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三尖瓣關閉不全的外科處理LUShuyang三尖瓣關閉不全的外科處理1Thetricuspidvalve:aneglectedvalvularlesionThetricuspidvalve:2Historymitralvalvereplacementaloneleadstoresolutionofseverefunctionaltricuspidregurgitationandthereforetricuspidvalvesurgerywasnotindicated.（mid-1960sbyBraunwaldetal）theopposingviewofroutinevalverepairforfunctionaltricuspidregurgitation.（late1960sbyCarpentieretal

）annuloplastyattheinitialmitralvalveoperationinthe1970sHistorymitralvalvereplacemen3TricuspidanatomyTricuspidanatomy4TricuspidphysiologyTheclosingmechanismofthetricuspidvalvemainlydependsonrightventricularcontractilityLeft-sidedvalvularlesionsmayinfluencetricuspidvalvefunctionPhysiologicalchangesoftricuspidvalveringduringcardiaccycleTricuspidphysiologyTheclosin5Mechanismsofsignificant

tricuspidregurgitationMechanismsofsignificant

tric6StagesofprimaryandfunctionalTR

(StageA-B)Stagesofprimaryandfunction7StagesofprimaryandfunctionalTR

(StageC-D)Stagesofprimaryandfunction8IndicationsofTRSurgery2014AHA/ACCGuidelineIndicationsofTRSurgery20149IndicationsofTRSurgery2014AHA/ACCGuidelineIndicationsofTRSurgery201410Howtodealwiththetricuspidvalve?AmyriadofpossibilitiesHowtodealwiththetricuspid11Valverepair–AnnuloplastyReductionoftheannuluswithoutsupportAnnularreductionsupportedbysuturesSelectivereductionsupportedbystripsorpledgetsofsyntheticmaterialAnnularreductionbydifferenttypesofprostheticringsValverepair–AnnuloplastyRed12DeVegaannuloplastyPreservationofvalvularmechanismItmaintainsthephysiologicalflexibilityoftheannulusNoprostheticmaterialisrequiredNodamagetotheconductiontissueItiseasy,fasttoperform,cheapClassicalDeVegaModificationofDeVegaDeVegaannuloplastyPreservati13ClassicalDeVegaannuloplastyClassicalDeVegaannuloplasty14WhyweneedAnnuloplastyringsCorrectionofannulardilatationRemodellingtheshapeoftheannulusImprovecoaptationbetweenleafletsduringsystoleStabilizationofrepairovertimeWhyweneedAnnuloplastyrings15AnnuloplastyringsEdwardsMC3StandardCarpentier–Edwards.AnnuloplastyringsEdwardsMC3S16BiodegradableringPoly-1,4-dioxanonepolymercurvedC-shapedringandsuturematerialextensionsateachendItsspecificmolecularweightprovidesstructuralmemorytoprotectitfromsubsequentdeformityBiodegradableringPoly-1,4-dio17BiodegradableringPreservationofthepotentialforgrowthofthemitralannulus(pediatricpopulation)Nosyntheticmaterial(lessriskofendocarditis)NoneedforanticoagulationduringthefirstthreepostoperativemonthsEasyimplantationtechnique(reductioninthedurationofaorticcrossclampandECC)BiodegradableringPreservation18TricuspidvalvereplacementTricuspidvalvereplacement19TVRORTVP?TVRORTVP?20RheumaticheartdiseasePatients 47Period 1977–2010Meanage 59.0±11.4yGender M 19.1% F 80.9%Atrialfibrillation 80.9%RheumaticheartdiseasePatient21TwogroupsaccordingtotricuspidvalvesurgeryRepair n=18(38.3%)Replacement