Calafiore Antonio M, Foschi Massimiliano, Kheirallah Hatim, Alsaied Mojtaba Mohammed, Alfonso Juan J, Tancredi Fabrizio, Gaudino Mario, Di Mauro Michele
Department of Cardiac Surgery and Cardiology, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia.
Department of Heart Disease, SS Hospital, Chieti, Italy.
J Card Surg. 2019 Jun;34(6):404-411. doi: 10.1111/jocs.14042. Epub 2019 Apr 8.
We sought to identify subgroups of patients at a higher probability of tricuspid annuloplasty (TAP) failure early after surgery.
From May 2009 to December 2015, 688 patients undergoing TAP for functional tricuspid regurgitation (FTR) at a single institution were included in the study. In all patients, a complete transthoracic echocardiographic evaluation of right ventricle (RV) and tricuspid valve (TV) apparatus was collected.
Twenty-six patients (3.8%) died within the first 30 days of surgery. Residual TR after TAP was recorded in 85 (12.4%), moderate in 80 (11.7%) and severe in 5 (0.7%). Preoperative TV apparatus remodeling was associated with residual TR; in particular, the following cutoffs were identified: TV coaptation depth ≥6.5 mm, tenting area ≥0.85 cm , and tricuspid annulus ≥35 mm. The entire cohort was stratified in three subsets: patients having preoperative mild/moderate TR without preoperative TV apparatus and/or RV remodeling (n = 178); patients having mild/moderate TR with TV apparatus and/or RV remodeling (n = 317); patients with severe TR regardless of TV apparatus and/or RV remodeling (n = 193). Residual TR was 2.8%, 10.4%, and 24.3%, respectively (P < 0.001). At multivariable analysis, patients showing preoperative mild/moderate TR with TV apparatus and/or RV remodeling as well as patients with severe TR were at significantly higher risk for early failure. No difference was found regarding the type of TV repair performed.
Prophylactic TAP should be encouraged among surgeons even earlier than guidelines recommend, and decision-making for the treatment of low-grade FTR at the time of left-sided valve surgery should take into consideration not only annular size but also tethering severity and RV dilatation.
我们试图确定术后早期三尖瓣环成形术（TAP）失败概率较高的患者亚组。
2009年5月至2015年12月，本研究纳入了在单一机构接受TAP治疗功能性三尖瓣反流（FTR）的688例患者。对所有患者进行了完整的经胸超声心动图评估，以获取右心室（RV）和三尖瓣（TV）装置的情况。
26例患者（3.8%）在术后30天内死亡。TAP术后残留三尖瓣反流（TR）的有85例（12.4%），其中中度反流80例（11.7%），重度反流5例（0.7%）。术前TV装置重塑与残留TR相关；具体而言，确定了以下临界值：TV瓣叶对合深度≥6.5毫米，帐篷面积≥0.85平方厘米，三尖瓣环≥35毫米。整个队列被分为三个亚组：术前有轻度/中度TR但无术前TV装置和/或RV重塑的患者（n = 178）；有轻度/中度TR且伴有TV装置和/或RV重塑的患者（n = 317）；无论TV装置和/或RV重塑情况如何均有重度TR的患者（n = 193）。残留TR分别为2.8%、10.4%和24.3%（P < 0.001）。在多变量分析中，术前有轻度/中度TR且伴有TV装置和/或RV重塑的患者以及有重度TR的患者早期失败风险显著更高。在进行的TV修复类型方面未发现差异。
应鼓励外科医生甚至比指南建议的时间更早地进行预防性TAP，并且在进行左侧瓣膜手术时，对于低度FTR的治疗决策不仅应考虑瓣环大小，还应考虑瓣叶附着严重程度和RV扩张情况。
