慢性心房颤动所致功能性三尖瓣反流：一项实时三维经食管超声心动图研究
Functional Tricuspid Regurgitation Caused by Chronic Atrial Fibrillation: A Real-Time 3-Dimensional Transesophageal Echocardiography Study.
作者信息
Utsunomiya Hiroto, Itabashi Yuji, Mihara Hirotsugu, Berdejo Javier, Kobayashi Sayuki, Siegel Robert J, Shiota Takahiro
机构信息
From Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (H.U., Y.I., H.M., J.B., S.K., R.J.S., T.S.); and University of California, Los Angeles (R.J.S., T.S.).
出版信息
Circ Cardiovasc Imaging. 2017 Jan;10(1). doi: 10.1161/CIRCIMAGING.116.004897.
BACKGROUND
Functional tricuspid regurgitation (TR) with a structurally normal tricuspid valve (TV) may occur secondary to chronic atrial fibrillation (AF). However, the clinical and echocardiographic differences according to functional TR subtypes are unclear. Therefore, characterization of functional TR because of chronic AF (AF-TR) remains undetermined.
METHODS AND RESULTS
To investigate the prevalence of AF-TR, 437 patients with moderate to severe TR underwent 3-dimensional (3D) transesophageal echocardiography. TR severity was determined by the averaged vena contracta width on apical and parasternal inflow views. The prevalence of AF-TR was 9.2%, whereas that of functional TR because of left-sided heart disease was 45.3%. Clinical features of AF-TR included advanced age, female sex, greater right atrial than left atrial enlargement and lower systolic pulmonary artery pressure compared with left-sided heart disease-TR with sinus rhythm (all P<0.05). In 3D TV assessment, patients with AF-TR had a larger TV annular area with weaker annular contraction (both P<0.001) but a smaller tethering angle (P<0.001) despite a similar leaflet coaptation status compared with patients with left-sided heart disease-TR with sinus rhythm. On multivariable analysis, only the TV annular area in midsystole (coefficient, 0.059; 95% confidence interval, 0.041-0.078 per 100 mm; P<0.001) was associated with TR severity in AF-TR. The annular area was more closely correlated with the right atrial volume than right ventricular end-systolic volume in AF-TR (P<0.001).
CONCLUSIONS
AF-TR is not rare and is associated with advanced age and right atrial enlargement. TV deformations and their association with right heart remodeling differ between AF-TR and left-sided heart disease-TR. Our results suggest that in patients with TR secondary to AF, TV annuloplasty should be effective because this entity has annular dilatation without leaflet deformation.
背景
三尖瓣结构正常的功能性三尖瓣反流（TR）可能继发于慢性心房颤动（AF）。然而，根据功能性TR亚型的临床和超声心动图差异尚不清楚。因此，慢性AF所致功能性TR（AF-TR）的特征仍未确定。
方法与结果
为研究AF-TR的患病率，对437例中重度TR患者进行了三维（3D）经食管超声心动图检查。TR严重程度通过心尖和胸骨旁流入道视图上的平均缩流颈宽度确定。AF-TR的患病率为9.2%，而左侧心脏病所致功能性TR的患病率为45.3%。与窦性心律的左侧心脏病-TR相比，AF-TR的临床特征包括高龄、女性、右心房大于左心房扩大以及收缩期肺动脉压较低（均P<0.05）。在3D三尖瓣评估中，与窦性心律的左侧心脏病-TR患者相比，AF-TR患者的三尖瓣环面积更大，环收缩更弱（均P<0.001），但尽管瓣叶对合状态相似，其束缚角更小（P<0.001）。多变量分析显示，仅收缩中期的三尖瓣环面积（系数，0.059；95%置信区间，每100 mm为0.041-0.078；P<0.001）与AF-TR中的TR严重程度相关。在AF-TR中，环面积与右心房容积的相关性比与右心室收缩末期容积的相关性更密切（P<0.001）。
结论
AF-TR并不罕见，且与高龄和右心房扩大有关。AF-TR和左侧心脏病-TR之间的三尖瓣变形及其与右心重塑的关系有所不同。我们的结果表明，在AF继发的TR患者中，三尖瓣环成形术应该有效，因为该类型存在环扩张但无瓣叶变形。
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