Mascherbauer Julia, Kammerlander Andreas A, Zotter-Tufaro Caroline, Aschauer Stefan, Duca Franz, Dalos Daniel, Winkler Susanne, Schneider Matthias, Bergler-Klein Jutta, Bonderman Diana
From the Department of Cardiology, Medical University of Vienna, Vienna General Hospital, Vienna, Austria.
PLoS One. 2017 Feb 15;12(2):e0171542. doi: 10.1371/journal.pone.0171542. eCollection 2017.
Diastolic dysfunction of the left ventricle is common but frequently under-diagnosed. Particularly in advanced stages affected patients may present with significant functional tricuspid regurgitation (TR) as the most prominent sign on echocardiography. The underlying left ventricular pathology may eventually be missed and symptoms of heart failure are attributed to TR, with respective therapeutic consequences. The aim of the present study was to determine prevalence and mechanisms underlying TR evolution in heart failure with preserved ejection fraction (HFpEF).
Consecutive HFpEF patients were enrolled in this prospective, observational study. Confirmatory diagnostic tests including echocardiography and invasive hemodynamic assessments were performed. Of the 175 patients registered between 2010 and 2014, 51% had significant (moderate or severe) TR without structural abnormalities of the tricuspid valve. Significant hemodynamic differences between patients with and without relevant TR were encountered. These included elevated pulmonary vascular resistance (p = 0.038), reduced pulmonary arterial compliance (PAC, p = 0.005), and elevated left ventricular filling pressures (p = 0.039) in the TR group. Multivariable binary logistic regression analysis revealed diastolic pulmonary artery pressure (p = 0.029) and PAC (p = 0.048) as independent determinants of TR. Patients were followed for 18.1±14.1 months, during which 32% had a cardiac event. While TR was associated with outcome in the univariable analysis, it failed to predict event-free survival in the multivariable model.
The presence of ´isolated´ functional TR should prompt the suspicion of HFpEF. Our data show that significant TR is a marker of advanced HFpEF but neither an isolated entity nor independently associated with event-free survival.
左心室舒张功能障碍很常见，但常常诊断不足。特别是在疾病晚期，受影响的患者可能出现明显的功能性三尖瓣反流（TR），这是超声心动图上最突出的表现。潜在的左心室病变最终可能被漏诊，心力衰竭症状被归因于TR，并导致相应的治疗后果。本研究的目的是确定射血分数保留的心力衰竭（HFpEF）患者中TR演变的患病率及其潜在机制。
本前瞻性观察性研究纳入了连续的HFpEF患者。进行了包括超声心动图和有创血流动力学评估在内的确诊诊断测试。在2010年至2014年登记的175例患者中，51%有显著（中度或重度）TR，且三尖瓣无结构异常。有和没有相关TR的患者之间存在显著的血流动力学差异。这些差异包括TR组的肺血管阻力升高（p = 0.038）、肺动脉顺应性（PAC）降低（p = 0.005）和左心室充盈压升高（p = 0.039）。多变量二元逻辑回归分析显示，舒张期肺动脉压（p = 0.029）和PAC（p = 0.048）是TR的独立决定因素。患者随访了18.1±14.1个月，在此期间32%发生了心脏事件。虽然在单变量分析中TR与预后相关，但在多变量模型中它未能预测无事件生存期。
“孤立性”功能性TR的存在应引起对HFpEF的怀疑。我们的数据表明，显著的TR是晚期HFpEF的一个标志，但既不是一个孤立的实体，也不与无事件生存期独立相关。
