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中华心脏与心律电子杂志 ›› 2024, Vol. 12 ›› Issue (03) : 129 -139. doi: 10.3877/cma.j.issn.2095-6568.2024.03.001

标准与规范

三尖瓣反流经导管治疗的中国专家共识
中国医师协会心血管内科医师分会结构性心脏病学组, 苏州工业园区东方华夏心管健康研究院   
  • 收稿日期:2024-09-24 出版日期:2024-09-25

Chinese expert consensus on transcatheter tricuspid valve intervention therapy

College of Cardiovascular Physicians Structural Cardiology Group,China Heart House Chinese   

  • Received:2024-09-24 Published:2024-09-25
引用本文:

中国医师协会心血管内科医师分会结构性心脏病学组, 苏州工业园区东方华夏心管健康研究院. 三尖瓣反流经导管治疗的中国专家共识[J]. 中华心脏与心律电子杂志, 2024, 12(03): 129-139.

College of Cardiovascular Physicians Structural Cardiology Group,China Heart House Chinese. Chinese expert consensus on transcatheter tricuspid valve intervention therapy[J]. Chinese Journal of Heart and Heart Rhythm(Electronic Edition), 2024, 12(03): 129-139.

三尖瓣反流(TR)是较常见的心脏瓣膜疾病之一,既往标准治疗为外科手术,但该方法创伤大、风险高。近年来,经导管三尖瓣介入治疗(TTVI)技术实现重大突破,在国外已步入临床推广阶段,并且相继推出了TTVI 专家共识文件。但在我国,目前仍缺乏该方面的共识性文件。为推进该技术在我国安全、规范、健康地发展,特编写此专家共识。本共识将从TR 的解剖与流行病学、分类与发病机制、传统治疗与TTVI、TTVI术前评估及临床疗效终点等方面予以介绍,并梳理总结十个核心观点,以便读者能够快速掌握共识的精髓要点。

