Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, A Vienna, Austria.
FH Campus Vienna and Complexity Research, Favoritenstraße 226, A Vienna, Austria.
Eur Heart J Cardiovasc Imaging. 2019 May 1;20(5):565-573. doi: 10.1093/ehjci/jey178.
Bivalvular functional regurgitation (BVFR) defined as concomitant mitral and tricuspid insufficiency has not been described or systematically assessed before. Therefore, this study sought to define incidence, impact and natural history of BVFR in heart failure with reduced ejection fraction (HFrEF) to provide the foundation for risk assessment and directions for potential treatment strategies.
We enrolled 1021 consecutive patients with HFrEF under guideline-directed medical therapy and performed comprehensive echocardiographic and neurohumoral profiling. All-cause mortality during a 5 years of follow-up served as the primary endpoint. Thirty percent of patients suffered from moderate or severe BVFR. Long-term mortality increased with the presence and severity of functional regurgitation (FR) with severe BVFR representing the highest risk-subset (P < 0.001). Severe BVFR patients were more symptomatic and displayed an adverse remodelling and neurohumoral activation pattern (all P < 0.05). Severe BVFR was associated with excess mortality independently of clinical [adjusted hazard ratio (HR) 1.52, 95% confidence interval (CI) 1.39-1.84; P < 0.001] and echocardiographic (adjusted HR 1.31, 95% CI 1.11-1.54; P = 0.001) confounders, guideline-directed medical therapy (adjusted HR 1.55, 95% CI 1.35-1.79; P < 0.001) and neurohumoral activation (adjusted HR 1.31, 95% CI 1.07-1.59; P = 0.009). Moderate BVFR (n = 99) comprised equal baseline characteristics and similar risk as isolated severe FR (HR 0.95, 95% CI 0.69-1.30; P = 0.73).
This long-term outcome study shows the multi-faceted nature of FR and defines BVFR as an important clinical entity associated with impaired functional class, adverse cardiac remodelling, and excess risk of mortality. Moderate BVFR conveys similar risk as isolated severe FR reflecting the deleterious impact of the global regurgitant load on the failing heart and the need of an integrated understanding for risk-assessment.
双瓣功能性反流（BVFR）定义为同时存在二尖瓣和三尖瓣关闭不全，以前尚未对其进行描述或系统评估。因此，本研究旨在确定射血分数降低的心力衰竭（HFrEF）中 BVFR 的发生率、影响和自然病史，为风险评估和潜在治疗策略提供基础。
我们纳入了 1021 例接受指南指导的药物治疗的 HFrEF 连续患者，并进行了全面的超声心动图和神经激素分析。5 年随访期间的全因死亡率为主要终点。30%的患者存在中重度 BVFR。随着功能性反流（FR）的存在和严重程度的增加，长期死亡率增加，重度 BVFR 代表最高风险亚组（P<0.001）。重度 BVFR 患者症状更明显，表现出不良的重塑和神经激素激活模式（均 P<0.05）。重度 BVFR 与死亡率增加独立相关，不受临床[调整后的危险比（HR）1.52，95%置信区间（CI）1.39-1.84；P<0.001]和超声心动图[调整后的 HR 1.31，95%CI 1.11-1.54；P=0.001]混杂因素、指南指导的药物治疗（调整后的 HR 1.55，95%CI 1.35-1.79；P<0.001）和神经激素激活（调整后的 HR 1.31，95%CI 1.07-1.59；P=0.009）的影响。中度 BVFR（n=99）具有相等的基线特征和与孤立性重度 FR 相同的风险（HR 0.95，95%CI 0.69-1.30；P=0.73）。
这项长期预后研究表明 FR 的多方面性质，并将 BVFR 定义为与功能分级受损、心脏不良重塑和死亡率增加相关的重要临床实体。中度 BVFR 与孤立性重度 FR 具有相似的风险，反映了整体反流负荷对衰竭心脏的有害影响，需要对风险评估有一个综合的理解。
