Dreyfus Gilles D, Essayagh Benjamin, Benfari Giovanni, Dulguerov Filip, Haley Shelley Rahman, Dommerc Carine, Albert Adelin, Enriquez-Sarano Maurice
Department of Cardiac Surgery, Institut Mutualiste Montsouris, Paris, France.
Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom.
JTCVS Open. 2021 Jul 20;7:125-138. doi: 10.1016/j.xjon.2021.07.010. eCollection 2021 Sep.
Despite coherent guidelines, management of functional tricuspid regurgitation (FTR) consequences on outcome in the context of degenerative mitral regurgitation (DMR) remains controversial due to lacking series of large magnitude with rigorous application of tricuspid guidelines and strict long-term echocardiographic follow-up. Thus, we aimed at gathering such a cohort to examine outcomes of patients undergoing DMR surgery following tricuspid surgery guidelines.
All consecutive patients with isolated DMR 2005-2015 operated on with baseline FTR assessment and tricuspid annulus diameter measurement were identified. Operative complications, postoperative tricuspid regurgitation incidence, and survival were assessed overall and stratified by guideline-based tricuspid annuloplasty (TA) indication (severe FTR or tricuspid annulus diameter ≥40 mm).
Among 441 patients with DMR undergoing mitral repair (66 ± 13 years, 30% female, ejection fraction 66 ± 10%, systolic pulmonary artery pressures 39 ± 12 mm Hg) followed 6 [3-9] years, patients with TA (n = 234, 53%) had generally similar presentation versus without TA (n = 207, 47%; all ≥ .2) except for more atrial fibrillation and larger left ventricle (both ≥ .0003). Patients with TA showed longer bypass time, more maze procedures (all ≤ .001), but hospital stay, renal-failure, pacemaker implantation, and operative mortality (overall 0.9%) were comparable (all ≥ .2). Postoperative incidence of moderate/severe FTR (0% at 1 year) became over time greater among patients without TA (5-year 8% [4%-13%] vs 3% [1%-11%] and 10-year 10% [6%-16%] vs 4% [1%-16%], = .01). Survival (95% confidence interval) throughout follow-up was 85% (77%-89%) at 10 years, with hazard ratio 0.57 (0.29-1.10), = .09. for patients with TA versus without.
In this large surgical DMR cohort, guideline-based FTR management was safe and effective. While long-term mortality did not reach significance, postoperative incidence of moderate/severe FTR, overall low, was nevertheless greater in patients who did not appear to require TA at surgery and linked to tricuspid annular dimension. Thus, future multicenter prospective cohorts with long-term follow-up are warranted to re-examine thresholds for TA performance and impact on survival.
尽管有一致的指南，但由于缺乏大量严格应用三尖瓣指南并进行严格长期超声心动图随访的研究，退行性二尖瓣反流（DMR）背景下功能性三尖瓣反流（FTR）对预后的管理仍存在争议。因此，我们旨在收集这样一组队列，以检查遵循三尖瓣手术指南接受DMR手术的患者的预后。
确定了2005年至2015年期间所有接受孤立性DMR手术且进行了基线FTR评估和三尖瓣环直径测量的连续患者。总体评估手术并发症、术后三尖瓣反流发生率和生存率，并根据基于指南的三尖瓣环成形术（TA）指征（严重FTR或三尖瓣环直径≥40mm）进行分层。
在441例接受二尖瓣修复的DMR患者（66±13岁，30%为女性，射血分数66±10%，收缩期肺动脉压39±12mmHg）中，随访6[3 - 9]年，接受TA的患者（n = 234，53%）与未接受TA的患者（n = 207，47%；所有p≥0.2）总体表现相似，但房颤更多见且左心室更大（两者p≥0.0003）。接受TA的患者体外循环时间更长，迷宫手术更多（所有p≤0.001），但住院时间、肾衰竭、起搏器植入和手术死亡率（总体0.9%）相当（所有p≥0.2）。术后中度/重度FTR的发生率（1年时为0%）随时间推移在未接受TA的患者中更高（5年时为8%[4% - 13%]对3%[1% - 11%]，10年时为10%[6% - 16%]对4%[1% - 16%]，p = 0.01）。整个随访期间的生存率（95%置信区间）在10年时为85%（77% - 89%），接受TA与未接受TA的患者的风险比为0.57（0.29 - 1.10），p = 0.09。
在这个大型手术DMR队列中，基于指南的FTR管理是安全有效的。虽然长期死亡率没有达到显著差异，但术后中度/重度FTR的发生率总体较低，在手术时似乎不需要TA的患者中更高，且与三尖瓣环尺寸有关。因此，未来需要多中心前瞻性队列进行长期随访，以重新审视TA手术的阈值及其对生存的影响。