表1 三尖瓣反流的发病机制及病因
图1 不同病因的三尖瓣反流基础治疗策略[22]a.心内膜炎时应川抗生素;b.右冠状动脉疾病导致右心室衰竭的情况下进行血运重建,治疗特定心肌病(如淀粉样变性、结节病);c.针对肺实质性疾病、慢性阻塞性肺疾病和限制性疾病,以及肺动脉高压和肺动脉血栓栓塞症的特定治疗] TR 为三尖瓣反流,CIED 为心血管植入型电子器械,RVD 为右心室功能障碍,HFpEF 为射血分数保留型心力衰竭,HFrEF 为射血分数降低型心力衰竭,SGLT2i为钠-葡萄糖协同转运蛋白2抑制剂,CRT为心脏再同步治疗,PH 为肺动脉高压
表2 经导管三尖瓣介入治疗器械选择的解剖标准
器械原理 适合的解剖 可行的解剖 不适合的解剖
缘对缘修复[38] 1.对合间隙≤7mm 1.7mm<对合间隙≤8.5mm 1.对合间隙>8.5mm
2.反流束在前叶-隔叶之间 2.反流束在后叶-隔叶之间 2.瓣叶增厚/明显缩短(如风湿性心脏病,肿瘤等引起)/穿孔
3.局限性脱垂或连枷样病变 3.形态非三叶瓣 3.超声影像质量差
4.形态为三叶瓣 4.起搏导线未压迫瓣膜 4.起搏导线压迫瓣膜
瓣环成形[39-40] 1.三尖瓣反流的主要原因是瓣环扩张 1.中度腱索拴系(0.76cm≤瓣叶对合帐篷高度<1.0cm,1.63cm2≤帐篷面积<2.5cm2,2.3ml≤帐篷容积[3D]<3.5ml) 1.严重瓣叶栓系(瓣叶对合帐篷高度≥1.0cm,帐篷容积[3D]≥3.5ml)
2.轻度腱索栓系(瓣叶对合帐篷高度<0.76cm,帐篷面积<1.63cm2,帐篷容积[3D]<2.3ml) 2.起搏导线未压迫瓣膜 2.超声影像无法清晰显示瓣环组织
3.中央型反流束 3.瓣环非常接近右冠状动脉
4.器械锚定有足够的空间位置 4.起搏导线压迫瓣膜
原位瓣膜植入[41] 1.既往三尖瓣手术修复失败或生物瓣膜置换术后损毁 1.瓣叶对合间隙巨大 1.瓣环极度扩张(超过器械尺寸)
2.瓣叶增厚/明显缩短(如风湿性心脏病、肿瘤等引起) 2.起搏导线压迫瓣膜 2.器械置入角度无法同轴
3.起搏导线未压迫瓣膜 3.重度右心室功能障碍
4.任何瓣叶形态
异位瓣膜植入[41] 1.适当的腔静脉内径 1.右心房靠近肝静脉开口(<10~12mm)
2.不适合行原位瓣膜置入的选择 2.双腔静脉内瓣膜支架骨折导致肺动脉和右心耳压力严重增加的风险高
表3 三尖瓣反流严重程度分级的超声心功能评估
[1]
Singh JP, Evans JC, Levy D, et al. Prevalence and clinical determinants of mitral, tricuspid, and aortic regurgitation(the Framingham Heart Study) [J]. Am J Cardiol, 1999,83(6):897-902.
[2]
Coffey S, d'Arcy JL, Loudon MA, et al. The OxVALVE population cohort study (OxVALVE-PCS) -population screening for undiagnosed valvular heart disease in the elderly: study design and objectives[J]. Open Heart, 2014,1(1):e000043.
[3]
Gössl M, Stanberry L, Benson G, et al. Burden of undiagnosed valvular heart disease in the elderly in the community: heart of new ulm valve study[J]. JACC Cardiovasc Imaging, 2023, 16(8):1118-1120.
[4]
Shiran A, Sagie A. Tricuspid regurgitation in mitral valve disease incidence, prognostic implications, mechanism,and management[J]. J Am Coll Cardiol, 2009, 53(5):401-408.
[5]
Généreux P, Pibarot P, Redfors B, et al. Staging classification of aortic stenosis based on the extent of cardiac damage[J]. Eur Heart J, 2017, 38(45):3351-3358.DOI: 10.1093/eurheartj/ehx381.
[6]
Vassileva CM, Shabosky J, Boley T, et al. Tricuspid valve surgery: the past 10 years from the Nationwide Inpatient Sample (NIS) database[J]. J Thorac Cardiovasc Surg, 2012,143(5):1043-1049.
[7]
Zack CJ, Fender EA, Chandrashekar P, et al. National trends and outcomes in isolated tricuspid valve surgery[J]. J Am Coll Cardiol, 2017, 70(24):2953-2960.
[8]
Maisano F, Hahn R, Sorajja P, et al. Transcatheter treatment of the tricuspid valve: current status and perspectives[J]. Eur Heart J, 2024, 45(11):876-894.
[9]
Hahn RT, Lawlor MK, Davidson CJ, et al. Tricuspid valve academic research consortium definitions for tricuspid regurgitation and trial endpoints[J]. J Am Coll Cardiol,2023, 82(17):1711-1735.
[10]
Davidson LJ, Tang GHL, Ho EC, et al. Council on Cardiovascular surgery and anesthesia; and council on cardiovascular and stroke nursing. the tricuspid valve: a review of pathology, imaging, and current treatment options: a scientific statement from the American Heart Association[J]. Circulation, 2024, 149(22):e1223-e1238.
[11]
Hahn RT, Weckbach LT, Noack T, et al. Proposal for a standard echocardiographic tricuspid valve nomenclature[J]. JACC Cardiovasc Imaging, 2021, 14(7):1299-1305.
[12]
Prihadi EA, van der Bijl P, Gursoy E, et al. Development of significant tricuspid regurgitation over time and prognostic implications: new insights into natural history[J]. Eur Heart J, 2018, 39(39):3574-3581.
[13]
Mutlak D, Khalil J, Lessick J, et al. Risk factors for the development of functional tricuspid regurgitation and their population-attributable fractions[J]. JACC Cardiovasc Imaging, 2020, 13(8):1643-1651.
[14]
Wang N, Fulcher J, Abeysuriya N, et al. Tricuspid regurgitation is associated with increased mortality independent of pulmonary pressures and right heart failure: a systematic review and meta-analysis[J]. Eur Heart J, 2019, 40(5):476-484.
