Atrial ventricular plication and tricuspid valve replacement

Tricuspid valve disease is a common disease of heart valves. At present, tricuspid valvuloplasty can be used to obtain satisfactory results. However, for patients with severe lesions and tricuspid valvuloplasty, tricuspid valve replacement can only be used. Cases are rare; patients with tricuspid valvular distraction can be treated with atrial ventricular folding. Patients with tricuspid valve replacement have poor right heart function, most of which are re-cardiac surgery. At the same time, other heart disease changes are needed, so the risk of treatment is high and the incidence of postoperative complications is high. Treatment of diseases: tricuspid atresia tricuspid stenosis Indication Ventricular ventricular folding and tricuspid valve replacement are suitable for: 1. In children or adults with progressive hair loss or cardiac function III ~ IV, early use of ventricular ventricular folding or tricuspid valve replacement. 2. Cardiothoracic ratio 0.65, regardless of whether the patient has symptoms, surgery should be performed at an optional stage. 3. In cases of large atrial septal defect, patent ductus arteriosus or pre-excitation syndrome, even if the tricuspid regurgitation is very light, the tricuspid valve should be repaired at the same time as the combined malformation. 4. In patients with type I, tricuspid posterior annuloplasty and/or atrial ventricular plication, most type II ventricular laparotomy and tricuspid annuloplasty or tricuspid valvuloplasty, and III Type and a small number of type II tricuspid valve replacement. Left Ebstein heart malformation, tricuspid valve replacement. 5. The functional ventricle is too small, and the bidirectional cavopulmonary shunt is applied at the same time as the Ebstein cardiac malformation operation. Contraindications 1. Left ventricular dysplasia, left ventricular end-diastolic volume index <30ml/m2. 2. There are severe respiratory insufficiency. 3. Have severe liver and kidney dysfunction. Preoperative preparation 1. Regardless of children and adults with cyanosis and heart failure, apply oxygen therapy, digitalis and diuretics. If the above treatment has no obvious effect, continuous intravenous infusion of dopamine or dobutamine is applied, and the operation is performed after the heart failure is improved. 2. Patients with atrial fibrillation, digitalis drugs; ventricular tachycardia with verapamil or propafenone. 3. Precisely observe and review the echocardiogram before surgery, paying particular attention to the severity of tricuspid malformation and downshift, valve mobility, subvalvular structure and right ventricular function. If valve activity is good and the subvalvular structure is normal, atrial ventricular plication and tricuspid annuloplasty should be used. Severe valve malformation or valve attachment to the ventricular wall is poor or functional ventricular small (functional ventricle and entire right ventricular volume) The ratio of <0.35) should be performed with tricuspid valve replacement or with bidirectional cavopulmonary bypass. 4. Patients with pre-excitation syndrome should undergo electrophysiological examination before operation, and the outer membrane of the operation center should be marked, and the abnormal atrioventricular conduction beam should be cut off simultaneously during the operation. Surgical procedure The median incision of the chest was inserted into the arterial infusion tube through the ascending aorta, and the right anastomosis was directly inserted into the right angle tube through the superior and inferior vena cava tubes, and the left heart decompression tube was inserted through the right superior vein. Following extracorporeal circulation cooling and cardiac arrest, the following procedures were performed. 1. The ventricular ventricular folding and tricuspid annuloplasty are parallel to the right interventricular septum incision. If the right atrium is significantly enlarged, the right atrium should be partially removed. Closed atrial septal defect or patent foramen ovale, small can be directly sutured, the diameter of > 2cm should be patch repair. After the tricuspid valve and its subvalvular structure were explored, it was decided to perform atrial ventricular folding. Firstly, the valve was moved down, and a double-ended needle with a spacer was applied. The lower part of the myocardium was moved from the lowest point of the posterior valvular lower needle, and the needle was taken out from the ventricular