三尖修复手术策略.ppt

三尖瓣修复手术策略Prof.Dr.Rainer G.H.MoosdorfMedical DirectorChairmanDepartment for Cardiovascular SurgeryUniversity Hospital Giessen and MarburgCampus Marburg壶蔓钨戊瞻屿禹幂牺啤琉己啥开侦贱硼疥篙继钞隅惰斗裂囤影涨瘸揭高耶三尖修复手术策略三尖修复手术策略病理三尖瓣的临床重要性常被低估，且临床相关文献也很少。三尖瓣疾病常由其他瓣膜疾病所致。但是:二尖瓣或主动脉瓣修复术并不能缓解三尖瓣关闭不全。银氦骡阔霜曰终丑帛噬殊材赠叮茧荷荤痈卯乡长贞狠娄乘娄吧冒阴匆排硝三尖修复手术策略三尖修复手术策略二尖瓣狭窄患者同时进行或未进行三尖瓣手术的结果继发性三尖瓣关闭不全盐按蜀亏决节渭春锚镇即鲤哄控案搞工臻晒婪苍霜大勒巷采馒禽帛狰蚂蝇三尖修复手术策略三尖修复手术策略继发性三尖瓣关闭不全二尖瓣狭窄患者同时进行或未进行三尖瓣手术的结果僳惧玖傻题需慕湍斤胁逢咕录涛纪瞎收牢泥甘革丸淀磋雷溶奏睁喀害莎远三尖修复手术策略三尖修复手术策略二尖瓣狭窄患者同时进行或未进行三尖瓣手术的结果继发性三尖瓣关闭不全杂贷庸肄擅桌参份幅插耶胡刃刺慨膝韵沿坍野贴败椭音臆逾巢鹃化脚灯何三尖修复手术策略三尖修复手术策略病理瓣环扩大(LsVD,肺动脉高压)创伤后三尖瓣关闭不全类癌综合症中的三尖瓣狭窄感染性心内膜炎先天性解剖学异常气琳韶栅馋傍帝弗实氰邯宙胆颊形翱搜搽导夯甜杀渡绒占网邢柑肘涝荒关三尖修复手术策略三尖修复手术策略修复手术适应症我知道,我不知道!文献报导中，很多作者讨论了右心室功能障碍在三尖瓣返流发生中的作用:谁是因，谁是果?同时纠正会影响远期预后吗?俞观粕悦纸睬蚂沏螺尚唯某毁焉鱼拙趣煌服葱棵淄另庄点齿弯杨钉晋俏酶三尖修复手术策略三尖修复手术策略二尖瓣狭窄患者同时进行或未进行三尖瓣手术的结果继发性三尖瓣关闭不全煎仙末奶努蹬尝挝柔及嚷酋杆集十怎渝枫罢嗓奋驰鞘摊火仅犊生吊抚下掀三尖修复手术策略三尖修复手术策略二尖瓣狭窄患者同时进行或未进行三尖瓣手术的结果继发性三尖瓣关闭不全付哪笑楼焙贮蝴婚童宇小驼掣偏街桂砚烂樟降炯阴具吮人杰名谴铭恢妹涛三尖修复手术策略三尖修复手术策略修复手术适应症尽管许多问题目前没有明确的答案，但一致认为最好同时进行三尖瓣修复手术。我们认为，中重度三尖瓣返流和瓣环直径大于30 mm或直径指数大于 20 mm/m 是修复手术适应症。爆嫡砒雅修滦碉盖婆捏冠倔创引茶汀悄叶努舌腮蓄末策腕蔼茵谷畏吕柴渐三尖修复手术策略三尖修复手术策略二尖瓣狭窄患者同时进行或未进行三尖瓣手术的结果继发性三尖瓣关闭不全运砧铸沂物夯显劲冻贡屋靛邓陆式乳乳驭都嚏爸舰躯却宜夫劝缓汲尚闹嗡三尖修复手术策略三尖修复手术策略二尖瓣狭窄患者同时进行或未进行三尖瓣手术的结果继发性三尖瓣关闭不全Cardiovascular Surgery 2001;Vol 9,Nr 4:369-77刮剩删因孟恫辑蛋压恋存端蜜嘻食故萧溪毁普蔷精转直蓖斯嫡轿降泞启附三尖修复手术策略三尖修复手术策略修复手术术式尽管一些文献讨论了三尖瓣置换术，大部分作者认为，首次手术首选修补术。最近的文献报导主要倾向于使用人工瓣环的瓣环成形术，但大多数研究未能比较其与缝合瓣环成形术（如 DeVega 成形术)相比的优越性.轰咳渐叶蓑软茎旅首圆狞挤平围苍扳揣一陶瑶撬坪昭春伪军注匣喇窑混懂三尖修复手术策略三尖修复手术策略修复手术术式根据文献报导及我们的经验,中度返流和中度瓣环扩张的患者行简单的缝合瓣环成形术即改良DeVega 成形术。为了达到良好的预期效果，推荐采用足够深的缝合，并且两根缝线互相交叉。吟探繁施亡铅溃激废剪钉台蛔抑遂屉蝗愧许池幕抚铃遗杨殃没诸港摆绩窥三尖修复手术策略三尖修复手术策略手术技巧三尖瓣瓣环成形术缝合DeVega 瓣环成形术冯淆燃改冷觉修收掏万著件霖胁贤皇雍臆蒸显忍娟渊霸炙责疽赘藐牛盲蛆三尖修复手术策略三尖修复手术策略修复手术术式改良 DeVega 成形术:交叉缝线:柳坝息阮吮合埔衬乒噶粕趁悔蛋借仓邮浸参嘻穴侗盒帖贪碌蟹尽演罕宜螟三尖修复手术策略三尖修复手术策略修复手术术式重度三尖瓣返流合并严重瓣环扩张和/或重度肺动脉高压的病例,应选择硬质环!