Ye Ying, Desai Ravi, Vargas Abello Lina M, Rajeswaran Jeevanantham, Klein Allan L, Blackstone Eugene H, Pettersson Gösta B
Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio.
Department of Vascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
J Thorac Cardiovasc Surg. 2014 Nov;148(5):2012-2020.e8. doi: 10.1016/j.jtcvs.2014.02.082. Epub 2014 Mar 1.
The study objective was to investigate whether, in patients undergoing surgery for degenerative mitral valve disease, associated right ventricular remodeling and dysfunction are stronger determinants of preoperative organ dysfunction and prognosis than functional tricuspid regurgitation.
From January 2001 to January 2011, 4197 patients underwent primary mitral valve surgery for degenerative valve disease at Cleveland Clinic. Using a quasi-experimental enriched study design, 781 patients were randomly selected within each grade of functional tricuspid regurgitation. Renal function was assessed by glomerular filtration rate and blood urea nitrogen, and hepatic function was assessed by Model for End-stage Liver Disease (MELD) score. Preoperative and postoperative right ventricular morphology and function were measured de novo on stored echocardiographic images. To assess survival, 3471 patient-years of follow-up data were available for analysis.
Several preoperative right ventricular variables, but not functional tricuspid regurgitation grade (P>.05), were associated with preoperative renal and hepatic dysfunction, but neither was associated with early mortality (<6 months after surgery). However, worse preoperative right ventricular myocardial performance index (P=.001), but not functional tricuspid regurgitation grade (P>.2), was among the risk factors for later mortality. Postoperative unadjusted right ventricular function, but not functional tricuspid regurgitation grade (P≥.2), was associated with both early (P=.04) and later (P=.01) mortality, but in multivariable analysis appeared to be a surrogate for worse preoperative condition.
Together with patient comorbidities and operative factors, right ventricular morphology and function are associated more strongly with preoperative organ dysfunction and prognosis than is functional tricuspid regurgitation severity in patients undergoing surgery for degenerative mitral valve disease. Our previous study showed that tricuspid valve repair remains the most effective treatment to improve right ventricular function.
本研究旨在探讨在接受退行性二尖瓣疾病手术的患者中，相关的右心室重塑和功能障碍是否比功能性三尖瓣反流更能决定术前器官功能障碍和预后。
2001年1月至2011年1月，4197例患者在克利夫兰诊所接受了原发性二尖瓣手术治疗退行性瓣膜疾病。采用准实验性富集研究设计，在每个功能性三尖瓣反流分级中随机选择781例患者。通过肾小球滤过率和血尿素氮评估肾功能，通过终末期肝病模型（MELD）评分评估肝功能。术前和术后右心室形态和功能在储存的超声心动图图像上重新测量。为评估生存率，有3471患者年的随访数据可供分析。
几个术前右心室变量与术前肾和肝功能障碍相关，但功能性三尖瓣反流分级无关（P>0.05），两者均与早期死亡率（术后<6个月）无关。然而，术前右心室心肌性能指数较差（P=0.001）是后期死亡的危险因素之一，而功能性三尖瓣反流分级无关（P>0.2）。术后未调整的右心室功能与早期（P=0.04）和后期（P=0.01）死亡率均相关，但功能性三尖瓣反流分级无关（P≥0.2），但在多变量分析中似乎是术前病情较差的替代指标。
在接受退行性二尖瓣疾病手术的患者中，与患者合并症和手术因素一起，右心室形态和功能比功能性三尖瓣反流严重程度与术前器官功能障碍和预后的相关性更强。我们之前的研究表明，三尖瓣修复仍然是改善右心室功能最有效的治疗方法。
