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Cone Reconstruction for Patients with Ebstein's Anomaly

So far, there have been several kinds of valvuloplasty techniques for Ebstein's anomaly. Cone reconstruction which was developed by Da Silver and his coworkers has attracted much attention from worldwide cardiac surgeons. Because this technique could reconstruct the leaflet to leaflet coapatation which permits central blood flow during diastole period. It is probably the most efficient anatomical correction method. We make a comprehensive literature retrieval concerning the Cone reconstruction for Ebstein's anomaly. Its development, key points of technique skills and prognosis evaluation are reviewed meticulously.

Risk Factors of Secondary Tricuspid Regurgitation: A Meta-Analysis

Objective　To analyze and explore the risk factors of secondary tricuspid regurgitation (TR) after left-sided valve surgery (left cardiac valve replacement or valvuloplasty) using meta-analysis, so as to provide evidence for clinical diagnosis and treatment of secondary TR. Methods　We electronically searched databases including PubMed, MEDLINE, CBM, CNKI, VIP, for literature on the risk factors of secondary TR after left-sided valve surgery from 1995 to 2012. According to the inclusion and exclusion criteria, we screened literature, extracted data, and assessed methodological quality. Then, meta-analysis was performed using RevMan 5.0 software. Results　A total of 6 case-control studies were included, involving 437 patients and 2 102 controls. The results of meta-analysis showed that, the risk factors of progressive exacerbation of secondary TR after left-sided valve surgery included preoperative atrial fibrillation (OR=3.90, 95%CI 3.00 to 5.07; adjusted OR=3.04, 95%CI 2.21 to 4.16), age (MD=5.36, 95%CI 3.49 to 7.23), huge left atrium (OR=5.17, 95%CI 3.12 to 8.57; adjusted OR=1.91, 95%CI 1.49 to 2.44) or left atrium diameter (MD=4.85, 95%CI 3.18 to 6.53), degradation of left heart function (OR=2.97, 95%CI 1.73 to 5.08), rheumatic pathological change (OR=3.06, 95%CI 1.66 to 4.68), preoperative TR no less than 2+ (OR=3.52, 95%CI 1.26 to 9.89), and mitral valve replacement (MVR) (OR=2.35, 95%CI 1.68 to 3.30). Sex (OR=1.54, 95%CI 0.94 to 2.52) and preoperative pulmonary arterial hypertension (OR=1.28, 95%CI 0.77 to 2.12) were not associated with secondary TR after left-sided valve surgery. Conclusion　The risk factors of progressive exacerbation of secondary TR after left-sided valve surgery include preoperative atrial fibrillation, age, huge left atrium or left atrium diameter, degradation of left heart function, rheumatic pathological change, preoperative TR no less than 2+, and MVR. Understanding these risk factors helps us to improve the long-time effectiveness of preventing and treating TR after left-sided valve surgery.

The Efficacy of Modified De Vega Technique Compares with the Traditional De Vega Technique for the Correction of Severe Tricuspid Regurgitation

