左心瓣膜病合并三尖瓣关闭不全的诊断及外科治疗

左心瓣膜术后出现三尖瓣关闭不全及其加重严重影响瓣膜患者术后的生活质量,目前如何正确的诊断和治疗左心瓣膜疾病合并的三尖瓣关闭不全已成为心脏外科的热点,现就其诊断及治疗做一综述。     

Impact of Massive or Torrential Tricuspid Regurgitation in Patients Undergoing Transcatheter Tricuspid Valve Intervention

ObjectivesThe aim of this study was to assess the clinical outcome of baseline massive or torrential tricuspid regurgitation (TR) after transcatheter tricuspid valve intervention (TTVI).BackgroundThe use of TTVI to treat symptomatic severe TR has been increasing rapidly, but little is known regarding the impact of massive or torrential TR beyond severe TR.MethodsThe study population comprised 333 patients with significant symptomatic TR from the TriValve Registry who underwent TTVI. Mid-term outcomes after TTVI were assessed according to the presence of massive or torrential TR, defined as vena contracta width ≥14 mm. Procedural success was defined as patient survival after successful device implantation and delivery system retrieval, with residual TR ≤2+. The primary endpoint comprised survival rate and freedom from rehospitalization for heart failure, survival rate, and rehospitalization at 1 year.ResultsBaseline massive or torrential TR and severe TR were observed in 154 patients (46.2%) and 179 patients (53.8%), respectively. Patients with massive or torrential TR had a higher prevalence of ascites than those with severe TR (27.3% vs. 20.4%, respectively; p = 0.15) and demonstrated a similar procedural success rate (83.2% vs. 77.3%, respectively; p = 0.21). The incidence of peri-procedural adverse events was low, with no significant between-group differences. Freedom from the composite endpoint was significantly lower in patients with massive or torrential TR than in those with severe TR, which was significantly associated with an increased risk for 1-year death of any cause or rehospitalization for heart failure (adjusted hazard ratio: 1.91; 95% confidence interval: 1.10 to 3.34; p = 0.022). Freedom from the composite endpoint was significantly higher in patients with massive or torrential TR when procedural success was achieved (69.9% vs. 54.2%, p = 0.048).ConclusionsBaseline massive or torrential TR is associated with an increased risk for all-cause mortality and rehospitalization for heart failure 1 year after TTVI. Procedural success is related to better outcomes, even in the presence of baseline massive or torrential TR. (International Multisite Transcatheter Tricuspid Valve Therapies Registry [TriValve]; NCT03416166)     

Tricuspid Intervention Following Pulmonary Valve Replacement in Adults With Congenital Heart Disease

BackgroundTricuspid regurgitation (TR) is common among adults with corrected tetralogy of Fallot (TOF) or pulmonary stenosis (PS) referred for pulmonary valve replacement (PVR). Yet, combined valve surgery remains controversial.ObjectivesThis study sought to evaluate the impact of concomitant tricuspid valve intervention (TVI) on post-operative TR, length of hospital stay, and on a composite endpoint consisting of 7 early adverse events (death, reintervention, cardiac electronic device implantation, infection, thromboembolic event, hemodialysis, and readmission).MethodsThe national Canadian cohort enrolled 542 patients with TOF or PS and mild to severe TR who underwent isolated PVR (66.8%) or PVR+TVI (33.2%). Outcomes were abstracted from charts and compared between groups using multivariable logistic and negative binomial regression.ResultsMedian age at reintervention was 35.3 years. Regardless of surgery type, TR decreased by at least 1 echocardiographic grade in 35.4%, 66.9%, and 92.8% of patients with pre-operative mild, moderate, and severe insufficiency. In multivariable analyses, PVR+TVI was associated with an additional 2.3-fold reduction in TR grade (odds ratio [OR]: 0.44; 95% confidence interval [CI]: 0.25 to 0.77) without an increase in early adverse events (OR: 0.85; 95% CI: 0.46 to 1.57) or hospitalization time (incidence rate ratio: 1.17; 95% CI: 0.93 to 1.46). Pre-operative TR severity and presence of transvalvular leads independently predicted post-operative TR. In contrast, early adverse events were strongly associated with atrial tachyarrhythmia, extracardiac arteriopathy, and a high body mass index.ConclusionsIn patients with TOF or PS and significant TR, concomitant TVI is safe and results in better early tricuspid valve competence than isolated PVR.     