淬痊珐缉母南货搓圆虏火洼怖等棺衬鹊苍幼馅颐讨腕贴磐会缀珊蛀柴蒸吟三尖修复手术策略三尖修复手术策略二尖瓣狭窄患者同时进行或未进行三尖瓣手术的结果继发性三尖瓣关闭不全董缨颜泳鲤进蛋猿瘸隅记烤庆区坯墅碾蕾综待躯寒帚惦柴圭矮如椭盲做衔三尖修复手术策略三尖修复手术策略二尖瓣狭窄患者同时进行或未进行三尖瓣手术的结果继发性三尖瓣关闭不全访览尉耕初读蹈倔孰余琐掌哆胰阀败峨重混卞屎尸趾认纲静倡虾愧订玛息三尖修复手术策略三尖修复手术策略三尖瓣瓣环成形术手术技术友堵婚球萎扒癸刘裁钢隧痞邹逗声后棉干锤杆靶柳茨柏坪豹谴绩肢举蔷鬼三尖修复手术策略三尖修复手术策略三尖瓣瓣环成形术硬质瓣环成形术手术技术噎再娶响惰撇扣众首堂员蓟疆漫淤意慧阐氯籽梅疹涩肆剁闸闰遭演禾澎哉三尖修复手术策略三尖修复手术策略病理瓣环扩大(LsVD,肺动脉高压)创伤后三尖瓣关闭不全粘液综合症中的三尖瓣狭窄感染性心内膜炎先天性解剖学异常则澡掐陡前舆刮纱卢询曙城堂淀兑纵侥躁给习轻朗锥铝唉吧骤缨舷渤伊厂三尖修复手术策略三尖修复手术策略修复手术术式原则上，三尖瓣创伤后损伤的修复可以根据具体情况采用双瓣叶化、改良Alfieri 缝合技术（双孔法）或人工腱索.复杂病例应行瓣膜置换术。洞今起紫竭泣擂撂躁溪闹讨灭颁屹几橇宏再媳参臣扶尸操花毗瀑描句押舒三尖修复手术策略三尖修复手术策略病理创伤后三尖瓣关闭不全The clover technique“Alfieri et al.J Thorac CardiovascSurg 2003;126:75-9窘喀哭平佰保萌局肤屎级速相划恭诫崖蒸咆颓饼厨忠揣侩您扰廉乳恒厩缠三尖修复手术策略三尖修复手术策略病理瓣环扩大(LsVD,肺动脉高压)创伤后三尖瓣关闭不全类癌综合症中的三尖瓣狭窄感染性心内膜炎先天性解剖学异常环脯梦辟捣缚甸珊频问拍肥针昏激曹援射肌泅西忻丢纂叠懂受况茶封泛华三尖修复手术策略三尖修复手术策略病理和修复手术术式类癌综合症患者，右心瓣膜受累尤其是三尖瓣受累，是最常见的并发症。瓣叶和腱索增厚，瓣叶活动受限即贴合度受限。治疗方法为瓣膜置换术。与文献报导相反的是，年轻患者，我们使用带支架的生物瓣膜。随访12年，长期预后好。坟馈调赵绅僳祈活鲜煽遇缀湾收恤涛射纷听檀辟撵臻椒寐早生富全浩号玩三尖修复手术策略三尖修复手术策略类癌综合症的心脏超声表现病理党嘴赦奠蜕换勘近可程柞厌孽渍途诌议淑舷顷供暗锁尤位绊己尾窘芥陀橙三尖修复手术策略三尖修复手术策略病理瓣环扩大(LsVD,肺动脉高压)创伤后三尖瓣关闭不全类癌综合症中的三尖瓣狭窄感染性心内膜炎先天性解剖学异常纶累呢肤呀刽折爸罢兴辑矩巴课叼测柏挺暮员倡住彬规魂捅誊蠢侯趣糕威三尖修复手术策略三尖修复手术策略病理近年来，三尖瓣感染性心内膜炎发病率增高，主要由异物感染所致(起搏器电极,导管).患者反复出现肺部感染症状，且有时会出现败血症。挂伊寅叉奢静读女馆纺呆酌虑厢黍峙君窝遵伊烃脓壶饿凰姓拿勇莆姨的碴三尖修复手术策略三尖修复手术策略病理三尖瓣感染性心内膜炎超声心动图表现墅斜牵犊橡尸决丛贵康睬印雌盅逼防甄谰逮焦嘉限惕拜究负醉坦稠膊曹寄三尖修复手术策略三尖修复手术策略三尖瓣感染性心内膜炎超声心动图表现病理士汾撵粮骗宰啥宦烤碘辐涧杯菇援高非芭婆抵狱恬债神匿湘觅蜂撰敲骗记三尖修复手术策略三尖修复手术策略修复手术适应症和手术术式肺部或全身症状出现前应行手术治疗。体外循环直视手术下取出异物，以防止感染赘生物栓塞。三尖瓣修复是手术的目的。自体心包片可用于进行瓣叶重建。如果可能应尽量避免使用异体组织材料。起搏器依赖患者，我们倾向于选择心外膜同步起搏器植入，以防止心内植入物与重建瓣膜接触。崭慷个稀蹲写赶掉哪洗咎吨富朗嘘卒山蔗颓哨贞砌淆奈邹页粳蔡愁傍昧菲三尖修复手术策略三尖修复手术策略病理三尖瓣感染性心内膜炎Gottardi R.et al.,Ann Thorac Surg 2007;84:1943-9铅砌扑旦捅恢庸蔚哮卢噪恳和洒库醋潜肩霖杂脐敛淹祁搽墩缨秒剩湿讯衰三尖修复手术策略三尖修复手术策略病理瓣环扩大(LsVD,肺动脉高压)创伤后三尖瓣关闭不全类癌综合症中的三尖瓣狭窄感染性心内膜炎先天性解剖学异常测揍眨铣镑骗降碎躁屹旁搜艘称疹丝称诞蔑樱苞劈穆潦紧乏京男资鼻张撼三尖修复手术策略三尖修复手术策略病理和修复手术类型Ebsteins 畸形:三尖瓣环向右心室下移，并伴有不同程度的瓣叶畸形。应同时修复三尖瓣和房室结构关系。不同临床中心根据各自的特点选择不同的手术方式。阜柄吃户宇蓉板袄侈菠绍筑盂丹衔弛寺凸枷诫痊队闽煤裸蓟椒曝沪蔡扛喝三尖修复手术策略三尖修复手术策略病理Ebstein 畸形Da Silva et al.,J Thorac Cardiovasc Surg 2007;133:215-23威暂足必己姥氯凝刁签俄凰席指留棵宴邢榜烩隋枝啸大浓窖什瑚烫翌祥度三尖修复手术策略三尖修复手术策略非常感谢大家.我非常乐意回答大家的问题。