摘要:目的:探讨改良De Vega环缩术与经典De Vega环缩术相比对于治疗重度三尖瓣返流是否具有更好的成形效果。方法: 2007年12月至2009年3月对29例重度三尖瓣返流的患者行De Vega环缩术。其中16例行改良De Vega环缩术,13例行经典De Vega环缩术,随访比较两组患者三尖瓣返流程度,右心室舒张期末内径,EF值及心功能分级。以秩和检验分析研究两组患者三尖瓣返流程度和心功能分级的差异,以t检验研究两组患者右心室舒张末期内径及EF值变化。结果:术前两组患者一般指标无显著差异。两组患者随访时间无显著差异。随访经典De Vega组重度返流1例,中度返流5例,轻度返流5例,微量及无返流2例;改良De Vega组无中、重度返流,轻度返流8例,微量及无返流8例。经分析显示两组患者三尖瓣返流程度结果差异有统计学意义(Plt;0.05)。经典De Vega组心功能分级I级5例,II级7例,III级1例;改良De Vega组I级7例,II级8例,III级1例,两组患者心功能差异无统计学意义(Pgt;0.05)。两组患者右室舒张期末内径及EF值组内比较随访与术前差异均有统计学意义(Plt;0.05),随访时组间比较差异有统计学意义(Plt;0.05), 改良De Vega环缩术随访时右室舒张期末内径缩小更显著,射血分数改善更明显。结论:改良De Vega环缩术治疗重度三尖瓣返流效果优于经典De Vega环缩术。Abstract: Objective: To compare the efficacy of one kind of modified De Vega technique and traditional De Vega technique for the correction of severe tricuspid regurgitation. Methods: From December 2007 to March 2009, 29 patients were treated with tricuspid valve annuloplasty. These were 16 patients in modified De Vega annuloplasty group and the others (13 patients) in traditional De Vega annuloplasty group. The grade of tricuspid regurgitation、New York Heart Association (NYHA) functional class、ejection fraction (EF) and the right ventricular enddiastolic dimension of two groups were followed and reviewed. Results: There was no statistically difference between two groups about preoperative characteristics and followup time. There was 1 patient with severe TR, 5 patients with moderate TR, 5 patients with mild TR and 2 patients without TR in traditional De Vega annuloplasty group after the operations. In modified De Vega annuloplasty group, no patient was observed with severe or moderate TR, 8 patients with mild TR, and 8 patients without TR. At interval time, there was significant difference in the grade of tricuspid regurgitation between two groups (Plt;0. 05). Both tricuspid valve plasty techniques could reduce the right ventricular enddiastolic dimension and improve ejection fraction significantly (Plt; 0. 05), and there was significant difference in the right ventricular enddiastolic dimension and ejection fraction at interval time between two groups (Plt;0.05). Conclusions: The outcome of modified tricuspid De Vega technique is superior to that of traditional De Vega technique in correcting severe tricuspid regurgitation.

Clinical Application of Annuloplasty Ring in Tricuspid Valvuloplasty for the Treatment of Tricuspid Regurgitation

Objective To observe early and intermediate-term clinical outcomes of tricuspid valvuloplasty withannuloplasty ring for the treatment of secondary tricuspid regurgitation （TR） of patients with rheumatic heart disease. MethodsFrom December 2009 to September 2011, 41 patients with rheumatic heart disease underwent left-side heart valve replacementand concomitant tricuspid valvuloplasty with annuloplasty ring in Sichuan Jianyang People’s Hospital. There were 12 males and 29 females with their mean age of 49 （21-67） years. Preoperatively, there were 38 patients with atrial fibrillation, 13 patients with left atrial thrombus; 2 patients with trivial TR, 5 patients with mild TR, 11 patients with moderate TR, and 23 patients with severe TR. Twenty-eight patients received mitral valve replacement and 13 patients received mitral and aortic valve replacement. All the patients were followed up every 3 months at the outpatient department, and received color Doppler echocardiography examination to observe TR degree at the 6th postoperative month. Results Postoperative heart function improved by 2-3 class in all the patients. There were 39 patients with New York Heart Association (NYHA) classⅠorⅡ postoperatively, and postoperative heart function was significantly better than preoperative heart function（P＜0.05）. All the patients were followed up for 6-27 months, and there was no death during follow-up. Color Doppler echocardiography at the 6th postoperative month showed that TR degrees were significantly decreased than preoperative TR degrees. There were 39 patients with trivial or mild TR during follow-up, which was significantly different with preoperativeTR degree （P＜0.05）. Right ventricle dimension decreased from preoperative 20 mm to 17 mm during follow-up, which were statistically different （P＜0.05）. Conclusion Early and intermediate-term clinical outcomes of tricuspid valvuloplasty with annuloplasty ring for the treatment of TR are satisfactory, while further evaluation for its long-term outcome is needed.

