Division of Cardiology, Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China.
Division of Cardiology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China.
Clin Res Cardiol. 2023 Oct;112(10):1463-1474. doi: 10.1007/s00392-023-02265-6. Epub 2023 Aug 4.
The nonuniform benefit of tricuspid annuloplasty may be explained by the proportionality of tricuspid regurgitation (TR) severity to right ventricular (RV) area. The purpose of this study was to delineate distinct morphological phenotypes of functional TR and investigate their prognostic implications in patients undergoing tricuspid annuloplasty during left-sided valvular surgery.
The ratios of pre-procedural effective regurgitant orifice area (EROA) with right ventricular end-diastolic area (RVDA) were retrospectively assessed in 290 patients undergoing tricuspid annuloplasty. Based on optimal thresholds derived from penalized splines and maximally selected rank statistics, patients were stratified into proportionate (EROA/RVDA ratio ≤ 1.74) and disproportionate TR (EROA/RVDA ratio > 1.74).
Overall, 59 (20%) and 231 (80%) patients had proportionate and disproportionate TR, respectively. Compared to those with proportionate TR, patients with disproportionate TR were older, had a higher prevalence of atrial fibrillation, lower pulmonary pressures, more impaired RV function, and larger tricuspid leaflet tenting area. Over a median follow-up of 4.1 years, 79 adverse events (47 heart failure hospitalizations and 32 deaths) occurred. Patients with disproportionate TR had higher rates of adverse events than those with proportionate TR (32% vs 10%; P = 0.001) and were independently associated with poor outcomes on multivariate analysis. TR proportionality outperformed guideline-based classification of TR severity in outcome prediction and provided incremental prognostic value to both the EuroSCORE II and STS score (incremental χ = 6.757 and 9.094 respectively; both P < 0.05).
Disproportionate TR is strongly associated with adverse prognosis and may aid patient selection and risk stratification for tricuspid annuloplasty with left-sided valvular surgery.
三尖瓣环成形术的获益不均可能与三尖瓣反流（TR）严重程度与右心室（RV）面积的比例有关。本研究旨在描绘功能性 TR 的不同形态表型，并探讨其在接受左侧瓣膜手术后行三尖瓣环成形术患者中的预后意义。
回顾性评估 290 例行三尖瓣环成形术患者的术前有效反流口面积（EROA）与右心室舒张末期面积（RVDA）比值。基于惩罚样条和最大选择秩统计得出的最佳阈值，将患者分为比例性（EROA/RVDA 比值≤1.74）和非比例性 TR（EROA/RVDA 比值>1.74）。
总体而言，59 例（20%）和 231 例（80%）患者分别为比例性和非比例性 TR。与比例性 TR 患者相比，非比例性 TR 患者年龄更大，心房颤动发生率更高，肺动脉压更低，RV 功能受损更严重，三尖瓣叶幕面积更大。中位随访 4.1 年后，发生 79 例不良事件（47 例心力衰竭住院和 32 例死亡）。非比例性 TR 患者的不良事件发生率高于比例性 TR 患者（32%比 10%；P=0.001），且在多变量分析中与不良结局独立相关。TR 比例性优于基于指南的 TR 严重程度分类，在预后预测方面具有更好的预测价值，并为 EuroSCORE II 和 STS 评分提供了额外的预后价值（分别为增量 χ2=6.757 和 9.094；均 P<0.05）。
非比例性 TR 与不良预后密切相关，可能有助于选择患者并对行左侧瓣膜手术后行三尖瓣环成形术进行风险分层。
