性药物的给药，有助于在术中支持RV。在发生难治性RV衰竭时，体外机械血流动力学支持应始终作为“补救措施”备用。总之，接受TV手术的患者情况复杂，只有详细的麻醉和外科检查才能降低围手术期的死亡率和发病率。
