Mahía Patricia, Aguilar Río, De Agustín José Alberto, Marcos-Alberca Pedro, Islas Fabián, Tirado Gabriela, Nogales María Teresa, Gómez de Diego José Juan, Luaces María, Rodrigo José Luis, Cobos Miguel Ángel, Macaya Carlos, Pérez de Isla Leopoldo
Instituto Cardiovascular, Hospital Universitario Clínico San Carlos, Madrid, Spain.
Departamento de Cardiología, Hospital Universitario de La Princesa, Madrid, Spain.
Rev Esp Cardiol (Engl Ed). 2019 Sep;72(9):732-739. doi: 10.1016/j.rec.2018.06.009. Epub 2018 Jul 21.
Late functional tricuspid regurgitation after rheumatic left-sided valve surgery is an important predictor of poor prognosis. This study investigated the usefulness and accuracy of 3-dimensional transthoracic echocardiography tricuspid area compared with conventional 2-dimensional diameter (2DD) for assessing significant tricuspid annulus dilatation, providing cutoff values that could be used in clinical practice to improve patient selection for surgery.
We prospectively included 109 patients with rheumatic heart disease in the absence of previous valve replacement. Tricuspid regurgitation was divided into 3 groups: mild, moderate, and severe. Optimal 3-dimensional area (3DA) and 2DD cutoff points for identification of significant tricuspid annulus dilatation were obtained and compared with current guideline thresholds. Predictive factors for 3DA dilatation were also assessed.
Optimal cutoff points for both absolute and adjusted to body surface area (BSA) tricuspid annulus dilatation were identified (3DA: 10.4 cm, 6.5 cm/m; 2DD: 35 mm, 21 mm/m); 3DA/BSA had the best diagnostic performance (AUC=0.83). Three-dimensional transthoracic echocardiography tricuspid area helped to reclassify surgical indication in 14% of patients with mild tricuspid regurgitation (95%CI, 1%-15%; P=.03) and 37% with moderate tricuspid regurgitation (95%CI, 22%-37%; P<.0001), whereas 3DA/BSA changed surgery criteria in cases of mild tricuspid regurgitation (17%; 95%CI, 3%-17%; P=.01) compared with 2DD/BSA. On multivariable analysis, right and left atrial volumes and basal right ventricle diameter were independently correlated with 3DA.
The current 40 mm threshold underestimates tricuspid annulus dilatation. Although 21 mm/m seems to be a reasonable criterion, the combination with 3DA assessment improves patient selection for surgery.
风湿性左侧瓣膜手术后晚期功能性三尖瓣反流是预后不良的重要预测指标。本研究比较了三维经胸超声心动图测量的三尖瓣面积与传统二维直径（2DD）在评估显著三尖瓣环扩张方面的有效性和准确性，提供可用于临床实践以改善手术患者选择的临界值。
我们前瞻性纳入了109例既往未行瓣膜置换的风湿性心脏病患者。三尖瓣反流分为3组：轻度、中度和重度。获得了用于识别显著三尖瓣环扩张的最佳三维面积（3DA）和2DD临界值，并与当前指南阈值进行比较。还评估了3DA扩张的预测因素。
确定了绝对和根据体表面积（BSA）调整后的三尖瓣环扩张的最佳临界值（3DA：10.4 cm，6.5 cm/m；2DD：35 mm，21 mm/m）；3DA/BSA具有最佳诊断性能（AUC = 0.83）。三维经胸超声心动图三尖瓣面积有助于对14%轻度三尖瓣反流患者（95%CI，1%-15%；P = 0.03）和37%中度三尖瓣反流患者（95%CI，22%-37%；P < 0.0001）的手术指征进行重新分类，而与2DD/BSA相比，3DA/BSA改变了轻度三尖瓣反流病例的手术标准（17%；95%CI，3%-17%；P = 0.01）。多变量分析显示，右心房和左心房容积以及右心室基底直径与3DA独立相关。
目前40 mm的阈值低估了三尖瓣环扩张。虽然21 mm/m似乎是一个合理的标准，但结合3DA评估可改善手术患者的选择。