同期矫治先天性三尖瓣狭窄合并心内畸形一例

二尖瓣病变合并肺动脉高压致三尖瓣关闭不全的外科处理及中期随访

目的　探讨二尖瓣病变合并肺动脉高压致三尖瓣关闭不全外科治疗的方法，总结相关治疗经验。 方法　回顾性分析2005年6月至2011年6月我院行外科手术治疗二尖瓣病变合并肺动脉高压致三尖瓣关闭不全118例患者的临床资料，男52例、女66例，年龄31～68 （48.25±9.83） 岁。三尖瓣轻度反流28例，中度反流59例，重度反流31例。所有患者术前均有不同程度的肺动脉高压（38～82 mm Hg）。术中行二尖瓣手术时同期行三尖瓣手术。体外循环停机后，术中采用经食管超声心动图（TEE）评价术后即刻治疗效果，出院前再次复查经胸超声心动图评价手术治疗效果。 结果　术中TEE结果提示，三尖瓣无反流50例，轻度反流67例，1例患者三尖瓣成形术后仍存在重度反流，遂再次在体外循环下行三尖瓣置换术。术后早期死亡4例（3.39%），其余患者均痊愈出院。随访12～84（41.72±22.90） 个月，完整随访105例，远期死亡3例，其余患者三尖瓣无反流30例，轻度反流66例，中度反流4例，重度反流2例。全组患者术后5年生存率为93.6%±2.4%；术后5年三尖瓣免除再手术率为94.9%±3.6%。 结论　对二尖瓣病变合并肺动脉高压所致的功能性三尖瓣关闭不全患者，在解决二尖瓣病变时同期纠治存在的三尖瓣病变，可降低术后三尖瓣的再手术率，早、中期疗效满意。术中根据三尖瓣瓣环的扩张程度选择适当的手术方式是提高手术治疗效果的关键。

Correction of Ebstein’s Anomaly Using a Modified Carpentier’s Method

Abstract： Objective To explore the clinical correction of Ebstein’s anomaly using a modified Carpentier’s method and summarize the clinical experience . Methods We retrospectively analyzed data for 13 consecutive patients（ 6 males and 7 females, with an age of 26.8±13.5 years） with Ebstein’s anomaly who underwent operation in the First Affiliated Hospital of Anhui Medical University between June 2006 and August 2010. All patients underwent correction using a modified Carpentier’s method. Operative techniques included excising and suturing the right atrialized chamber; puckering and shortening the tricuspid annulus；detaching the septal and posterior leaflet and/or part of the anterior leaflet from the displaced annulus; broadening and enlarging the area of the posterior/septal valve leaflet using autologous pericardium, and reattaching them to the true tricuspid annulus；transecting and reimplanting the papillary muscle and chordae; and simultaneously correcting any other congenital malformations. Results All patients survived and recovered well. The cardiac functional grading ranged from Ⅰ to Ⅱ (New York Heart Association ). All patients were followed up for 3 to 15 months (average 8 months). Postoperative echocardiograpy showed disappearance of tricuspid incompetence in 10 patients and mild or moderate tricuspid incompetence in 3 patients. The patients’ tricuspid valve leaflets were all at the normal level. At three months and at one year postoperation, rechecked echocardiograpy showed opening and closing of the tricuspid and right ventricular function recovering well, with no obvious incompetence in 12 patients, and moderate tricuspid incompetence lightened to mild in 1 patient. All patients returned to normal work and life. Conclusion Our technique for correcting Ebstein’s anomaly using a modified Carpentier’s method had satisfactory early results. The patients’ right ventricles were effectively reshaped and recovered function through excising and suturing the right atrialized chamber, and favorable tricuspid valvuloplasty effect was achieved by reattaching the enlarged leaflets using autologous pericardium to the true tricuspid annulus, and by transecting and reimplantating the papillary muscle and chordae.