[15]
Offen S, Playford D, Strange G, et al. Adverse prognostic impact of even mild or moderate tricuspid regurgitation:insights from the national echocardiography database of Australia[J]. J Am Soc Echocardiogr, 2022, 35(8):810-817.
[16]
Topilsky Y, Maltais S, Medina Inojosa J, et al. Burden of tricuspid regurgitation in patients diagnosed in the community setting[J]. JACC Cardiovasc Imaging, 2019,12(3):433-442.
[17]
Wang TKM, Akyuz K, Mentias A, et al. Contemporary etiologies, outcomes, and novel risk score for isolated tricuspid regurgitation[J]. JACC Cardiovasc Imaging, 2022,15(5):731-744.
[18]
Dreyfus J, Audureau E, Bohbot Y, et al. TRI-SCORE: a new risk score for in-hospital mortality prediction after isolated tricuspid valve surgery[J]. Eur Heart J, 2022,43(7):654-662.
[19]
Yang L, Chen H, Pan W, et al. Analyses for prevalence and outcome of tricuspid regurgitation in China: an echocardiography study of 134, 874 patients[J].Cardiology, 2019, 142(1):40-46.
[20]
Xu H, Liu Q, Cao K, et al. Distribution, characteristics, and management of older patients with valvular heart disease in China: China-DVD study[J]. JACC Asia, 2022, 2(3):354-365.
[21]
Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines[J]. Circulation, 2021, 143(5):e35-e71.
[22]
Adamo M, Chioncel O, Pagnesi M, et al. Epidemiology,pathophysiology, diagnosis and management of chronic right-sided heart failure and tricuspid regurgitation. A clinical consensus statement of the Heart Failure Association (HFA) and the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC[J]. Eur J Heart Fail, 2024, 26(1):18-33.
[23]
Patlolla SH, Schaff HV, Nishimura RA, et al. Incidence and burden of tricuspid regurgitation in patients with atrial fibrillation[J]. J Am Coll Cardiol, 2022, 80(24):2289-2298.
[24]
Cho MS, Cha MJ, Nam GB, et al. Incidence and predictors of severe tricuspid regurgitation in atrial fibrillation patients without structural heart disease[J]. Am J Cardiol,2023, 203:288-294.
[25]
Vahanian A, Beyersdorf F, Praz F, et al. 2021 ESC/EACTS Guidelines for the management of valvular heart disease[J]. Eur Heart J, 2022, 43(7):561-632.
[26]
Chen Q, Bowdish ME, Malas J, et al. Isolated tricuspid operations: the society of thoracic surgeons adult cardiac surgery database analysis[J]. Ann Thorac Surg, 2023,115(5):1162-1170.
[27]
Sorajja P, Whisenant B, Hamid N, et al. Transcatheter repair for patients with tricuspid regurgitation[J]. N Engl J Med, 2023, 388(20):1833-1842.
[28]
Kodali SK, Hahn RT, Davidson CJ, et al. 1-year outcomes of transcatheter tricuspid valve repair[J]. J Am Coll Cardiol,2023, 81(18):1766-1776.
[29]
Gray WA, Abramson SV, Lim S, et al. 1-year outcomes of cardioband tricuspid valve reconstruction system early feasibility study[J]. JACC Cardiovasc Interv, 2022,15(19):1921-1932.
[30]
Zhang X, Jin Q, Pan W, et al. First-in-human study of the K-Clip ™ transcatheter annular repair system for severe functional tricuspid regurgitation[J]. Int J Cardiol,2023,390:131174.
[31]
Kodali SK. TRISCEND Ⅱ : a randomized trial of transcatheter tricuspid valve replacement in patients with severe tricuspid regurgitation[EB/OL]. (2023-10-27)[2024-09-10] https://www.tctmd.com/slide/triscend-ii-randomized-trial-transcatheter-tricuspid-valve-replacement-patients-severe.
[32]
Zhang Y, Lu F, Li W, et al. A first-in-human study of transjugular transcatheter tricuspid valve replacement with the LuX-Valve Plus system[J]. EuroIntervention,2023, 18(13):e1088-e1089.
[33]
Ge J. One-month outcomes of the multicenter TRAVEL Ⅱ(transvascular tricuspid valve replacement with the LuX-Valve Plus System)study[EB/OL]. (2023-10-26)[2024-09-10] https://www.tctmd.com/slide/one-month-outcomes-multicenter-travel-ii-transvasculartricuspid-valve-replacement-lux-valve.
