Division of Cardiovascular Diseases and Internal Medicine, Tel Aviv Medical Center, Tel Aviv, Israel.
Division of Cardiovascular Diseases and Internal Medicine, Mayo College of Medicine, Mayo Clinic, Rochester, Minnesota.
JACC Cardiovasc Imaging. 2014 Dec;7(12):1185-94. doi: 10.1016/j.jcmg.2014.07.018. Epub 2014 Nov 5.
The aim of this study was to assess the outcome of isolated tricuspid regurgitation (TR) and the added value of quantitative evaluation of its severity.
TR is of uncertain clinical outcome due to confounding comorbidities. Isolated TR (without significant comorbidities, structural valve disease, significant pulmonary artery systolic pressure elevation by Doppler, or overt cardiac cause) is of unknown clinical outcome.
In patients with isolated TR assessed both qualitatively and quantitatively by a proximal isovelocity surface area method, a long-term outcome analysis was conducted. Patients with severe comorbid diseases were excluded.
The study involved 353 patients with isolated TR (age 70 years; 33% male; ejection fraction, 63%; all with right ventricular systolic pressure <50 mm Hg). Severe isolated TR was diagnosed in 76 patients (21.5%) qualitatively and 68 patients (19.3%) by quantitative criteria (effective regurgitant orifice [ERO] ≥40 mm(2)). The 10-year survival and cardiac event rates were 63 ± 5% and 29 ± 5%. Severe isolated TR independently predicted higher mortality (adjusted hazard ratio: 1.78 [95% confidence interval (CI): 1.10 to 2.82], p = 0.02 for qualitative definition and 2.67 [95% CI: 1.66 to 4.23] for an ERO ≥40 mm(2), p < 0.0001). The addition of grading by quantitative criteria in nested models eliminated the significance of the qualitative grading and improved the model prediction (p < 0.001 for survival and p = 0.02 for cardiac events). The 10-year survival rate was lower with an ERO ≥40 mm(2) versus <40 mm(2) (38 ± 7% vs. 70 ± 6%; p < 0.0001), independent of all characteristics, right ventricular size or function, comorbidity, or pulmonary pressure (p < 0.0001 for all), and lower than expected in the general population (p < 0.001). Freedom from cardiac events was lower with an ERO ≥40 mm(2) versus <40 mm(2) independently of all characteristics, right ventricular size or function, comorbidity, or pulmonary pressure (p < 0.0001 for all). Cardiac surgery for severe isolated TR was rarely performed (16 ± 5% 5 years after diagnosis).
Isolated TR can be severe and is associated with excess mortality and morbidity, warranting heightened attention to diagnosis and quantitation. Quantitative assessment of TR, particularly ERO measurement, is a powerful independent predictor of outcome, superior to standard qualitative assessment.
本研究旨在评估孤立性三尖瓣反流（TR）的结局，并评估其严重程度的定量评估的附加价值。
由于混杂的合并症，TR 的临床结局不确定。孤立性 TR（无明显合并症、结构性瓣膜疾病、多普勒测量的显著肺动脉收缩压升高或明显的心脏原因）的临床结局未知。
对通过近端等速表面积法进行定性和定量评估的孤立性 TR 患者进行长期预后分析。排除严重合并症患者。
研究共纳入 353 例孤立性 TR 患者（年龄 70 岁；33%为男性；射血分数 63%；所有患者的右心室收缩压均<50mmHg）。76 例患者（21.5%）定性诊断为严重孤立性 TR，68 例患者（19.3%）定量标准（有效反流口面积[ERO]≥40mm²）诊断为严重孤立性 TR。10 年生存率和心脏事件发生率分别为 63±5%和 29±5%。严重孤立性 TR 独立预测死亡率升高（校正后的危险比：1.78[95%置信区间（CI）：1.10 至 2.82]，p=0.02 用于定性定义，2.67[95%CI：1.66 至 4.23]用于 ERO≥40mm²，p<0.0001）。嵌套模型中定量标准分级的添加消除了定性分级的意义，并改善了模型预测（生存率的 p<0.001，心脏事件的 p=0.02）。ERO≥40mm²的 10 年生存率低于 ERO<40mm²（38±7% vs. 70±6%；p<0.0001），独立于所有特征、右心室大小或功能、合并症或肺动脉压（p<0.0001 所有），且低于一般人群的预期（p<0.001）。ERO≥40mm²的无心脏事件率低于 ERO<40mm²，独立于所有特征、右心室大小或功能、合并症或肺动脉压（p<0.0001 所有）。严重孤立性 TR 的心脏手术很少进行（诊断后 5 年为 16±5%）。
孤立性 TR 可能很严重，与死亡率和发病率增加相关，需要加强对诊断和定量的重视。TR 的定量评估，特别是 ERO 测量，是一种强大的独立预后预测指标，优于标准的定性评估。