Doppler-Phonocardiographic Findings in Tricuspid Valve Prolapse

A loud systolic click was heard at the left lower sternal border and xiphisternal area in a 71-year-old man. The click showed striking phasic mobility (with reference to first and second heart sound), becoming late systolic in inspiration and early systolic in expiration. Two-dimensional echocardiography showed tricuspid valve prolapse as well as mild mitral valve prolapse. Continuous-wave and color flow Doppler recording of the tricuspid regurgitant jet showed marked phasic variation in duration of late systolic tricuspid regurgitation. Phasic respiratory variation in timing of a systolic click is an important auscultatory sign of tricuspid prolapse, serving to distinguish it from mitral prolapse.     

Role of Angiogenetic Factors in Cardiac Valve Homeostasis and Disease

The aging of populations worldwide and the habitual consumption of food high in calories and cholesterol have led to recent increases in morbidity from calcific aortic valve disease. At the same time, rupture of the chordae tendineae cordis, which is a component of the mitral valve complex, is one of the major causes of mitral regurgitation. Surgery is the basis of treatment for these diseases, and little is known about their causes and mechanisms. A balance of angiogenetic and angioinhibitory factors is crucial for normal development and homeostasis of many organs. Although the heart is a vascular-rich organ, most of the cardiac valve complex is avascular like cartilage and tendons. Our studies have focused on the role of angiogenetic factors expressed in the cartilage and tendons in cardiac valve homeostasis. Recently, we found that chondromodulin-I, tenomodulin, and periostin play essential roles in degeneration and/or rupture of the cardiac valve complex by controlling angiogenesis and matrix metalloproteinase production. Here, we review the mechanistic insights provided by these studies and the proposed roles of angiogenetic factors in cardiac valve homeostasis and disease.     

Evolving Indications for Tricuspid Valve Surgery

More attention has been paid to the mitral valve (MV) than the tricuspid valve (TV), and this relative paucity of data has led to confusion regarding the timing of TV surgery. We review the American College of Cardiology/American Heart Association and European Society of Cardiology guidelines to identify areas of concordance (severe tricuspid regurgitation [TR] in a patient undergoing mitral valve surgery); discordance (less than severe TR but with markers for late TR recurrence such as pulmonary hypertension, a dilated TV annulus, atrial fibrillation, permanent transtricuspid pacing wires and others); and disagreement (surgery for primary TR). We provide our perspective from Northwestern University on these issues and where the guidelines are silent (TR in patients undergoing non-mitral valve operations). Finally, we review recent publications on the results of TV repair and replacement. Although there have been scant publications in the past, there have been more useful publications in recent years to guide our decision making.     

Health Status After Transcatheter Tricuspid Valve Repair in Patients With Functional Tricuspid Regurgitation