改良三尖瓣成形术的效果评价

目的 比较一种改良三尖瓣成形术与Kay 成形术的成形效果，总结治疗经验。 方法 回顾性分析江苏省人民医院2006 年1 月至2008 年1 月60 例功能性三尖瓣反流患者的临床资料。按手术方式不同将60 例患者分为两组：改良三尖瓣成形术组（改良组），30 例，其中男14 例，女16 例；年龄（42.80±5.70）岁；Kay 成形术组，30 例，其中男15 例，女15 例；年龄（45.30±8.30）岁。术前两组患者的年龄、性别、心功能分级（NYHA）和三尖瓣反流分级差异均无统计学意义（P ＞ 0.05)。比较两组患者术前、术后住院及术后随访期间的右心房横径、右心室舒张期末内径和三尖瓣反流面积。 结果 两组患者手术时间、体外循环时间、住重症监护室时间、呼吸机辅助时间、住院时间差异均无统计学意义。术后全部患者痊愈出院。改良组随访时间为（19.62±8.65）个月，远期1 例死于肺部感染；随访三尖瓣无反流13 例，Ⅰ级反流14 例，Ⅱ级反流2 例，Ⅲ级反流1 例，无Ⅳ级反流。Kay 成形术组随访时间为（18.96±9.23）个月，远期死亡2 例，分别死于顽固性右心衰竭和脑出血；随访无三尖瓣反流9 例，Ⅰ级反流12 例，Ⅱ级反流5 例，Ⅲ级反流2 例，Ⅳ级反流2 例。术后早期改良组和Kay 成形术组右心房横径[（4.51±0.85）cm vs. (5.69±1.21) cm]、右心室舒张期末内径[（2.85±0.45） cm vs.（ 3.47±0.83） cm] 和三尖瓣反流面积[（4.17±2.54） cm2 vs.（ 25.12±2.39 cm2）] 较术前均明显下降（P ＜ 0.05）；术后随访改良组和Kay成形术组右心房横径[（3.95±0.66） cm vs.（ 4.52±0.38） cm，P=0.705] 差异无统计学意义，右心室舒张期末内径[（2.59±0.63）cm vs.（ 2.98±0.47） cm， P=0.002] 和三尖瓣反流面积[（8.76±3.45） cm2 vs.（ 12.16±5.28） cm2， P=0.004] 改良组优于Kay 成形术组。 结论 改良三尖瓣成形术的远期成形效果优于Kay 成形术。

Ring Annuloplasty Using Prosthetic Vascular Graft for the Treatment of Tricuspid Regurgitation：Experience in 56 Patients.

Abstract： Objective To evaluate the surgical effect of ring annuloplasty using prosthetic vascular graft for the treatment of tricuspid regurgitation. Methods From July 2000 to July 2010, ring annuloplasty using prosthetic vascular graft was performed to a total of 56 patients with tricuspid regurgitation in Changhai Hospital of Second Military Medical University. There were 24 male patients and 32 female patients. Their mean age was（45.7±21.8）years (ranging from 14 to 73 years). All the patients were diagnosed as moderate to severe tricuspid regurgitation by color Doppler echocardiography examination, including 47 patients with rheumatic heart valve diseases, and 9 patients with congenital heart disease (Ebstein’s anomaly). All the 56 patients underwent ring annuloplasty using prosthetic vascular graft instead of Carpentier annuloplasty ring for the treatment of tricuspid regurgitation. Results There was no in-hospital death. Postoperatively, one patient had acute respiratory failure, one patient had acute kidney failure, and one patient had re-exploration for bleeding. All patients had none or mild tricuspid regurgitation by echocardiography examination one month after surgery. Forty eight patients were followed up from 1.0 to 9.5 years with a median follow-up time of 3.8 years. During follow-up, there was no late death, but one patient had brain embolism as an anticoagulation complication. Sixteen patients were in New York Heart Association (NYHA) functional classⅠ, 26 patients in NYHA classⅡ, and 6 patients in NYHA class Ⅲ. Thirty six patients had no tricuspid regurgitation, 10 patients had mild tricuspid regurgitation, and 2 patients had moderate tricuspid regurgitation by echocardiography examination during follow-up. Conclusion The early and mid-term follow-up results of ring annuloplasty using prosthetic vascular graft instead of Carpentier annuloplasty ring for the treatment of tricuspid regurgitation are satisfactory. It is a good choice for the surgical treatment of tricuspid regurgitation.

Progress in Surgical Treatment of Secondary Tricuspid Insufficiency

Abstract： Tricuspid insufficiency founded in the setting of left-sided heart disease is usually secondary tricuspid insufficiency caused by tricuspid valve annular dilation. Some patients had rheumatic tricuspid valve diseases. Tricuspid valve repair rather than valve replacement is recommend for functional tricuspid regurgitation. Linear annuloplasty and ring annuloplasty are two main tricuspid valve repair methods. However, the indications for treatment of secondary tricuspid regurgitation remain controversial. The optimal surgical repair technique to eliminate secondary tricuspid regurgitation remains challenging. In this article, we review the assessment of tricuspid valve lesions, criteria for correction, and surgical management of secondary tricuspid insufficiency.methods. However, the indications for treatment of secondary tricus