Department of Cardiology, Tel Aviv Medical Center, Tel Aviv, Israel.
Department of Cardiothoracic Surgery, Tel Aviv Medical Center, Tel Aviv, Israel.
J Am Soc Echocardiogr. 2018 Oct;31(10):1101-1108. doi: 10.1016/j.echo.2018.07.002. Epub 2018 Aug 11.
Severe aortic stenosis (AS) and severe tricuspid regurgitation (TR) may coexist. The aim of this study was to determine the change in right ventricular (RV) function and TR after surgical aortic valve replacement combined with tricuspid valve repair (SAVR+TVr), transcatheter aortic valve replacement (TAVR), or conservative management and compare outcomes dependent on RV functional parameters and treatment allocation.
A retrospective analysis was conducted in 147 consecutive patients with severe AS and TR of baseline and 6-month clinical and echocardiographic parameters, including quantitative estimation of RV size and function (end-diastolic and end-systolic areas, tricuspid annular plane systolic excursion, fractional area change, and Tei index).
SAVR+TVr and TAVR were associated with superior reduction in TR jet area after 6 months (P = .01 for time × group interaction) compared with conservative therapy. However, RV function (tricuspid annular plane systolic excursion and stroke volume) improved after TAVR but not after SAVR+TVr (P = .007 and P = .02 for time × group interaction, respectively). Conservative therapy for combined AS and TR was associated with >80% mortality in <4 years. TAVR and SAVR+TVr were associated with improved survival compared with conservative therapy (P < .0001), without significant difference between each other. Quantitative RV functional parameters were associated with poor outcomes, including tricuspid annular plane systolic excursion (P = .002), Tei index (P = .02), and RV fractional area change (P = .03).
In this nonrandomized, retrospective, observational study, SAVR+TVr and TAVR were associated with reductions in TR in patients with severe AS combined with severe TR. Importantly, RV function improved after TAVR but not after SAVR+TVr. Patients with severe AS and TR have a very poor prognosis with conservative therapy. When contemplating invasive procedures, assessment should include quantitative functional RV parameters.
严重主动脉瓣狭窄（AS）和严重三尖瓣反流（TR）可能同时存在。本研究的目的是确定手术主动脉瓣置换联合三尖瓣修复（SAVR+TVr）、经导管主动脉瓣置换（TAVR）或保守治疗后右心室（RV）功能和 TR 的变化，并根据 RV 功能参数和治疗分配比较结果。
对 147 例基线时伴有严重 AS 和 TR 的连续患者进行回顾性分析，记录其 6 个月的临床和超声心动图参数，包括 RV 大小和功能的定量评估（舒张末期和收缩末期面积、三尖瓣环平面收缩期位移、分数面积变化和 Tei 指数）。
与保守治疗相比，SAVR+TVr 和 TAVR 治疗 6 个月后 TR 射流面积明显降低（P 值为时间×组间交互作用=0.01）。然而，TAVR 治疗后 RV 功能（三尖瓣环平面收缩期位移和每搏量）改善，但 SAVR+TVr 治疗后无明显改善（P 值分别为时间×组间交互作用=0.007 和 0.02）。对于合并 AS 和 TR 的患者，保守治疗<4 年内死亡率>80%。与保守治疗相比，TAVR 和 SAVR+TVr 与改善的生存率相关（P 值均<.0001），但两者之间无显著差异。定量 RV 功能参数与不良预后相关，包括三尖瓣环平面收缩期位移（P=0.002）、Tei 指数（P=0.02）和 RV 分数面积变化（P=0.03）。
在这项非随机、回顾性、观察性研究中，SAVR+TVr 和 TAVR 可降低严重 AS 合并严重 TR 患者的 TR 程度。重要的是，TAVR 治疗后 RV 功能改善，但 SAVR+TVr 治疗后无明显改善。采用保守治疗的严重 AS 和 TR 患者预后极差。当考虑介入治疗时，应包括 RV 功能的定量参数评估。
