缺血性二尖瓣反流手术后三尖瓣反流的进展。
Progression of Tricuspid Regurgitation After Surgery for Ischemic Mitral Regurgitation.
机构信息
Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA.
Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
出版信息
J Am Coll Cardiol. 2021 Feb 16;77(6):713-724. doi: 10.1016/j.jacc.2020.11.066.
BACKGROUND
Whether to repair nonsevere tricuspid regurgitation (TR) during surgery for ischemic mitral valve regurgitation (IMR) remains uncertain.
OBJECTIVES
The goal of this study was to investigate the incidence, predictors, and clinical significance of TR progression and presence of ≥moderate TR after IMR surgery.
METHODS
Patients (n = 492) with untreated nonsevere TR within 2 prospectively randomized IMR trials were included. Key outcomes were TR progression (either progression by ≥2 grades, surgery for TR, or severe TR at 2 years) and presence of ≥moderate TR at 2 years.
RESULTS
Patients' mean age was 66 ± 10 years (67% male), and TR distribution was 60% ≤trace, 31% mild, and 9% moderate. Among 2-year survivors, TR progression occurred in 20 (6%) of 325 patients. Baseline tricuspid annular diameter (TAD) was not predictive of TR progression. At 2 years, 37 (11%) of 323 patients had ≥moderate TR. Baseline TR grade, indexed TAD, and surgical ablation for atrial fibrillation were independent predictors of ≥moderate TR. However, TAD alone had poor discrimination (area under the curve, ≤0.65). Presence of ≥moderate TR at 2 years was higher in patients with MR recurrence (20% vs. 9%; p = 0.02) and a permanent pacemaker/defibrillator (19% vs. 9%; p = 0.01). Clinical event rates (composite of ≥1 New York Heart Association functional class increase, heart failure hospitalization, mitral valve surgery, and stroke) were higher in patients with TR progression (55% vs. 23%; p = 0.003) and ≥moderate TR at 2 years (38% vs. 22%; p = 0.04).
CONCLUSIONS
After IMR surgery, progression of unrepaired nonsevere TR is uncommon. Baseline TAD is not predictive of TR progression and is poorly discriminative of ≥moderate TR at 2 years. TR progression and presence of ≥moderate TR are associated with clinical events. (Comparing the Effectiveness of a Mitral Valve Repair Procedure in Combination With Coronary Artery Bypass Grafting [CABG] Versus CABG Alone in People With Moderate Ischemic Mitral Regurgitation, NCT00806988; Comparing the Effectiveness of Repairing Versus Replacing the Heart's Mitral Valve in People With Severe Chronic Ischemic Mitral Regurgitation, NCT00807040).
背景
在缺血性二尖瓣反流（IMR）手术中是否修复非重度三尖瓣反流（TR）仍不确定。
目的
本研究旨在探讨 IMR 手术后 TR 进展和存在≥中度 TR 的发生率、预测因素和临床意义。
方法
纳入了 2 项前瞻性随机 IMR 试验中未经治疗的非重度 TR 患者（n=492）。主要结局为 TR 进展（≥2 级进展、TR 手术或 2 年时重度 TR）和 2 年时存在≥中度 TR。
结果
患者的平均年龄为 66±10 岁（67%为男性），TR 分布为 60%为微量，31%为轻度，9%为中度。在 2 年幸存者中，20（6%）例 325 例患者发生 TR 进展。基线三尖瓣环直径（TAD）不能预测 TR 进展。2 年后，323 例患者中有 37（11%）例存在≥中度 TR。基线 TR 分级、TAD 指数和心房颤动的手术消融是≥中度 TR 的独立预测因素。然而，TAD 本身的鉴别能力较差（曲线下面积，≤0.65）。在有 MR 复发的患者中（20% vs. 9%；p=0.02）和有永久性起搏器/除颤器的患者中（19% vs. 9%；p=0.01），2 年时存在≥中度 TR 的比例更高。在有 TR 进展的患者中（55% vs. 23%；p=0.003）和 2 年时存在≥中度 TR 的患者中（38% vs. 22%；p=0.04），临床事件发生率（复合 1 例或以上纽约心脏协会功能分级增加、心力衰竭住院、二尖瓣手术和中风）更高。
结论
在 IMR 手术后，未修复的非重度 TR 进展并不常见。基线 TAD 不能预测 TR 进展，对 2 年时的 TR 进展和存在≥中度 TR 的鉴别能力较差。TR 进展和存在≥中度 TR 与临床事件相关。（比较在中度缺血性二尖瓣反流患者中，二尖瓣修复术联合冠状动脉旁路移植术（CABG）与 CABG 单独治疗的效果，NCT00806988；比较在严重慢性缺血性二尖瓣反流患者中，修复与置换心脏二尖瓣的效果，NCT00807040）。
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