Essayagh Benjamin, Antoine Clémence, Benfari Giovanni, Maalouf Joseph, Michelena Hector I, Crestanello Juan A, Thapa Prabin, Avierinos Jean-François, Enriquez-Sarano Maurice
Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
Department of Cardiology, APHM, La Timone Hospital, Bd Jean Moulin, 13005 Marseille, France.
Eur Heart J. 2020 May 21;41(20):1918-1929. doi: 10.1093/eurheartj/ehaa192.
To assess functional tricuspid regurgitation (FTR) determinants, consequences, and independent impact on outcome in degenerative mitral regurgitation (DMR).
All patients diagnosed with isolated DMR 2003-2011, with structurally normal tricuspid leaflets, prospective FTR grading and systolic pulmonary artery pressure (sPAP) estimation by Doppler echocardiography at diagnosis were identified and long-term outcome analysed. The 5083 DMR eligible patients [63 ± 16 years, 47% female, ejection fraction (EF) 63 ± 7%, and sPAP 35 ± 13 mmHg] presented with FTR graded trivial in 45%, mild in 37%, moderate in 15%, and severe in 3%. While pulmonary hypertension (PHTN-sPAP ≥ 50 mmHg) was the most powerful FTR severity determinant, other strong FTR determinants were older age, female sex, lower left ventricle EF, DMR, and particularly atrial fibrillation (AFib) (all P ≤ 0.002). Functional tricuspid regurgitation moderate/severe was independently linked to more severe clinical presentation, more oedema, lower stroke volume, and impaired renal function (P ≤ 0.01). Survival (95% confidence interval) throughout follow-up [70% (69-72%) at 10 years] was strongly associated with FTR severity [82% (80-84%) for trivial, 69% (66-71%) for mild, 51% (47-57%) for moderate, and 26% (19-35%) for severe, P < 0.0001]. Excess mortality persisted after comprehensive adjustment [adjusted hazard ratio 1.40 (1.18-1.67) for moderate FTR and 2.10 (1.63-2.70) for severe FTR, P ≤ 0.01]. Excess mortality persisted adjusting for sPAP/right ventricular function (P < 0.0001), by matching [adjusted hazard ratios 2.08 (1.50-2.89), P < 0.0001] and vs. expected survival [risk ratio 1.79 (1.48-2.16), P < 0.0001]. Within 5-year of diagnosis valve surgery was performed in 73% (70-75%) and 15% (13-17%) of severe and moderate DMR and in only 26% (19-34%) and 6% (4-8%) of severe and moderate FTR. Valvular surgery improved outcome without alleviating completely higher mortality associated with FTR (P < 0.0001).
In this large DMR cohort, FTR was frequent and causally, not only linked to PHTN but also to other factors, particularly AFib. Higher FTR severity is associated at diagnosis with more severe clinical presentation. Long term, FTR is independently of all confounders, associated with considerably worse mortality. Functional tricuspid regurgitation moderate and even severe is profoundly undertreated. Thus careful assessment, consideration for tricuspid surgery, and testing of new transcatheter therapy is warranted.
评估退行性二尖瓣反流（DMR）中功能性三尖瓣反流（FTR）的决定因素、后果及其对预后的独立影响。
确定所有在2003年至2011年期间诊断为孤立性DMR且三尖瓣叶结构正常的患者，在诊断时通过多普勒超声心动图对FTR进行前瞻性分级并估计收缩期肺动脉压（sPAP），并分析长期预后。5083例符合条件的DMR患者[年龄63±16岁，女性占47%，射血分数（EF）63±7%，sPAP 35±13 mmHg]，其中45%的患者FTR分级为轻度，37%为轻度，15%为中度，3%为重度。虽然肺动脉高压（PHTN - sPAP≥50 mmHg）是FTR严重程度的最有力决定因素，但其他重要的FTR决定因素包括年龄较大、女性、左心室EF较低、DMR，尤其是心房颤动（AFib）（所有P≤0.002）。中度/重度功能性三尖瓣反流与更严重的临床表现、更多水肿、更低的每搏输出量和肾功能受损独立相关（P≤0.01）。整个随访期间的生存率（95%置信区间）[10年时为70%（69 - 72%）]与FTR严重程度密切相关[轻度为82%（80 - 84%），中度为69%（66 - 71%），重度为51%（47 - 57%），极重度为26%（19 - 35%），P<0.0001]。在进行全面调整后，额外死亡率仍然存在[中度FTR的调整后风险比为1.40（1.18 - 1.67），重度FTR为2.10（1.63 - 2.70），P≤0.01]。在调整sPAP/右心室功能后额外死亡率仍然存在（P<0.0001），通过匹配[调整后风险比2.08（1.50 - 2.89），P<0.0001]以及与预期生存率比较[风险比1.79（1.48 - 2.16），P<0.0001]。在诊断后的5年内，73%（70 - 75%）的重度和中度DMR患者以及15%（13 - 17%）的重度和中度FTR患者接受了瓣膜手术。瓣膜手术改善了预后，但并未完全消除与FTR相关的较高死亡率（P<0.0001）。
在这个大型DMR队列中，FTR很常见，其病因不仅与PHTN有关，还与其他因素有关，尤其是AFib。在诊断时，较高的FTR严重程度与更严重的临床表现相关。长期来看，FTR独立于所有混杂因素，与显著更差的死亡率相关。中度甚至重度功能性三尖瓣反流的治疗严重不足。因此，有必要进行仔细评估、考虑三尖瓣手术以及测试新的经导管治疗方法。