chamber. This line can be seen to show the full length of the ventricular chamber, and then parallel to the tricuspid annulus under the endocardial ventricular sinus opening to the right front of the coronary sinus opening. Thus, from the lower back of the tricuspid valve and / or the lower end of the septum to the tricuspid annulus 3 to 4 with a padded suture, through the spacer, push the knot hole. Then do posterior annuloplasty. If the tricuspid annulus is still large, a segmental DeVega tricuspid annuloplasty is added. Finally, the tricuspid valve can pass 2 to 3 fingers. Repeated water injection during the operation to test the tricuspid opening and closing, such as a small number of small holes in the anterior valve, can be applied with 5-0 polypropylene suture, at this time in the left heart gas open aortic forceps, observed under the heart beat three When the cusp is opened and closed well and there is no closure, the right atrium incision is sutured. When there is a tricuspid stenosis, one side of the junction can be cut, and then the chamber is folded. In the case of pre-excitation syndrome, epicardial mapping and abnormal atrioventricular conduction beam ablation should be performed first, followed by atrial ventricular folding. 2. Fanghua ventricular longitudinal folding and tricuspid valve repair (1) Carpentier method: through the right atrial incision, observe the posterior valve development of the tricuspid anterior valve and the size of the ventricular ventricle. The anterior and adjacent posterior lobes are cut on the tricuspid annulus and the fibrous cord attached to the wall of the ventricle, and 1/3 of the anterior borderlet of the anterior border remains attached to the annulus. The anterior chamber folds the ventricle and the adjacent right atrium to rebuild the right ventricle and narrow the enlarged right atrium. The incision anterior and posterior flaps are repositioned onto the annulus, covering the entire flap in a normal position plus an artificial annulus. (2) Quaegebeur method: the right atrial incision of the interventricular septum, the morphology and mobility of the tricuspid anterior and posterior lobes and the subvalvular structure. The posterior lobes from the annulus and the inferior flap along the annulus and the septum are cut at the right ventricle attachment, but the anterior flap is attached to the annulus adjacent to the septal junction. Abnormal fibrous strip attached to the wall of the ventricle under the valve was removed and the papillary muscle was carefully dissected until the tip of the right ventricle. The 4-0 polypropylene thread continuous suture and longitudinal folding were used to move the ventricle between the posterior flap and the septum, and the suture range was triangular. The edge of the incision leaflet was sutured to the annulus using a 5-0 polypropylene thread continuous suture and an artificial annulus was added. Repeated water injection test the degree of perfection of tricuspid valve repair. Closed atrial septal defect and right atrial incision. Quaegebeur believes that the advantages of this surgical approach are: 1 right ventricular longitudinal folding can maintain the right ventricular height and geometry, reconstructing the atrioventricular valve just in the atrioventricular junction. 2 Incision and freeing of the anterior and posterior lobes, in accordance with Danielson's single-lobe view, make valve repair more complete. 3 After the operation, the ventricular ventricle merges into the functional ventricle, and the right ventricular systolic function is strengthened. 3. Atrial septal defect and posterior annuloplasty This procedure is suitable for large atrial septal defect and type I Ebstein cardiac malformation. The right atrium incision in the parallel chamber groove was performed to investigate the size and location of the atrial septal defect, the extent of the tricuspid valve and the degree of closure. For example, when the tricuspid valve and the posterior flap are mild to moderately displaced and closed, the pericardium is used to repair the atrial septal defect as well as longitudinal and posterior annuloplasty. 