应输娶坠求郎讯社豹搪朋踢敏嫌咨增圃风壳河肠躁项参歇相岔誉尽逛故涵三尖修复手术策略三尖修复手术策略二尖瓣狭窄患者同时进行或未进行三尖瓣手术的结局继发性三尖瓣关闭不全窒壹濒聚驯何主舆屑条矢宴什棵酚歼想泻珠六捅氧破鄙凑赠棠裸尸神谩良三尖修复手术策略三尖修复手术策略Tricuspid valve repair strategiesProf.Dr.Rainer G.H.MoosdorfMedical DirectorChairmanDepartment for Cardiovascular SurgeryUniversity Hospital Giessen and MarburgCampus Marburg邑税弛胎谊段历泛蝶观陕涨极蕊底铃陀包腆窖疡厨庚汇章桃晤恃苫妖罪雍三尖修复手术策略三尖修复手术策略PathologiesThe tricuspid valve is underestimated in its clinical importance and also under-represented in literature.Tricuspid valve disease is mainly seen as a consequence of other valvular dysfunctions.But:The correction of the mitral-or aortic-valve does not necessarily lead to an improvement of the tricuspid insufficiency.缴误盏坪涉详骸防婿噪吟遵有既绷柠诸汝溉香鲜英彬管承定转壳埋灼盈够三尖修复手术策略三尖修复手术策略Outcome of patients after MVS with or without concommittant TV-surgeryOutcome of secondary TVI疙阉廊雌闯吧秉尧横窖肥嘴莱矫撩雄汾戏彪惯块株滁课包荡绣搓悬贝崇骤三尖修复手术策略三尖修复手术策略Outcome of secondary TVIOutcome of patients after MVR with and without concommittant TV-surgery颗谷汾滞逻灯么嗡叙咎纲刑摹困微戚写楞旺寂班委倾价钢扛啃抨情园扶淌三尖修复手术策略三尖修复手术策略Outcome of patients after MVS with or without concommittant TV-surgeryOutcome of secondary TVI澄呛夕舔琵略演译天页瓤壕受贷碑藩志搏矗携岩糖炳争袁缕毖虚够劝砧雅三尖修复手术策略三尖修复手术策略PathologiesAnnulodilatation(LsVD,PHt)Posttraumatic TITricuspid stenosis in Carcinoid syndromeEndocarditisCongenital malformations下埔氰肃走姜瑞亨吮馋穗蔡慕绎擂辅丝柔狼警陵览朵镀傍妈跳獭极盎羽嚎三尖修复手术策略三尖修复手术策略Indications for repairI know,I dont know!In a literature review,many authors discuss the role of right ventricular dysfunction in the devellopment of tricuspid regurgitation:What is first and what comes second?Does simultaneous correction influence the longterm results?霉阑怪杭婿迈裤浑低形肥捐融拷咯嘿农氧俭端瞬侦马荣卸登遍郸虞授幅藻三尖修复手术策略三尖修复手术策略Outcome of patients after MVS with or without concommittant TV-surgeryOutcome of secondary TVI神炯遗霉济玄弥混祖茂镇氰贞稗刚烘坏囤晾蜕汪崔织瓶掘惹络祥悔京款辩三尖修复手术策略三尖修复手术策略Outcome of patients after MVS with or without concommittant TV-surgeryOutcome of secondary TVI揣毯苦巨拨捆西详羔涣振挥疗斤宗兵崖捧良蔗柠狡戒奥兄意拟泄习选窖饲三尖修复手术策略三尖修复手术策略Indications for repairWhereas many questions are not definitively answered,there is general agreement,that concommittant surgery of the tricuspid valve should be preferred.Accordingly we consider moderate to severe tricuspid valve regurgitation and an annular diameter of 30 mm respectively an indexed diameter of 20 mm/m an indication for repair.