肺动脉内膜剥脱术后右心重构和三尖瓣反流的特征及预后意义。
Characteristics and prognostic significance of right heart remodeling and tricuspid regurgitation after pulmonary endarterectomy.
机构信息
Department of Surgery, Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, NY.
Department of Surgery, Center for Innovation and Outcomes Research, Columbia University Medical Center, New York, NY.
出版信息
J Thorac Cardiovasc Surg. 2024 Feb;167(2):658-667.e7. doi: 10.1016/j.jtcvs.2022.04.002. Epub 2022 Apr 8.
OBJECTIVE
Right heart remodeling and tricuspid regurgitation (TR) are common in patients with chronic thromboembolic pulmonary hypertension. This study aimed to investigate the significance of right heart remodeling and TR after pulmonary endarterectomy (PEA) in patients with chronic thromboembolic pulmonary hypertension.
METHODS
Patients who underwent PEA with preoperative and postoperative transthoracic echocardiograms at our center between June 2010 and July 2019 were retrospectively reviewed. The composite end point was defined as death or hospitalization due to worsening heart failure, bleeding, or recurrent pulmonary embolism.
RESULTS
In total, 158 patients were included for analysis. Right ventricular basal (48 [45-52] vs 43 [39-47] mm, P < .001), midcavitary (46 [42-50] vs 38 [34-42] mm, P < .001), and longitudinal dimensions (87 [83-93] vs 80 [75-84] mm, P < .001), along with the right atrial volume index (37 [25-51] vs 24 [18-34] mL/m, P < .001), significantly decreased, whereas left ventricular and atrial sizes and left ventricular ejection fraction increased after PEA. Overall, 78 patients (49%) showed significant TR on preoperative transthoracic echocardiograms, and 33 (21%) had significant residual TR after PEA. Fourteen patients died, and 24 patients met the composite end point. Residual TR after PEA was independently associated with mortality (P = .005) and the composite end point (P = .003). Patients with residual TR had significantly worse survival (log-rank P < .001) and greater event rates (log-rank P = .003) than those without residual TR.
CONCLUSIONS
Significant improvements in right heart remodeling were seen following PEA. However, residual TR was a poor prognostic marker.
目的
右心重构和三尖瓣反流（TR）在慢性血栓栓塞性肺动脉高压患者中较为常见。本研究旨在探讨慢性血栓栓塞性肺动脉高压患者行肺动脉内膜剥脱术（PEA）后右心重构和 TR 的意义。
方法
回顾性分析 2010 年 6 月至 2019 年 7 月在我院行 PEA 术且术前及术后均行经胸超声心动图检查的患者。复合终点定义为死亡或因心力衰竭恶化、出血或复发性肺栓塞住院。
结果
共纳入 158 例患者进行分析。右心室基底段（48[45-52]mm 比 43[39-47]mm，P<0.001）、中段（46[42-50]mm 比 38[34-42]mm，P<0.001）和长轴（87[83-93]mm 比 80[75-84]mm，P<0.001）以及右心房容积指数（37[25-51]mL/m 比 24[18-34]mL/m，P<0.001）均显著降低，而左心室和心房大小及左心室射血分数增加。总体而言，术前经胸超声心动图检查显示 78 例（49%）患者存在明显的 TR，33 例（21%）患者行 PEA 术后仍存在明显的 TR。14 例患者死亡，24 例患者符合复合终点。PEA 术后存在残余 TR 与死亡率（P=0.005）和复合终点（P=0.003）独立相关。存在残余 TR 的患者生存率显著降低（log-rank P<0.001），事件发生率更高（log-rank P=0.003）。
结论
PEA 术后右心重构明显改善，但残余 TR 是一个不良预后标志物。
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