原发性二尖瓣反流早期手术后右心室运动收缩储备与结局。
Right ventricular exercise contractile reserve and outcomes after early surgery for primary mitral regurgitation.
机构信息
Service de Cardiologie et Maladies Vasculaires, CHU Rennes, Rennes, France.
Université Rennes-1, INSERM 1099, Rennes, France.
出版信息
Heart. 2018 May;104(10):855-860. doi: 10.1136/heartjnl-2017-312097. Epub 2017 Dec 5.
OBJECTIVE
To assess if the lack of development of right ventricular (RV) contractile reserve during exercise echocardiography (ex-echo) might be a predictor of postoperative major adverse cardiovascular events (MACEs) in patients with primary mitral regurgitation (pMR) undergoing early surgery.
METHODS
Comprehensive resting and ex-echo were performed in 142 asymptomatic patients (58±21 years, 68% men, New York Heart Association functional class ≤2) with isolated severe pMR and preserved left ventricular (LV) function (LV ejection >60%, LV end-systolic diameter <45 mm) undergoing mitral valve replacement (n=20) or repair. Postoperative MACEs were defined as occurrence of atrial fibrillation, stroke, cardiac-related hospitalisation or death. RV function was evaluated at rest in every patient during ex-echo by measuring their tricuspid annular plane systolic excursion (TAPSE) value.
RESULTS
After median follow-up of 30 months (IQR 16-60 months), MACEs occurred in 48 (34%) patients. Using Bayesian model averaging, among all the characteristics including the type of surgery, exercise TAPSE (ex-TAPSE) emerged as the most likely predictor of prognosis (HR 0.91, 95% CI 0.86 to 0.96). Other probable predictors were exercise fractional area change (HR 0.02, 95% CI 0.00 to 0.80), male gender (HR 0.40, 95% CI 0.21 to 0.75) and RV basal diameter (HR 1.06, 95% CI 0.98 to 1.14). In the receiver operating characteristic curve analysis, an ex-TAPSE value of <26 mm (sensitivity 73% (95% CI 61 to 84) and specificity of 86% (95% CI 77% to 93%)) defined RV dysfunction. Event-free survival at 5 years was significantly lower in the patient group that exhibited no development of RV contractile reserve during exercise: 43.9% (95% CI 31.3 to 61.4) vs 75.8% (95% CI 64.8 to 88.7).
CONCLUSION
Lack of development of exercise-induced RV contractile reserve is a prognostic predictor in patients with severe pMR undergoing early mitral valve surgery.
目的
评估运动超声心动图（ex-echo）中右心室（RV）收缩储备的缺乏是否可预测原发性二尖瓣反流（pMR）患者早期手术的术后主要不良心血管事件（MACE）。
方法
对 142 例无症状患者（58±21 岁，68%为男性，纽约心脏协会功能分级≤2）进行了全面的静息和 ex-echo 检查，这些患者患有孤立性严重的 pMR 和保留的左心室（LV）功能（LV 射血分数>60%，LV 收缩末期直径<45mm），并接受二尖瓣置换术（n=20）或修复术。术后 MACE 定义为心房颤动、中风、心脏相关住院或死亡的发生。在 ex-echo 期间，通过测量三尖瓣环平面收缩期位移（TAPSE）值，在每位患者静息时评估 RV 功能。
结果
中位随访 30 个月（IQR 16-60 个月）后，48 例（34%）患者发生 MACE。使用贝叶斯平均模型，在包括手术类型在内的所有特征中，运动 TAPSE（ex-TAPSE）成为最有可能的预后预测指标（HR 0.91，95%CI 0.86 至 0.96）。其他可能的预测指标包括运动时的分数面积变化（HR 0.02，95%CI 0.00 至 0.80）、男性（HR 0.40，95%CI 0.21 至 0.75）和 RV 基底直径（HR 1.06，95%CI 0.98 至 1.14）。在受试者工作特征曲线分析中，ex-TAPSE 值<26mm（敏感性 73%（95%CI 61 至 84）和特异性 86%（95%CI 77%至 93%））定义 RV 功能障碍。在运动时无 RV 收缩储备发展的患者组中，5 年无事件生存率显著降低：43.9%（95%CI 31.3 至 61.4）与 75.8%（95%CI 64.8 至 88.7）。
结论
在接受早期二尖瓣手术的严重 pMR 患者中，运动诱导的 RV 收缩储备缺乏是预后预测指标。
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