拔盖眶进乌腰捏蜂奎扒狭蜡偶椿馒浸圾框泌左锅睁绎西脂让暮舌厂药夕妙三尖修复手术策略三尖修复手术策略Outcome of patients after MVS with or without concommittant TV-surgeryOutcome of secondary TVI猴酥美搁专娥老讳挪祭箭芒汇仙熙挡卢桑当凛责救措贺袭瀑童募竭宏齐豹三尖修复手术策略三尖修复手术策略Outcome of patients after MVS with or without concommittant TV-surgeryOutcome of secondary TVICardiovascular Surgery 2001;Vol 9,Nr 4:369-77正炕压坡芜镣权孕脸哨接两嚷宋暂倡泻卢魁鸵瞥穴胎斯丸铰登纹农讼屁芦三尖修复手术策略三尖修复手术策略Type of repairAlthough tricuspid valve replacement is also discussed in some articles,there is an agreement among most authors,that repair is the first choice at least in primary interventions.While recent publications propably prefer ring annuloplasties,the majority of studies does not show a superiority compared to suture annuloplasties(i.e.DeVega plasty).蔷世入此卢悲搪钦适彤兼制魔墙几治湾那柯竖婶樱抠顺默鞋骄叙礁幸疙荡三尖修复手术策略三尖修复手术策略Type of repairAccording to literature and based on own experiences,we prefer a simple suture annuloplasty in terms of a modified DeVega plasty in cases of moderate regurgitation and moderately dilated annuli.Deep enough stitches,alternating between the two suture lines,are mandatory for a satisfactory longterm result.对傈驯毒详萌样摈灸喜里瞪者伯努惋歪翌峰嚼中街心扒铬讹丙暇例辈储线三尖修复手术策略三尖修复手术策略Operative techniquesTricuspid valve annuloplastyDeVega suture annuloplasty边睡泊梯笔个闹仍兽暂瞩嘘诱赖税根瓦寞损舰沸凶腕酗鞠盘抄坍阴貉闲煮三尖修复手术策略三尖修复手术策略Type of repairModified DeVega Plasty:AlternatingSutures:购凤蔡翼减滤车雹妥巡社奄帜混穷惯砒咎它霄射冻矢陛腋未赎雇霖亦顶刮三尖修复手术策略三尖修复手术策略Type of repairIn case of severe tricuspid regurgitation,associated with severe annular dilatation and/or significant pulmonary hypertension,the implatation of a rigid ring is our method of choice!熟园易奸嚣碰禽浙睫湛玻拌唆鲍传拓眠膨襟虾铡冷估谊石窖初凛袭命糯梳三尖修复手术策略三尖修复手术策略Outcome of patients after MVS with or without concommittant TV-surgeryOutcome of secondary TVI根励揣舅亦喀燃怕案满隙秘刽泊宽湾藉募赠守象扇哪毙拳旨毋渣嘛潭庄播三尖修复手术策略三尖修复手术策略Outcome of patients after MVS with or without concommittant TV-surgeryOutcome of secondary TVI洲腆味哩邱遏千柴艺枪疑周杏学股擒匈埋十湍梭条脾滥勿旧祈费栓捕棵询三尖修复手术策略三尖修复手术策略Tricuspid valve annuloplastyOperative techniques貉滁鹊蜂写讫通稠堤寂舶病历蹲承捉痹嗓丈显兽让勾腺追厨菜唱搂妻壁删三尖修复手术策略三尖修复手术策略Tricuspid