Kim Yong-Jin, Kwon Dong-A, Kim Hyung-Kwan, Park Jin-Shik, Hahn Seokyung, Kim Kyung-Hwan, Kim Ki-Bong, Sohn Dae-Won, Ahn Hyuk, Oh Byung-Hee, Park Young-Bae
Cardiovascular Center, Seoul National University Hospital, Seoul, Korea.
Circulation. 2009 Oct 27;120(17):1672-8. doi: 10.1161/CIRCULATIONAHA.109.849448. Epub 2009 Oct 12.
We sought to identify preoperative predictors of clinical outcomes after surgery in patients with severe tricuspid regurgitation.
We prospectively enrolled 61 consecutive patients (54 women, aged 57+/-9 years) with isolated severe tricuspid regurgitation undergoing corrective surgery. Twenty-one patients (34%) were in New York Heart Association functional class II, 35 (57%) in class III, and 5 (9%) in class IV. Fifty-seven patients (93%) had previous history of left-sided valve surgery. Preoperative echocardiography revealed pulmonary artery systolic pressure of 41.5+/-8.7 mm Hg, right ventricular (RV) end-diastolic area of 35.1+/-9.0 cm(2), and RV fractional area change of 41.3+/-8.4%. The median follow-up duration after surgery was 32 months (range, 12 to 70). Six of the 61 patients died before discharge; thus, operative mortality was 10%. Three of the 55 patients who survived surgery died during follow-up, and 6 patients required readmission because of cardiovascular problems. Thus, 46 patients (75%) remained event free at the end of follow-up. In the 54 patients who underwent 6-month clinical and echocardiographic follow-up, RV end-diastolic area decreased by 29%, with a corresponding 26% reduction in RV fractional area change. Thirty-three patients (61%) showed improved functional capacity after surgery. On multivariable Cox regression analysis, preoperative hemoglobin level (P<0.001) and RV end-systolic area (P<0.001) emerged as independent determinants of clinical outcomes. On receiver operating characteristic curve analysis, we found that RV end-systolic area <20 cm(2) predicted event-free survival with a sensitivity of 73% and a specificity of 67%, and a hemoglobin level >11.3 g/dL predicted event-free survival with a sensitivity of 73% and a specificity of 83%.
Timely correction of severe tricuspid regurgitation carries an acceptable risk and improves functional capacity. Surgery should be considered before the development of advanced RV systolic dysfunction and before the development of anemia.
我们试图确定重度三尖瓣反流患者术后临床结局的术前预测因素。
我们前瞻性纳入了61例连续的孤立性重度三尖瓣反流患者，他们均接受了矫正手术（54例女性，年龄57±9岁）。21例患者（34%）为纽约心脏协会心功能II级，35例（57%）为III级，5例（9%）为IV级。57例患者（93%）有左侧瓣膜手术史。术前超声心动图显示肺动脉收缩压为41.5±8.7 mmHg，右心室舒张末期面积为35.1±9.0 cm²，右心室面积变化分数为41.3±8.4%。术后中位随访时间为32个月（范围12至70个月）。61例患者中有6例在出院前死亡，因此手术死亡率为10%。55例术后存活的患者中有3例在随访期间死亡，6例因心血管问题需再次入院。因此，46例患者（75%）在随访结束时无事件发生。在接受6个月临床和超声心动图随访的54例患者中，右心室舒张末期面积减少了29%，右心室面积变化分数相应减少了26%。33例患者（61%）术后心功能改善。多变量Cox回归分析显示，术前血红蛋白水平（P<0.001）和右心室收缩末期面积（P<0.001）是临床结局的独立决定因素。在受试者工作特征曲线分析中，我们发现右心室收缩末期面积<20 cm²预测无事件生存的敏感性为73%，特异性为67%，血红蛋白水平>11.3 g/dL预测无事件生存的敏感性为73%，特异性为83%。
及时矫正重度三尖瓣反流具有可接受的风险并可改善心功能。应在右心室出现严重收缩功能障碍和贫血发生之前考虑手术。
