Concomitant Tricuspid Repair in Patients with Degenerative Mitral Regurgitation.
Concomitant Tricuspid Repair in Patients with Degenerative Mitral Regurgitation.
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DOI：
10.1056/nejmoa2115961
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发表时间：
2022-01-27
期刊：
影响因子：
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通讯作者：
CTSN Investigators
中科院分区：
文献类型：
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作者：
Gammie JS;Chu MWA;Falk V;Overbey JR;Moskowitz AJ;Gillinov M;Mack MJ;Voisine P;Krane M;Yerokun B;Bowdish ME;Conradi L;Bolling SF;Miller MA;Taddei-Peters WC;Jeffries NO;Parides MK;Weisel R;Jessup M;Rose EA;Mullen JC;Raymond S;Moquete EG;O'Sullivan K;Marks ME;Iribarne A;Beyersdorf F;Borger MA;Geirsson A;Bagiella E;Hung J;Gelijns AC;O'Gara PT;Ailawadi G;CTSN Investigators
三尖瓣返流（TR）常见于重度原发性二尖瓣返流（MR）患者。然而，证据基础不足以决定在二尖瓣手术（MVS）期间存在中度TR或低于中度TR伴瓣环扩张的情况下进行三尖瓣修复。我们将401例接受MVS治疗原发性二尖瓣返流的患者随机分配接受MVS伴或不伴三尖瓣成形术（TA）。主要2年终点是死亡、TR再次手术和TR进展（相对于基线2级或存在重度TR）的复合终点。接受MVS+TA的患者发生的主要终点事件少于MVS患者（3.9% vs 10.2%; RR 0.37; CI 0.16-0.86; p=0.02）。MVS+TA患者的2年死亡率为3.2%，MVS患者为4.5%（RR 0.69; CI 0.25-1.88）。MVS+TA患者中重度TR的2年患病率较低（0.6% vs 5.6%; RR 0.10; CI 0.01-0.77）。2年时，两组间主要不良心脑血管事件、功能状态或生活质量无显著差异，但MVS+TA患者的永久起搏器植入率显著较高（14.1% vs 2.5%;率比5.75; CI 2.27-14.60）。在MVS时增加伴随TA降低了2年时的复合主要终点事件率，这是由于进展为重度TR的频率较低。三尖瓣修复导致更频繁地需要植入永久性起搏器。TR进展率降低是否会导致长期临床获益需要更长时间的随访。
Tricuspid regurgitation (TR) is common in patients with severe primary mitral regurgitation (MR). However, the evidence base is insufficient to inform a decision to perform tricuspid valve repair in the presence of moderate TR or less than moderate TR with annular dilation during mitral valve surgery (MVS). We randomly assigned 401 patients undergoing MVS for primary MR to receive MVS with or without tricuspid valve annuloplasty (TA). The primary 2-year endpoint was a composite of death, re-operation for TR, and progression of TR, either from baseline by 2 grades or presence of severe TR. Patients undergoing MVS+TA experienced fewer primary endpoint events than MVS patients (3.9% vs 10.2%; RR 0.37; CI 0.16-0.86; p=0.02). Two-year mortality was 3.2% in MVS+TA patients and 4.5% in MVS patients (RR 0.69; CI 0.25-1.88). The 2-year prevalence of severe TR was lower in MVS+TA patients (0.6% vs 5.6%; RR 0.10; CI 0.01-0.77). There were no significant between group differences in major adverse cardiac and cerebrovascular events, functional status or quality of life at 2 years, although the rate of permanent pacemaker implantation was significantly higher in MVS+TA patients (14.1% vs 2.5%;rate-ratio 5.75; CI 2.27-14.60). The addition of concomitant TA at time of MVS reduced the composite primary endpoint event rate at 2 years, driven by less frequent progression to severe TR. Tricuspid repair resulted in more frequent need for permanent pacemaker implantation. Whether a reduced rate of TR progression results in long-term clinical benefit requires longer follow-up.