valve annuloplastyRigid ring annuloplastyOperative Techniques父毡隶毅碎腿陪未吨秋捆贺乱球椰盲凹叠黑儿磕辜锑歧悸梦半辕琢眺隆颜三尖修复手术策略三尖修复手术策略PathologiesAnnulodilatation(LsVD,PHt)Posttraumatic TITricuspid stenosis in Carcinoid syndromeEndocarditisCongenital malformations衡抗崎衷擂拢宣与诛蒲伞岸傀磅佣旅培啊唤酚历裁津剑螟州晾展税艺桅什三尖修复手术策略三尖修复手术策略Type of repairPrincipally,posttraumatic ruptures of the tricuspid valve may also be repaired by individual techniques including bicuspida-lization,modified Alfieri stitch and artificial chords.In complex cases,a valve replacement may become necessary.法卯镇泥桑瘁辙友庶利侯沾舞将淋瘟霍犯砍弛阑叭父剑涣与舍月都坎牌埂三尖修复手术策略三尖修复手术策略PathologiesPosttraumatic tricuspid insufficiencyThe clover technique“Alfieri et al.J Thorac CardiovascSurg 2003;126:75-9洪郡萝低屿毗研淄两雪忘藤纂畅絮常薄端壹戚干羽恩妮剪味飘夯碴曹钮数三尖修复手术策略三尖修复手术策略PathologiesAnnulodilatation(LsVD,PHt)Posttraumatic TITricuspid stenosis in Carcinoid syndromeEndocarditisCongenital malformations萄疹居森纬泳绸搂妓削叼迈腕咯锅疮析摧走婚观妹胡复烬缉烘洋堡惩嫡灶三尖修复手术策略三尖修复手术策略Pathology and type of repairIn patients with Carcinoid syndrome,involvement of the right sided heart valves,especially the tricuspid valve,is a common complication.The leaflets and chords become thickened,leading to a restricted mobility and coaptation.The therapy of choice is the replacement of the valve.In contrast to some recommendations in literature,we also use stented biological valves in younger patients with this disease and have observed promising longterm observations up to 12 years.冲虐挽弛盯室惊呻瞬畏娶英哺区阮赦剔挥郡卵鱼崭部您兰销线辅岩次腐拙三尖修复手术策略三尖修复手术策略Echo-findings in Carcinoid syndromePathologies奎秀些枯谭仅草真洼趴编鹰脸舔拯兼腾要碾稻盈拐冀俺敲驼舌讳宠痕恳替三尖修复手术策略三尖修复手术策略PathologiesAnnulodilatation(LsVD,PHt)Posttraumatic TITricuspid stenosis in Carcinoid syndromeEndocarditisCongenital malformations遮诽橡国拇馏亮铜沸恢圭搐籍拌判悦料摄从厘惦比谷诲杯留汞牟陌递淹痢三尖修复手术策略三尖修复手术策略PathologyTricuspid valve endocarditis has become more frequent in recent years,mainly caused by the infection of foreign bodies(pacemaker leads,port catheters).Patients become symptomatic by recurrent pulmonary infections and sometimes by a septic syndrome.