Goldstone Andrew B, Howard Jessica L, Cohen Jeffrey E, MacArthur John W, Atluri Pavan, Kirkpatrick James N, Woo Y Joseph
Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa.
Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif.
J Thorac Cardiovasc Surg. 2014 Dec;148(6):2802-9. doi: 10.1016/j.jtcvs.2014.08.001. Epub 2014 Aug 6.
The management of coexistent tricuspid regurgitation in patients with mitral regurgitation remains controversial. We sought to define the incidence and natural history of coexistent tricuspid regurgitation in patients undergoing isolated mitral surgery for degenerative mitral regurgitation, as well as the effect of late secondary tricuspid regurgitation on cardiovascular symptom burden and survival.
To minimize confounding, analysis was limited to 495 consecutive patients who underwent isolated mitral surgery for degenerative mitral valve disease between 2002 and 2011. Patients with coexistent severe tricuspid regurgitation were excluded because such patients typically undergo concomitant tricuspid intervention.
Grade 1 to 3 coexistent tricuspid regurgitation was present in 215 patients (43%) preoperatively. Actuarial freedom from grade 3 to 4 tricuspid regurgitation 1, 5, and 9 years after surgery was 100% ± 0%, 90% ± 2%, and 64% ± 7%, respectively. Older age (P < .001) and grade of preoperative tricuspid regurgitation (P = .006) independently predicted postoperative progression of tricuspid regurgitation on multivariable analysis. However, when limited to patients with mild or absent tricuspid regurgitation, indexed tricuspid annular diameter was the only significant risk factor for late tricuspid regurgitation (P = .04). New York Heart Association functional class and long-term survival did not worsen with development of late secondary tricuspid regurgitation (P = .4 and P = .6, respectively). However, right ventricular dysfunction was significantly more common in patients with more severe late tricuspid regurgitation (P = .007).
Despite durable correction of degenerative mitral regurgitation, less than severe tricuspid regurgitation is likely to progress after surgery if uncorrected. Given the low incremental risk of tricuspid annuloplasty, a more aggressive strategy of concomitant tricuspid repair may be warranted.
二尖瓣反流患者并存三尖瓣反流的管理仍存在争议。我们试图确定因退行性二尖瓣反流接受单纯二尖瓣手术患者并存三尖瓣反流的发生率和自然病史，以及晚期继发性三尖瓣反流对心血管症状负担和生存的影响。
为尽量减少混杂因素，分析仅限于2002年至2011年间因退行性二尖瓣疾病接受单纯二尖瓣手术的495例连续患者。并存严重三尖瓣反流的患者被排除，因为这类患者通常会接受三尖瓣同期干预。
215例患者（43%）术前存在1至3级并存三尖瓣反流。术后1年、5年和9年无3至4级三尖瓣反流的精算生存率分别为100%±0%、90%±2%和64%±7%。多变量分析显示，年龄较大（P<.001）和术前三尖瓣反流分级（P=.006）独立预测术后三尖瓣反流进展。然而，当仅限于轻度或无三尖瓣反流的患者时，三尖瓣环指数直径是晚期三尖瓣反流的唯一显著危险因素（P=.04）。纽约心脏协会功能分级和长期生存率并未因晚期继发性三尖瓣反流的发生而恶化（分别为P=.4和P=.6）。然而，更严重的晚期三尖瓣反流患者右心室功能障碍明显更常见（P=.007）。
尽管退行性二尖瓣反流得到了持久纠正，但如果不进行纠正，轻度以下的三尖瓣反流术后仍可能进展。鉴于三尖瓣成形术的增量风险较低，可能有必要采取更积极的三尖瓣同期修复策略。