n=29(61.7%)Twogroupsaccordingtotricus22TVReplacementTVrepairAge59.9±13.662.3±5.5Range21–7653-76Female23(79.3%)15(83.3%)Weight59.6±11.566.5±10.3Height157.3±6.5160.9±7.4Bodysurfacearea24.1±4.425.7±3.5TVReplacementTVrepairAge59.9±123TVReplacementTVrepairAtrialfibrillation27(93.1%)14(77.8%)Cardiacindex2.0±0.72.1±0.3PAsistolicpressure43.3±13.742.7±11.3Pulmonarycapillarypressure26.5±2.421.7±4.2LeftventricularEF57.8±10.154.3±11.7MeanTVregurgitation3.573.55TVReplacementTVrepairAtrialfi24TVReplacementTVrepairPreviousTVsurgeryRepair7(24.1%)2(11.1%)Replacement4(13.8%)-PreviousCPBoperationsOne11(37.9%)6(33.3%)Two9(31.0%)2(11.1%)Three2(6.9%)-TVReplacementTVrepairPrevious25TVReplacementTVrepairNYHAclassIII7(24.1%)12(66.7%)NYHAclassIV19(65.5%)4(22.2%)TVReplacementTVrepairNYHAclas26TRICUSPIDREPAIRDeVegaannuloplasty(8pts)Duranringannuloplasty(10pts)Commissurotomy(2pts)TRICUSPIDREPLACEMENTMechanicalvalve(14pts)Bioprosthesis(15pts)TRICUSPIDREPAIRTRICUSPIDREPL27Follow-upCompletefollow-up 97.8%Meanfollow-up 16.2yearsRange 1month–33yearsFollow-up28TVReplacementTVrepairCPBtime79.9±42.875.7±45.7Ischemictime21.8±23.164.5±48.8Mortality8(27.6%)-Cardiac6Bleeding1Neurologic1TVReplacementTVrepairCPBtime729TVReplacementTVrepairLatemortality15(51.7%)9(50.0%)Cardiac23Valvular11Unknown71Reoperation12Thromboembolism1Hemorrhage1Malignacy1Othersnoncardiac21LateresultsTVReplacementTVrepairLatemort30SurvivalSurvival31FreedomfromreoperationFreedomfromreoperation32TVRn=29Alive20.7%ClassI 2ClassII 3ClassIII 1Repairn=18Alive50.0%ClassI 3ClassII 4ClassIII 2TVRn=29Repair33Isolatedtricuspidvalvesurgerywithnormalfunctioningleftsidevalveoccursaftermitraland/oraorticvalvesurgeryIsolatedtricuspidvalvesurgeryhasahighearlyandlatemortalityduetocardiaccausesTricuspidvalvereplacemententailsaworseresultcomparingwithtricuspidvalverepairConclusionsIsolatedtricuspidvalvesurge34OtheroptionsOtheroptions35ConclusionsThetricuspidvalveisstillchallengingThereisvariabilityinapproachandtechniquesSpecificsubsetsofpatientsareathighriskofmorbidityandmortalityConclusionsThetricuspidvalve36三尖瓣關閉不全的外科處理LUShuyang三尖瓣關閉不全的外科處理37Thetricuspidvalve:aneglectedvalvularlesionThetricuspidvalve:38Historymitralvalvereplacementaloneleadstoresolutionofseverefunctionaltricuspidregurgitationandthereforetricuspidvalvesurgerywasnotindicated.（mid-1960sbyBraunwaldetal）theopposingviewofroutinevalverepairforfunctionaltricuspidregurgitation.（late1960sbyCarpentieretal

）annuloplastyattheinitialmitralvalveoperationinthe1970sHistorymitralvalvereplacemen39TricuspidanatomyTricuspidanatomy40TricuspidphysiologyTheclosingmechanismofthetricuspidvalvemainlydependsonrightventricularcontractilityLeft-sidedvalvularlesionsmayinfluencetricuspidvalvefunctionPhysiologicalchangesoftricuspidvalveringduringcardiaccycleTricuspidphysiologyTheclosin41Mechanismsofsignificant