4. Tricuspid valve replacement removes the tricuspid valve and its chordae, and retains a portion of the anterior and valvular movements to prevent damage to the conduction beam. On the outside of the opening of the coronary sinus, the lower edge of the Tadaro ligament and other parts of the tricuspid annulus were sutured with a padded suture, which was then sutured on the suture ring of the artificial flap and pushed down for ligation. St Jude double leaf flaps are generally used with an inner diameter of 27 to 31 cm. 5. Intracardiac repair and ventricular volume load reduction This procedure, also known as partial biventricular repair or one and half ventricular repair, is suitable for severe Ebstein cardiac malformations, and its functional ventricle is approximately equal to normal. 1/2 or 1/3 of the right ventricle. Its function is to improve the right ventricular work efficiency after the tricuspid valve is formed; reduce the right ventricular volume load, and improve the left and right ventricle and tricuspid valve function. This procedure can be performed with a two-way cavopulmonary bypass, but atrialized ventricular folding or tricuspid valve replacement is performed. You can also do atrial ventricular folding or tricuspid valve replacement. After the patient is out of the extracorporeal circulation, the esophageal echocardiography can be used to find that the right ventricle still has dysfunction, such as right atrial pressure >12mmHg (while left atrial pressure is 5mmHg). And the enlarged right ventricle still bulges the chamber and compresses the left ventricle, and then undergoes extracorporeal circulation, and a bidirectional cavopulmonary shunt is performed under the heart beat. complication 1. Low cardiac output syndrome: Ebstein cardiac malformation in patients with cardiac function III to IV and cardiothoracic ratio > 0.65, postoperative low cardiac output syndrome, dopamine and / or dobutamine Sodium nitroprusside is continuously infused intravenously for 3 to 7 days, sometimes for up to 2 weeks. Appropriate blood supplementation to achieve a hematocrit of 35%, later supplemented with plasma and albumin, maintaining a central venous pressure of about 15mmHg. The urine volume per hour is maintained above 40 ml, and furosemide is given when there is little urine. 2. Heart failure: Some patients have symptoms of heart failure such as hepatomegaly after operation, and digitalis and diuretics are used for 2 to 3 months to properly supplement potassium to prevent arrhythmia caused by hypokalemia. To observe the therapeutic effects of heart failure, such as echocardiography confirmed significant or severe tricuspid regurgitation, should be actively prepared for tricuspid valve replacement. 3. Arrhythmia: Sudden onset of supraventricular tachycardia in the recent postoperative period, may miss the diagnosis of pre-excitation syndrome or abnormal intraventricular conduction beam cut, should be done electrophysiological examination and catheter radiofrequency ablation. 4. Chronic pericardial effusion: Preoperative cardiac enlargement is severe, and the postoperative heart shrinks to leave a large pericardial cavity, sometimes the effusion reaches the degree of pericardial tamponade. At present, partial pericardial resection is used to reduce the pericardial cavity and conventional right pericardial fenestration and closed thoracic drainage, and this complication is significantly reduced. Once chronic pericardial effusion occurs, pericardial puncture or closed pericardial drainage is used. 5. Tricuspid regurgitation: At present, in all tricuspid valve repair operations of Ebstein cardiac malformation, about 2% to 5% have moderate to severe tricuspid regurgitation in 4 to 10 years after surgery, sometimes combined with atrial fibrillation . Should actively treat heart failure, elective tricuspid valve replacement and right maze surgery. 6. Biological flap failure: Bioprosthetic tricuspid valve replacement in childhood. Heart failure occurs 6 to 10 years after surgery, and patients with valve tear and obvious closure due to echocardiography should undergo a second valve replacement. 7. Thrombosis and embolism: This complication is often caused by mechanical valve. The amount of warfarin anticoagulant should be adjusted continuously during follow-up to prevent thrombosis and embolism. Echocardiography should be performed regularly. If the mechanical valve activity is limited or the right atrial thrombus is found, tricuspid valve replacement should be performed again. 8. Bleeding: Bleeding is caused by excessive application of anticoagulant after mechanical replacement. Once bleeding occurs, stop the anticoagulant or reduce the dose of anticoagulant. If there is cerebral hemorrhage or pulmonary hemorrhage, anticoagulation and intravenous injection of vitamin K11 should be discontinued, and cerebral hemorrhage should be surgically treated.