【摘要】：第一部分以術(shù)中三尖瓣瓣環(huán)周長(zhǎng)指數(shù)作為同期三尖瓣成形術(shù)的手術(shù)標(biāo)準(zhǔn)的探討 目的：中度以下三尖瓣反流（tricuspid regurgitation，，TR）患者，以三尖瓣瓣環(huán)擴(kuò)張作為預(yù)防性三尖瓣成形的手術(shù)指征已被歐美指南所正式推薦。然而定義三尖瓣瓣環(huán)擴(kuò)張目前缺乏理想的標(biāo)準(zhǔn)。本課題組擬在術(shù)中直接測(cè)量三尖瓣瓣環(huán)周長(zhǎng)并量化評(píng)估三尖瓣環(huán)擴(kuò)張程度，初步探索該方法的可行性及提出對(duì)于繼發(fā)性三尖瓣反流量化的術(shù)中手術(shù)標(biāo)準(zhǔn)。 方法：本研究選取了2010年10月至2011年10月在北京安貞醫(yī)院九病房因單純的二尖瓣病變或二尖瓣合并主動(dòng)脈瓣病變，行二尖瓣置換術(shù)或主動(dòng)脈瓣及二尖瓣雙瓣置換術(shù)的患者，其中三尖瓣反流程度小于或等于2+及超聲測(cè)量三尖瓣瓣環(huán)“正�！敝睆降幕颊咦罱K納入本次研究。這些患者均僅行單純的左心瓣膜病變手術(shù)，并在術(shù)中測(cè)量了三尖瓣瓣環(huán)周長(zhǎng)。術(shù)后通過(guò)超聲心動(dòng)圖對(duì)患者進(jìn)行TR程度的隨訪監(jiān)測(cè)。定義終點(diǎn)事件為隨訪期三尖瓣反流程度與術(shù)前相比超過(guò)兩級(jí)或最后達(dá)到3+/4+TR級(jí)別。 結(jié)果：在一年的入組期內(nèi)，最終有127名患者列入了本次研究。其中，男性49例，女性78例；年齡53.3±10.9歲。有超過(guò)半數(shù)的患者合并有心房顫動(dòng)，且大多數(shù)患者左心瓣膜的病因?yàn)轱L(fēng)濕性。圍術(shù)期死亡患者1例。術(shù)后平均隨訪30.2±11.8月，有23例（18.7%）最終達(dá)到終點(diǎn)事件。通過(guò)單因素分析，得出術(shù)前合并房顫、左房直徑和術(shù)中測(cè)量的三尖瓣瓣環(huán)周長(zhǎng)指數(shù)（tricuspid annularcircumference index， TACI）可以預(yù)測(cè)術(shù)后三尖瓣反流的加重；將這三個(gè)指標(biāo)帶入多因素分析，僅有TACI為術(shù)后TR加重的獨(dú)立預(yù)測(cè)因素（OR,1.586;95%CI1.303to1.929; p0.001）。通過(guò)繪制受試者工作特征曲線，最終得出TACI需干預(yù)的截點(diǎn)值為83mm/m2，而此時(shí)的敏感度和特異度均表現(xiàn)出極佳的參考價(jià)值，分別為95.7%和87%。 結(jié)論：以三尖瓣塞規(guī)測(cè)量三尖瓣瓣環(huán)周長(zhǎng)是術(shù)中定量評(píng)估三尖瓣瓣環(huán)擴(kuò)張程度的一種較為理想的方法。在左心瓣膜病變患者中，三尖瓣瓣環(huán)周長(zhǎng)指數(shù)大于83mm/m2可考慮作為術(shù)中同期行三尖瓣成形的一個(gè)參考指征。傳統(tǒng)的二維超聲心動(dòng)圖會(huì)很大程度上低估三尖瓣瓣環(huán)擴(kuò)張程度，特別是非顯著性三尖瓣反流患者，而術(shù)中直接測(cè)量評(píng)估三尖瓣瓣環(huán)大小應(yīng)該作為一必要的補(bǔ)充，在術(shù)中常規(guī)進(jìn)行。 第二部分以術(shù)中三尖瓣瓣環(huán)周長(zhǎng)指數(shù)作為同期三尖瓣成形術(shù)的手術(shù)標(biāo)準(zhǔn)的驗(yàn)證 目的：以三尖瓣塞規(guī)測(cè)量三尖瓣瓣環(huán)周長(zhǎng)是術(shù)中定量評(píng)估三尖瓣瓣環(huán)擴(kuò)張程度的一種較為理想的方法。在本研究中，旨在通過(guò)再次的前瞻性臨床隨機(jī)對(duì)照研究，進(jìn)一步驗(yàn)證以三尖瓣瓣環(huán)周長(zhǎng)指數(shù)作為術(shù)中定量干預(yù)指征的可行性及可靠性。 