三尖瓣修复手术策略

Prof.Dr.RainerG.H.MoosdorfMedicalDirectorChairmanDepartmentforCardiovascularSurgeryUniversityHospitalGiessenandMarburgCampusMarburg病理继发性三尖瓣关闭不全继发性三尖瓣关闭不全继发性三尖瓣关闭不全病理瓣环扩大(LsVD,肺动脉高压)创伤后三尖瓣关闭不全类癌综合症中的三尖瓣狭窄感染性心内膜炎先天性解剖学异常我知道,我不知道!文献报导中，很多作者讨论了右心室功能障碍在三尖瓣返流发生中的作用:谁是因，谁是果?同时纠正会影响远期预后吗?继发性三尖瓣关闭不全继发性三尖瓣关闭不全继发性三尖瓣关闭不全继发性三尖瓣关闭不全CardiovascularSurgery2001;Vol9,Nr4:369-77交叉缝线:重度三尖瓣返流合并严重瓣环扩张和/或重度肺动脉高压的病例,应选择硬质环!继发性三尖瓣关闭不全继发性三尖瓣关闭不全病理瓣环扩大(LsVD,肺动脉高压)创伤后三尖瓣关闭不全粘液综合症中的三尖瓣狭窄感染性心内膜炎先天性解剖学异常病理创伤后三尖瓣关闭不全„Theclovertechnique“Alfierietal.JThoracCardiovascSurg2003;126:75-9病理瓣环扩大(LsVD,肺动脉高压)创伤后三尖瓣关闭不全类癌综合症中的三尖瓣狭窄感染性心内膜炎先天性解剖学异常类癌综合症的心脏超声表现病理病理瓣环扩大(LsVD,肺动脉高压)创伤后三尖瓣关闭不全类癌综合症中的三尖瓣狭窄感染性心内膜炎先天性解剖学异常病理近年来，三尖瓣感染性心内膜炎发病率增高，主要由异物感染所致(起搏器电极,导管).患者反复出现肺部感染症状，且有时会出现败血症。病理三尖瓣感染性心内膜炎超声心动图表现三尖瓣感染性心内膜炎超声心动图表现病理病理三尖瓣感染性心内膜炎GottardiR.etal.,AnnThoracSurg2007;84:1943-9病理瓣环扩大(LsVD,肺动脉高压)创伤后三尖瓣关闭不全类癌综合症中的三尖瓣狭窄感染性心内膜炎先天性解剖学异常病理Ebstein畸形DaSilvaetal.,JThoracCardiovascSurg2007;133:215-23非常感谢大家.我非常乐意回答大家的问题。继发性三尖瓣关闭不全Tricuspidvalve

