Afilalo Jonathan, Grapsa Julia, Nihoyannopoulos Petros, Beaudoin Jonathan, Gibbs J Simon R, Channick Richard N, Langleben David, Rudski Lawrence G, Hua Lanqi, Handschumacher Mark D, Picard Michael H, Levine Robert A
From the Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Canada (J.A., D.L., L.G.R.); Cardiac Ultrasound Laboratory, Division of Cardiology (J.G., P.N.) and National Pulmonary Hypertension Service, Division of Cardiology (J.S.R.G.), Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Pulmonary Hypertension and Thromboendarterectomy Program, Division of Pulmonary and Critical Care Medicine (R.N.C.) and Cardiac Ultrasound Laboratory, Division of Cardiology (J.A., J.B., L.H., M.D.H., M.H.P., R.A.L.), Massachusetts General Hospital, Harvard University, Boston.
Circ Cardiovasc Imaging. 2015 May;8(5). doi: 10.1161/CIRCIMAGING.114.002714.
Tricuspid regurgitation (TR) is a risk factor for mortality in pulmonary hypertension (PH). TR severity varies among patients with comparable degrees of PH and right ventricular remodeling. The contribution of leaflet adaptation to the pathophysiology of TR has yet to be examined. We hypothesized that tricuspid leaflet area (TLA) is increased in PH, and that the adequacy of this increase relative to right ventricular remodeling determines TR severity.
A prospective cohort of 255 patients with PH from pre and postcapillary pathogeneses was assembled from 2 centers. Patients underwent a 3-dimensional echocardiogram focused on the tricuspid apparatus. TLA was measured with the Omni 4D software package. Compared with normal controls, patients with PH had a 2-fold increase in right ventricular volumes, 62% increase in annular area, and 49% increase in TLA. Those with severe TR demonstrated inadequate increase in TLA relative to the closure area, such that the ratio of TLA:closure area <1.78 was highly predictive of severe TR (odds ratio, 68.7; 95% confidence interval, 16.2-292.7). The median vena contracta width was 8.5 mm in the group with small TLA and large closure area as opposed to 4.8 mm in the group with large TLA and large closure area.
TLA plays a significant role in determining which patients with PH develop severe functional TR. The ratio of TLA:closure area, reflecting the balance between leaflet adaptation versus annular dilation and tethering forces, is an indicator of TR severity that may identify which patients stand to benefit from leaflet augmentation during tricuspid valve repair.
三尖瓣反流（TR）是肺动脉高压（PH）患者死亡的危险因素。在PH程度相当且右心室重构程度相似的患者中，TR的严重程度各不相同。瓣叶适应性对TR病理生理学的影响尚未得到研究。我们假设PH患者的三尖瓣瓣叶面积（TLA）会增加，并且相对于右心室重构，这种增加的充足程度决定了TR的严重程度。
从2个中心纳入了255例毛细血管前和毛细血管后病因导致的PH患者组成前瞻性队列。患者接受了聚焦于三尖瓣装置的三维超声心动图检查。使用Omni 4D软件包测量TLA。与正常对照组相比，PH患者的右心室容积增加了2倍，瓣环面积增加了62%，TLA增加了49%。重度TR患者的TLA相对于瓣叶闭合面积增加不足，使得TLA与闭合面积之比<1.78对重度TR具有高度预测性（优势比为68.7；95%置信区间为16.2 - 292.7）。TLA小且闭合面积大的组中，收缩期狭窄处宽度中位数为8.5 mm，而TLA大且闭合面积大的组中为4.8 mm。
TLA在决定哪些PH患者会发生重度功能性TR方面起重要作用。TLA与闭合面积之比反映了瓣叶适应性与瓣环扩张及腱索牵拉力量之间的平衡，是TR严重程度的一个指标，可用于识别哪些患者在三尖瓣修复过程中可能从瓣叶增大术中获益。