方法：本研究連續(xù)入選從2012年10月至2013年11月，安貞醫(yī)院心外科九病房單純二尖瓣或二尖瓣合并主動(dòng)脈瓣病變，同時(shí)合并2+TR及超聲提示三尖瓣徑線＜21cm/m2的需手術(shù)者。對(duì)納入研究的患者隨機(jī)分為左心瓣膜手術(shù)同期行三尖瓣成形術(shù)（tricuspid valve plasty, TVP組），另一組只做單純左心瓣膜手術(shù)（non-tricuspid valve plasty, NTVP組）。術(shù)前及術(shù)后評(píng)估是基于二維超聲心動(dòng)圖對(duì)TR程度的評(píng)估。統(tǒng)計(jì)分析TVP組與NTVP組術(shù)后及隨訪期三尖瓣關(guān)閉不全程度是否有差異；再進(jìn)一步根據(jù)三尖瓣瓣環(huán)周長(zhǎng)指數(shù)（tricuspid annularcircumference index，TACI）大于等于或小于83mm/m2將TVP組和NTVP組再分別細(xì)分為兩亞組，統(tǒng)計(jì)分析兩組術(shù)后及隨訪三尖瓣關(guān)閉不全程度是否有差異。 結(jié)果：最后納入符合標(biāo)準(zhǔn)的左心瓣膜病變合并2+TR患者170例，根據(jù)研究方案隨機(jī)將患者分為T(mén)VP組（n=86）和NTVP組（n=84）。按照術(shù)中測(cè)量的TACI值，進(jìn)一步在TVP和NTVP中分別劃分成兩組。四個(gè)亞組間的患者年齡、性別、合并房顫率、左心瓣膜病變病因、單純二尖瓣手術(shù)/雙瓣手術(shù)構(gòu)成比，及超聲指標(biāo)差異均無(wú)統(tǒng)計(jì)學(xué)意義(p0.05)。圍術(shù)期無(wú)患者死亡。出現(xiàn)術(shù)后并發(fā)癥患者39例（22.8%）。隨訪過(guò)程中無(wú)死亡患者。隨訪期超聲心動(dòng)圖檢查率達(dá)98.2%（166/169）。平均隨訪時(shí)間為20.2±10.2月。TVP組患者出院時(shí)TR程度明顯低于術(shù)前程度，并在隨訪期保持穩(wěn)定。根據(jù)TACI值將TVP組分為Group1和Group2兩亞組，術(shù)后及隨訪期的TR程度均明顯降低，并保持穩(wěn)定。NTVP組患者出院時(shí)復(fù)查三尖瓣反流程度較術(shù)前亦有明顯減低，但在經(jīng)過(guò)平均20.2月隨訪，該組患者TR程度出現(xiàn)了惡化（p=0.009）。根據(jù)TACI值將NTVP組分為Group3和Group4。兩亞組患者出院時(shí)TR程度均較術(shù)前有明顯改善，但在隨訪期，Group3患者的TR程度尚能保持穩(wěn)定（p=0.530），而Group4的患者TR程度出現(xiàn)了顯著進(jìn)展（p=0.004）。在TACI≥83mm/m2的患者中，兩組術(shù)前基線資料無(wú)統(tǒng)計(jì)學(xué)差異，但出院及隨訪期，Group2TR程度顯著低于Group4（p0.001），且在短期隨訪內(nèi)，未預(yù)防性成形組有4例患者進(jìn)展為顯著的三尖瓣反流（TR≥3+）。 結(jié)論：在術(shù)中以三尖瓣塞規(guī)測(cè)量三尖瓣瓣環(huán)周長(zhǎng)的方法來(lái)定量評(píng)估三尖瓣瓣環(huán)擴(kuò)張程度具有簡(jiǎn)便易行、操作簡(jiǎn)單、重復(fù)性強(qiáng)的特點(diǎn)。在左心瓣膜病變手術(shù)中，三尖瓣瓣環(huán)周長(zhǎng)指數(shù)≥83mm/m2可作為2+TR患者術(shù)中同期行預(yù)防性三尖瓣成形術(shù)的手術(shù)指征。
[Abstract]:The first part discusses the operation standard of tricuspid valve annulus circumference index as the same period of tricuspid annuloplasty .