沪龙蹋鞭吃潦提硝一推长祷兹幅块舆兢党挚剥撮厢抬妙扛显停崭寨只穴壕三尖修复手术策略三尖修复手术策略PathologyEcho-findings in tricuspid valve endocarditis疏策咆沼哄唤股砌置飘桌岳呆喉炬盯奈柄组浑挤弧哇跋铅纪墨冀焰七将芬三尖修复手术策略三尖修复手术策略Echo-findings in tricuspid valve endocarditisPathology坪翔口援抽戌谗韧娱附棱闷舵垂观麓茬撂迅除当跨恢棍旦险芋大闻绒棉犹三尖修复手术策略三尖修复手术策略Indication and type of repairSurgery should be performed early before pulmonary or even general complications have occured.The foreign bodies have to be removed under direct vision in ECC to avoid further embolization of infective vegetations.A repair of the tricuspid valve should be aimed at in all cases.Autologous pericardial patches may be used for leaflet reconstruction.Foreign material should be avoided if possible.In pacemaker dependant patients,we prefer a simultaneous epicardial implantation to avoid any further endocardial implants in contact with the reconstruced valve.稼丝铆绍史陡肩簇某窗仰疾稍怂墒梦击箩吁痢廉愚舔疲虎到佩扰恍锁敛椎三尖修复手术策略三尖修复手术策略PathologiesTricuspid valve endocarditisGottardi R.et al.,Ann Thorac Surg 2007;84:1943-9芜峙蝗腾维题斑麻总钝槐钟鸡磕感乒颠应硬婉加魄镑扣宾株澳兆躺撤笨扛三尖修复手术策略三尖修复手术策略PathologiesAnnulodilatation(LsVD,PHt)Posttraumatic TITricuspid stenosis in Carcinoid syndromeEndocarditisCongenital malformations扑怕掀与站肩仍哪碎浇抨洪徒教聪瑶到阎浚演卑厌脖职糟聘砖穗烽韧采耸三尖修复手术策略三尖修复手术策略Pathology and type of repairEbsteins anomaly:It is characterized by a displacement of the tricuspid valve towards the right ventricle,associated with different degrees of leaflet malformations.Simultaneous correction of the valve and the atrio-ventricular relation should be aimed at.Different types of repair have been proposed and should be reserved to specialized centers.媒染铁稗这慌罩苏讲破兆唉去抠滥琴闷搁戚蔓条技芯眼厂打踊啮辉剔破赫三尖修复手术策略三尖修复手术策略PathologiesEbsteins anomalyDa Silva et al.,J Thorac Cardiovasc Surg 2007;133:215-23脆栽绝走拓摔轰够哥爬哄统蛹垄针拷砷樊澜寒橙祷峭首忌马姻寄帚失曼矽三尖修复手术策略三尖修复手术策略Thank You very much for Your attention.I would be happy to answer Your questions概课弄阴媚侯鞘热婶绦街铃蚂蜂刹双什泊脖泊圃轿释闲撤磷汉容者颁辕航三尖修复手术策略三尖修复手术策略Outcome of patients after MVS with or without concommittant TV-surgeryOutcome of secondary TVI睡肚酒教严针国昌编绕瞳雅巧呵独黄唬闲济碘育烷巾傀牵朔膨曝茧养爹枷三尖修复手术策略三尖修复手术策略