Division of Pediatric Cardiology, Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada.
Department of Biomedical Engineering, University of Alberta, Edmonton, Alberta, Canada.
J Am Soc Echocardiogr. 2021 Nov;34(11):1199-1210. doi: 10.1016/j.echo.2021.06.007. Epub 2021 Jun 18.
Tricuspid valve regurgitation (TR) is a risk factor for morbidity and mortality in children with hypoplastic left heart syndrome (HLHS). Surgical tricuspid valve (TV) repair is common, but durable repair remains challenging. The aim of this study was to examine mechanisms of TR requiring surgery, features associated with unsuccessful repair, and TV changes after surgical repair.
Thirty-six patients with HLHS requiring TV repair (TVR) and 36 matched control subjects with HLHS were assessed using two-dimensional and three-dimensional echocardiography. Using three-dimensional echocardiography, TV coordinates from the annulus, leaflet, and ventricle were used to measure annular, leaflet, prolapse, and tethering values and anterior papillary muscle angle. TR grade and ventricular size, function, and shape were assessed using two-dimensional echocardiography.
Patients requiring TVR had greater total leaflet prolapse, larger TV annular and leaflet areas, and flatter annuli, with no difference in tethering, coaptation index, or anterior papillary muscle angle. In patients with HLHS, successful TVR at follow-up (58%) was associated with preoperative total leaflet prolapse (especially posterior). Unsuccessful repair was associated with preoperative tethering of the septal leaflet. TVR in patients with HLHS caused a reduction of total annular and leaflet size and reduced prolapse and tethering of the posterior leaflet but did not affect anterior leaflet prolapse or septal leaflet tethering.
Features associated with TVR include a flattened and dilated TV annulus with leaflet prolapse. The additional presence of a tethered septal leaflet before TVR is associated with significant postoperative TR. Current surgical techniques, predominantly posterior annuloplasty and commissuroplasty, adequately address annular size and posterior leaflet pathology, but not septal leaflet tethering. Individualized and innovative surgical techniques are vital to improve surgical repair success.
三尖瓣反流（TR）是左心发育不全综合征（HLHS）患儿发病率和死亡率的一个危险因素。三尖瓣（TV）修复手术较为常见，但持久修复仍然具有挑战性。本研究旨在研究需要手术的 TR 机制、与手术修复失败相关的特征以及 TV 修复后的变化。
对 36 例需要 TV 修复（TVR）的 HLHS 患者和 36 例匹配的 HLHS 对照患者进行二维和三维超声心动图评估。使用三维超声心动图，从瓣环、瓣叶和心室测量 TV 坐标，以测量瓣环、瓣叶、脱垂和牵拉力值以及前乳头肌角度。使用二维超声心动图评估 TR 分级以及心室大小、功能和形状。
需要 TVR 的患者总瓣叶脱垂更大，TV 瓣环和瓣叶面积更大，瓣环更平坦，而牵拉力、对合指数或前乳头肌角度无差异。在 HLHS 患者中，随访时 TVR 成功（58%）与术前总瓣叶脱垂（尤其是后叶）相关。手术修复失败与术前隔瓣牵拉力相关。HLHS 患者的 TVR 导致总瓣环和瓣叶尺寸减小，后叶脱垂和牵拉力减小，但不影响前叶脱垂或隔瓣牵拉力。
与 TVR 相关的特征包括 TV 瓣环扁平扩张伴瓣叶脱垂。TVR 前存在被牵拉住的隔瓣与术后严重的 TR 相关。目前的手术技术主要为后瓣环成形术和交界切开术，可充分解决瓣环大小和后瓣叶病变，但不能解决隔瓣牵拉力问题。个体化和创新性的手术技术对于提高手术修复成功率至关重要。