tricuspidregurgitationMechanismsofsignificant

tric42StagesofprimaryandfunctionalTR

(StageA-B)Stagesofprimaryandfunction43StagesofprimaryandfunctionalTR

(StageC-D)Stagesofprimaryandfunction44IndicationsofTRSurgery2014AHA/ACCGuidelineIndicationsofTRSurgery201445IndicationsofTRSurgery2014AHA/ACCGuidelineIndicationsofTRSurgery201446Howtodealwiththetricuspidvalve?AmyriadofpossibilitiesHowtodealwiththetricuspid47Valverepair–AnnuloplastyReductionoftheannuluswithoutsupportAnnularreductionsupportedbysuturesSelectivereductionsupportedbystripsorpledgetsofsyntheticmaterialAnnularreductionbydifferenttypesofprostheticringsValverepair–AnnuloplastyRed48DeVegaannuloplastyPreservationofvalvularmechanismItmaintainsthephysiologicalflexibilityoftheannulusNoprostheticmaterialisrequiredNodamagetotheconductiontissueItiseasy,fasttoperform,cheapClassicalDeVegaModificationofDeVegaDeVegaannuloplastyPreservati49ClassicalDeVegaannuloplastyClassicalDeVegaannuloplasty50WhyweneedAnnuloplastyringsCorrectionofannulardilatationRemodellingtheshapeoftheannulusImprovecoaptationbetweenleafletsduringsystoleStabilizationofrepairovertimeWhyweneedAnnuloplastyrings51AnnuloplastyringsEdwardsMC3StandardCarpentier–Edwards.AnnuloplastyringsEdwardsMC3S52BiodegradableringPoly-1,4-dioxanonepolymercurvedC-shapedringandsuturematerialextensionsateachendItsspecificmolecularweightprovidesstructuralmemorytoprotectitfromsubsequentdeformityBiodegradableringPoly-1,4-dio53BiodegradableringPreservationofthepotentialforgrowthofthemitralannulus(pediatricpopulation)Nosyntheticmaterial(lessriskofendocarditis)NoneedforanticoagulationduringthefirstthreepostoperativemonthsEasyimplantationtechnique(reductioninthedurationofaorticcrossclampandECC)BiodegradableringPreservation54TricuspidvalvereplacementTricuspidvalvereplacement55TVRORTVP?TVRORTVP?56RheumaticheartdiseasePatients 47Period 1977–2010Meanage 59.0±11.4yGender M 19.1% F 80.9%Atrialfibrillation 80.9%RheumaticheartdiseasePatient57TwogroupsaccordingtotricuspidvalvesurgeryRepair n=18(38.3%)Replacement n=29(61.7%)Twogroupsaccordingtotricus58TVReplacementTVrepairAge59.9±13.662.3±5.5Range21–7653-76Female23(79.3%)15(83.3%)Weight59.6±11.566.5±10.3Height157.3±6.5160.9±7.4Bodysurfacearea24.1±4.425.7±3.5TVReplacementTVrepairAge59.9±159TVReplacementTVrepairAtrialfibrillation27(93.1%)14(77.8%)Cardiacindex2.0±0.72.1±0.3PAsistolicpressure43.3±13.742.7±11.3Pulmonarycapillarypressure26.5±2.421.7±4.2LeftventricularEF57.8±10.154.3±11.7MeanTVregurgitation3.573.55TVReplacementTVrepairAtrialfi60TVReplacementTVrepairPreviousTVsurgeryRepair7(24.1%)2(11.1%)Replacement4(13.8%)-PreviousCPBoperationsOne11(37.9%)6(33.3%)Two9(31.0%)2(11.1%)Three2(6.9%)-TVReplacementTVrepairPrevious61TVReplacementTVrepairNYHAclassIII7(24.1%)12(66.7%)NYHAclassIV19(65.5%)4(22.2%)TVReplacementTVrepairNYHAclas62TRICUSPIDREPAIRDeVegaannuloplasty(8pts)Duranringannuloplasty(10pts)Commissurotomy(2pts)TRICUSPIDREPLACEMENTMechanicalvalve(14pts)Bioprosthesis(15pts)TRICUSPIDREPAIRTRICUSPIDREPL63Follow-upCompletefollow-up 97.8%Meanfollow-up 16.2yearsRange 1month–33yearsFollow-up64TVReplacementTVrepairCPBtime79.9±42.875.7±45.7Ischemictime21.8±23.164.5±48.8Mortality8(27.6%)-Cardiac6

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