Tricuspid stenosis surgery

Organic tricuspid stenosis is most common in rheumatic heart disease, and its incidence is 1/10 of mitral stenosis. Autopsy confirmed that tridary stenosis was present in 14% of patients with high incidence of rheumatic heart disease. There were also autopsy reports that found tricuspid stenosis as high as 20% to 40%. Simple rheumatic tricuspid stenosis is very rare. Hanck reported that only 6 of 194 patients had diffuse fibrosis and junctional fusion of the valve and the valve was closed. Ribero et al observed 43 cases of tricuspid stenosis from ultrasound, accounting for 40% of all rheumatic heart disease, Zuvi et al reported 3.1%, and autopsy reported tricuspid stenosis as high as 20% to 40%. Tricuspid stenosis often coexists with mitral and aortic lesions. Rheumatic tricuspid stenosis is mainly caused by thickening of the valve leaflets, adhesion between the leaflets and the valve leaflets, limited opening of the valve leaflets, reduction of the valve area, and shortening of the chordae. The age of good hair is 20 to 60 years old. As with mitral stenosis, the incidence of tricuspid stenosis is higher in women than in men. Treatment of diseases: tricuspid stenosis Indication Tricuspid stenosis surgery is suitable for: 1. Tricuspid valve formation failed. 2. Tricuspid malformation, especially the anterior leaflet thickening, curling, and smaller. 3. The structure of the tricuspid valve is severe, such as the sacral papillary muscle is obviously shortened and fused. 4. Infective endocarditis tricuspid valve is severely damaged and cannot be repaired. 5. Congenital Ebstein malformation, valvular dysplasia. 6. Thoracic blunt trauma, multiple chordae rupture and valve damage, can not be repaired. Contraindications 1. Serious damage to vital organs of the body; 2. Right heart function damage to irreversible extent. Surgical procedure Tricuspid angioplasty Tricuspid angioplasty is feasible at the junction fusion site, general organic tricuspid stenosis, often combined with tricuspid regurgitation, closed separation often aggravated tricuspid regurgitation. Therefore, the boundary should be separated under direct vision. Tricuspid stenosis often occurs at the posterior septum junction. The leaflets are often thickened at the junction of the anterior septum. The small round blade is used to cut from the junction of the fusion. It should be 1-2 mm from the annulus to avoid incision of the annulus and leaflets to avoid causing The valve leaf prolapses, causing tricuspid regurgitation, and the anterior and posterior valve junctions should not be cut open. After the incision, the tricuspid regurgitation may be aggravated. If the chordae tendon is fused, the papillary muscles are shortened, and the fused chordae and papillary muscles can be cut with a small round knife to increase the valve activity. Make it tightly closed. After the angioplasty is completed, the tricuspid valve closure should be tested by water injection. If there is still reflux, the partial squatting and gasketing should be used. 2. Tricuspid valve replacement Tricuspid valve replacement, its indications should be strictly controlled, only when the valve disease is serious, can not do the angioplasty, only the replacement surgery, such as infective endocarditis, congenital Ebstein malformation, leaflet dysplasia and chest blunt Injury, multiple chordae rupture and tearing of the valve. According to the characteristics of the tricuspid blood flow, the flow rate is slower than the left ventricle, the right ventricular pressure is lower than the left ventricular pressure, and the tricuspid valve transvalvular pressure difference is also smaller than the mitral valve mouth. In addition, the mechanical valve has anticoagulant-related complications (bleeding, Thrombosis, embolism) Therefore, bioprosthetic replacement is often used in early years, but for young patients, new type of double-leaf valve replacement should be used. In recent years, in addition to elderly patients or patients who are not suitable for mechanical flaps, most of the central blood flow is applied. The mechanical valve is changed. Tricuspid valve replacement should generally use a 29-31mm artificial valve. Tricuspid valve replacement, according to the conventional chest median incision, or the right anterior chest incision, from the 4th intercostal space into the chest. After the establishment of extracorporeal circulation, the right atrium was cut in parallel with the right interventricular septum. Keep the leaflets, remove the anterior and posterior leaflets and all the chordae and part of the papillary muscles. With a 2-0 double-headed needle with a shimming, the suture is sutured. Firstly, the suture from the septum leaves, the needle from the atrial surface, close to the shallow joint of the root of the septum, and then the suture to the free edge of the valve leaf, so that the leaflets are folded, as a gasket of the needle, the suture is reinforced, Prevent the suture from being torn off and avoid damage to the deep conduction bundle of the annulus. In turn, the anterior annulus and the posterior annulus are sutured, sutured, and sequentially sewn to the artificial valve suture ring. After the flap is placed into the annulus, the knot is knotted. The stitching distance of each stitch of the tissue loop during suturing should be slightly larger than the spacing of the artificial annulus. In this way, the tricuspid annulus can be condensed and the artificial valve can be fixed reliably. The suture can also be placed over the coronary sinus opening on the side of the suture, and the coronary sinus is placed on the ventricular side. This surgical method avoids conduction beam damage. complication 1. Conduction block Tricuspid valve replacement, due to the special anatomical position of the atrioventricular node and His bundle, is easy to injure and conduct beam during tricuspid valve replacement, especially at the border of the septum and anterior septum, causing III degree atrioventricular block . It has been reported in the literature that its incidence is 2% to 7%. Therefore, when suturing at this site, it is a shallow seam, the second is to insert the needle from the ventricle surface of the septum, the acupuncture point is removed, and the third is to bypass the coronary sinus opening when suturing to avoid the Koch triangle. In cases of Ebstein malformation, if there is a large atrial septal defect, it can be repaired with pericardial patch to reduce tension and avoid complete atrioventricular block. 2. Thromboembolism Because the right heart is in the low-pressure region of the heart, the blood flow is relatively slow, and thromboembolism is easy to form. However, as long as the anticoagulation level is better controlled or anti-platelet aggregation drugs are added, the complications can be minimized. 3. Infective endocarditis After tricuspid valve replacement, artificial heart valve infective endocarditis can occur, especially intravenous drug abuse, which is more prone to infection and cause endocarditis.