ObjectivesThe aim of this study was to investigate changes in quality of life (QoL) after transcatheter tricuspid valve repair (TTVR) for tricuspid regurgitation (TR).BackgroundTTVR provides feasible and durable efficacy in reducing TR, but its clinical benefits on QoL still remain unclear.MethodsIn 115 subjects undergoing TTVR for severe functional TR, QoL was evaluated using the 36-Item Short Form Health Survey (SF-36) and the Minnesota Living With Heart Failure Questionnaire (MLHFQ). All-cause mortality, heart failure (HF) rehospitalization, and a composite endpoint of all-cause mortality, HF rehospitalization, and repeat TTVR were recorded as clinical events.ResultsSuccessful device implantation was achieved in 110 patients (96%). Moderate or less TR at discharge was achieved in 95 patients (83%). Mean SF-36 physical component summary (PCS) score improved from 34 ± 9 to 37 ± 9 points (+3 points; 95% CI: 1-5 points; P = 0.001), mean SF-36 mental component summary score improved from 49 ± 9 to 51 ± 10 points (+2 points; 95% CI: 0-4 points; P = 0.017), and mean MLHFQ score decreased from 29 ± 14 to 20 ± 15 points (−8 points; 95% CI: −11 to −5 points; P < 0.001). Baseline PCS, moderate or less TR at discharge, and baseline massive or torrential TR were associated with 1-month change in PCS score (P < 0.05). Change in PCS score after 1 month predicted HF rehospitalization after TTVR (adjusted HR: 0.74 [95% CI: 0.60-0.92] per 5-point increase in PCS score; P = 0.008).ConclusionsThis study demonstrates that TTVR provides improvement in QoL in patients with relevant TR. TR reduction to a moderate or less grade was associated with improvement of SF-36 and MLHFQ scores. Further, global QoL was associated with clinical outcomes and might serve as a future outcome surrogate following TTVR.     

Transcatheter Tricuspid Valve Intervention in Patients With Previous Left Valve Surgery

BackgroundScarce data exist on patients with previous left valve surgery (PLVS) undergoing transcatheter tricuspid valve intervention (TTVI). This study sought to investigate the procedural and early outcomes in patients with PLVS undergoing TTVI.MethodsThis was a subanalysis of the multicenter TriValve registry including 462 patients, 82 (18%) with PLVS. Data were analyzed according to the presence of PLVS in the overall cohort and in a propensity score–matched population including 51 and 115 patients with and without PLVS, respectively.ResultsPatients with PLVS were younger (72 ± 10 vs 78 ± 9 years; p < 0.01) and more frequently female (67.1% vs 53.2%; P = 0.02). Similar rates of procedural success (PLVS 80.5%; no-PLVS 82.1%; P = 0.73), and 30-day mortality (PLVS 2.4%, no-PLVS 3.4%; P = 0.99) were observed. After matching, there were no significant differences in both all-cause rehospitalisation (PLVS 21.1%, no-PLVS 26.5%; P = 0.60) and all-cause mortality (PLVS 9.8%, no-PLVS 6.7%; P = 0.58). At last follow-up (median 6 [interquartile range 1-12] months after the procedure), most patients (81.8%) in the PLVS group were in NYHA functional class I-II (P = 0.12 vs no-PLVS group), and TR grade was ≤ 2 in 82.6% of patients (P = 0.096 vs no-PVLS group). A poorer right ventricular function and previous heart failure hospitalization determined increased risks of procedural failure and poorer outcomes at follow-up, respectively.ConclusionsIn patients with PLVS, TTVI was associated with high rates of procedural success and low early mortality. However, about one-third of patients required rehospitalisation or died at midterm follow-up. These results would support TTVI as a reasonable alternative to redo surgery in patients with PLVS and suggest the importance of earlier treatment to improve clinical outcomes.     

成形软环应用于三尖瓣关闭不全修复的疗效评价

目的:了解国产三尖瓣成形软环对继发于左心系统瓣膜病变造成的三尖瓣关闭不全的治疗效果. 方法:自2002-08至2004-08,我院收治的63例继发性三尖瓣关闭不全病人,在行左心系统瓣膜病变矫治时,应用国产三尖瓣成形软环同期行三尖瓣成形术.49例病人获得随诊,平均随诊时间为17.4±10.3(3～33)个月. 结果:63例病人在术后早期均治愈出院.49例病人随诊时有l例病人死于非三尖瓣成形所致原因;其余48例随诊病人较术前症状均有改善,心功能较术前提高,超声检查示三尖瓣中量反流3例,大量反流1例. 结论:国产三尖瓣成形软环对三尖瓣关闭不全有明显的治疗效果.成形效果优劣的关键在于术中对三尖瓣瓣环的有效处理.三尖瓣瓣环越大,则更应选择相对较小的人工瓣环,成形时不仅要缩小三尖瓣的游离缘瓣环,还要将部分三尖瓣隔瓣瓣环予以缩小和固定.