repairstrategiesProf.Dr.RainerG.H.MoosdorfMedicalDirectorChairmanDepartmentforCardiovascularSurgeryUniversityHospitalGiessenandMarburgCampusMarburgPathologiesThetricuspidvalveisunderestimatedinitsclinicalimportanceandalsounder-representedinliterature.Tricuspidvalvediseaseismainlyseenasaconsequenceofothervalvulardysfunctions.But:Thecorrectionofthemitral-oraortic-valvedoesnotnecessarilyleadtoanimprovementofthetricuspidinsufficiency.OutcomeofpatientsafterMVSwithorwithoutconcommittantTV-surgeryOutcomeofsecondaryTVIOutcomeofsecondaryTVIOutcomeofpatientsafterMVRwithandwithoutconcommittantTV-surgeryOutcomeofpatientsafterMVSwithorwithoutconcommittantTV-surgeryOutcomeofsecondaryTVIPathologiesAnnulodilatation(LsVD,PHt)PosttraumaticTITricuspidstenosisinCarcinoidsyndromeEndocarditisCongenitalmalformationsIndicationsforrepairIknow,Idon´tknow!Inaliteraturereview,manyauthorsdiscusstheroleofrightventriculardysfunctioninthedevellopmentoftricuspidregurgitation:Whatisfirstandwhatcomessecond?Doessimultaneouscorrectioninfluencethelongtermresults?OutcomeofpatientsafterMVSwithorwithoutconcommittantTV-surgeryOutcomeofsecondaryTVIOutcomeofpatientsafterMVSwithorwithoutconcommittantTV-surgeryOutcomeofsecondaryTVIIndicationsforrepairWhereasmanyquestionsarenotdefinitivelyanswered,thereisgeneralagreement,thatconcommittantsurgeryofthetricuspidvalveshouldbepreferred.Accordinglyweconsidermoderatetoseveretricuspidvalveregurgitationandanannulardiameterof>30mmrespectivelyanindexeddiameterof>20mm/m²anindicationforrepair.OutcomeofpatientsafterMVSwithorwithoutconcommittantTV-surgeryOutcomeofsecondaryTVIOutcomeofpatientsafterMVSwithorwithoutconcommittantTV-surgeryOutcomeofsecondaryTVICardiovascularSurgery2001;Vol9,Nr4:369-77TypeofrepairAlthoughtricuspidvalvereplacementisalsodiscussedinsomearticles,thereisanagreementamongmostauthors,thatrepairisthefirstchoiceatleastinprimaryinterventions.Whilerecentpublicationspropablypreferringannuloplasties,themajorityofstudiesdoesnotshowasuperioritycomparedtosutureannuloplasties(i.e.DeVegaplasty).TypeofrepairAccordingtoliteratureandbasedonownexperiences,wepreferasimplesutureannuloplastyintermsofamodifiedDeVegaplastyincasesofmoderateregurgitationandmoderatelydilatedannuli.Deepenoughstitches,alternatingbetweenthetwosuturelines,aremandatoryforasatisfactorylongtermresult.OperativetechniquesTricuspidvalveannuloplastyDeVegasutureannuloplastyTypeofrepairModifiedDeVegaPlasty:AlternatingSutures:TypeofrepairIncaseofseveretricuspidregurgitation,associatedwithsevereannulardilatationand/orsignificantpulmonaryhypertension,theimplatationofarigidringisourmethodofchoice!OutcomeofpatientsafterMVSwithorwithoutconcommittantTV-surgeryOutcomeofsecondaryTVIOutcomeofpatientsafterMVSwithorwithoutconcommittantTV-surgeryOutcomeofsecondaryTVITricuspidvalveannuloplastyOperativetechniquesTricuspidvalveannuloplastyRigidringannuloplastyOperativeTechniquesPathologiesAnnulodilatation(LsVD,PHt)PosttraumaticTITricuspidstenosisinCarcinoidsyndromeEndocarditisCongenitalmalformationsTypeofrepairPrincipally,posttraumaticrupturesofthetricuspidvalvemayalsoberepairedbyindividualtechniquesincludingbicuspida-lization,modifiedAlfieristitchandartificialchords.Incomplexcases,avalvereplacementmaybecomenecessary.PathologiesPosttraumatictricuspidinsufficiency„Theclovertechnique“Alfierietal.JThoracCardiovascSurg2003;126:75-9PathologiesAnnulodilatation(LsVD,PHt)PosttraumaticTITricuspidstenosisinCarcinoidsyndromeEndocarditisCongenitalmalformationsPathologyandtypeofrepairInpatientswithCarcinoidsyndrome,involvementoftherightsidedheartvalves,especiallythetricuspidvalve,isacommoncomplication.Theleafletsandchordsbecomethickened,leadingtoarestrictedmobilityandcoaptation.Thetherapyofchoiceisthereplacementofthevalve.Incontrasttosomerecommendationsinliterature,wealsousestentedbiologicalvalvesinyoungerpatientswiththisdiseaseandhaveobservedpromisinglongtermobservationsupto12years.

Echo-findingsinCarcinoidsyndromePathologiesPathologiesAnnulodilatation(LsVD,PHt)PosttraumaticTITricuspidstenosisinCarcinoidsyndromeEndocarditisCongenitalmalformationsPathologyTricuspidvalveendocarditishasbecomemorefrequentinrecentyears,mainlycausedbytheinfectionofforeignbodies(pacemakerleads,portcatheters).Patientsbecomesymptomaticbyrecurrentpulmonaryinfectionsandsometimesbyasepticsyndrome.PathologyEcho-findingsintricuspidvalveendocarditisEcho-findingsintricuspidvalveendocarditisPathologyIndicationandtypeofrepairSurgeryshouldbeperformedearlybeforepulmonaryorevengeneralcomplicationshaveoccured.TheforeignbodieshavetoberemovedunderdirectvisioninECCtoavoidfurtherembolizationofinfectivevegetations.Arepairofthetricuspidvalveshouldbeaimedatinallcases.Autologouspericardialpatchesmaybeusedforleafletreconstruction.Foreignmaterialshouldbeavoidedifpossible.Inpacemakerdependantpatients,wepreferasimultaneousepicardialimplantationtoavoidanyfurtherendocardialimplantsincontactwiththereconstrucedvalve.PathologiesTricuspidvalveendocarditisGottardiR.etal.,AnnThoracSurg2007;84:1943-9PathologiesAnnulodilatation(LsVD,PHt)PosttraumaticTITr