Objective : To study the feasibility of the method and to propose a surgical standard for secondary tricuspid regurgitation .

Methods : In October 2010 to October 2011 , the patients who underwent mitral valve replacement or mitral valve double - valve replacement underwent mitral valve replacement or mitral valve double - valve replacement in nine wards of Beijing Anzhen Hospital . Among them , the tricuspid regurgitation was less than or equal to 2 + and the ultrasonic measurement of tricuspid valve annulus ' normal ' diameter was eventually included in this study .

Results : In the enrollment period of one year , 127 patients were included in the study , including 49 males and 78 females .
There were more than half of patients aged 53 . 3 鹵 10.9 years old . More than half of patients had atrial fibrillation , and most patients died of heart valves due to rheumatic heart disease . The mean follow - up was 30 . 2 鹵 11 . 8 months . 23 ( 18.7 % ) had end - point events . By single factor analysis , the tricuspid annular circumference index ( TACI ) was obtained for preoperative combined atrial fibrillation , left atrial diameter and intraoperative measurement .
These three indexes were brought into multi - factor analysis , with only TACI as an independent predictor of postoperative TR weighting ( OR , 1.586 ; 95 % CI 1.303to1.929 ; p0.001 ) . By plotting the working characteristic curve of the subject , it is concluded that the intercept value of the intervention of TACI is 83 mm / m2 , and the sensitivity and specificity at this time show excellent reference value , which is 95.7 % and 87 % , respectively .

Conclusion : The tricuspid valve annulus circumference is an ideal method to quantitatively assess the degree of tricuspid valve annulus dilation . In patients with left heart valve disease , tricuspid valve annulus circumference index is more than 83 mm / m2 . The traditional two - dimensional echocardiography can significantly underestimate the degree of tricuspid valve annulus dilation , especially the non - significant tricuspid regurgitation .

The second part is verified by the operation standard of tricuspid valve annulus circumference index as the same period of tricuspid annuloplasty .

Objective : To evaluate the feasibility and reliability of tricuspid valve annulus circumference index ( tricuspid valve annulus circumference index ) as a quantitative intervention index during operation in this study .

Methods : The study was performed continuously from October 2012 to November 2013 , while the patients with mitral or mitral valve combined with 2 + TR and ultrasound showed that the tricuspid valve diameter was less than 21cm / m2 . Patients included in the study were randomly divided into tricuspid valve plasty ( TVP group ) and tricuspid valve plasty ( NTVP group ) . Preoperative and postoperative assessments were based on two - dimensional echocardiography to assess the degree of TR . Statistical analysis showed that the degree of tricuspid insufficiency was different between the TVP group and the NTVP group and the follow - up period .
The TVP group and NTVP group were subdivided into two subgroups according to tricuspid annular circumference index ( TACI ) greater than or less than 83 mm / m2 .

Results : There were 170 patients with left heart valve lesion and 2 + TR patients who met the criteria . The patients were randomly divided into TVP group ( n = 86 ) and NTVP group ( n = 84 ) .

Conclusion : The tricuspid valve annulus circumference index is simple and easy to operate in operation , and the tricuspid valve annulus circumference index 鈮

本文編號(hào)：2121540