[34]
Blasco-Turrión S, Briedis K, Estévez-Loureiro R, et al.Bicaval TricValve implantation in patients with severe symptomatic tricuspid regurgitation: 1-year follow-up outcomes[J]. JACC Cardiovasc Interv, 2024, 17(1):60-72.
[35]
McElhinney DB, Cabalka AK, Aboulhosn JA, et al.Transcatheter tricuspid valve-in-valve implantation for the treatment of dysfunctional surgical bioprosthetic valves: an international, multicenter registry study[J].Circulation, 2016, 133(16):1582-1593.
[36]
Bouleti C, Himbert D, Brochet E, et al. Transfemoral tricuspid valve-in-ring implantation using the edwards Sapien XT valve: one-year follow-up[J]. Circ Cardiovasc Interv, 2015, 8(3) :e002225.
[37]
Condado J, Leonardi R, Babaliaros V. Percutaneous tricuspid valve-in-ring replacement for the treatment of recurrent severe tricuspid regurgitation[J]. Catheter Cardiovasc Interv, 2015, 86(7):1294-1298.
[38]
Besler C, Orban M, Rommel KP, et al. Predictors of procedural and clinical outcomes in patients with symptomatic tricuspid regurgitation undergoing transcatheter edge-to-edge repair[J]. JACC Cardiovasc Interv, 2018, 11(12):1119-1128.
[39]
Utsunomiya H, Itabashi Y, Mihara H,et al. Usefulness of 3D echocardiographic parameters of tricuspid valve morphology to predict residual tricuspid regurgitation after tricuspid annuloplasty[J]. Eur Heart J Cardiovasc Imaging, 2017, 18(7):809-817.
[40]
Fukuda S, Song JM, Gillinov AM, et al. Tricuspid valve tethering predicts residual tricuspid regurgitation after tricuspid annuloplasty[J]. Circulation, 2005, 111(8):975-979.
[41]
Praz F, Muraru D, Kreidel F, et al. Transcatheter treatment for tricuspid valve disease[J]. EuroIntervention, 2021,17(10):791-808.
[42]
Dreyfus J, Galloo X, Taramasso M, et al. TRI-SCORE and benefit of intervention in patients with severe tricuspid regurgitation[J]. Eur Heart J, 2024, 45(8):586-597.
[43]
Lu F, Xiong T, Chen M. Evaluation of systemic impact of tricuspid regurgitation: an appeal for the notion of tricuspid regurgitation syndrome[J]. Chin Med J (Engl),2023, 136(2):138-140.
[44]
Brener MI, Lurz P, Hausleiter J, et al. Right ventricular-pulmonary arterial coupling and afterload reserve in patients undergoing transcatheter tricuspid valve repair[J]. J Am Coll Cardiol, 2022, 79(5):448-461.
[45]
Fortuni F, Butcher SC, Dietz MF, et al. Right ventricular-pulmonary arterial coupling in secondary tricuspid regurgitation[J]. Am J Cardiol, 2021, 148:138-145.
[46]
Sugiura A, Tanaka T, Kavsur R, et al. Leaflet configuration and residual tricuspid regurgitation after transcatheter edge-to-edge tricuspid repair[J]. JACC Cardiovasc Interv,2021, 14(20):2260-2270.
[47]
Park JB, Kim HK, Jung JH, et al. Prognostic value of cardiac MR imaging for preoperative assessment of patients with severe functional tricuspid regurgitation[J]. Radiology,2016, 280(3):723-734.
[48]
Grapsa J, Praz F, Sorajja P, et al. Tricuspid regurgitation:from imaging to clinical trials to resolving the unmet need for treatment[J]. JACC Cardiovasc Imaging, 2024, 17(1):79-95.
[49]
Abraham WT, Psotka MA, Fiuzat M, et al. Standardized definitions for evaluation of heart failure therapies:scientific expert panel from the heart failure collaboratory and academic research consortium[J]. JACC Heart Fail, 2020, 8(12):961-972.
[50]
Ferreira JP, Duarte K, Graves TL, et al. Natriuretic peptides, 6-min walk test, and quality-of-life questionnaires as clinically meaningful endpoints in HF trials[J]. J Am Coll Cardiol, 2016, 68(24):2690-2707.
[51]
Addetia K, Miyoshi T, Amuthan V, et al. Normal values of three-dimensional right ventricular size and function measurements: results of the world alliance societies of echocardiography study[J]. J Am Soc Echocardiogr, 2023,36(8):858-866.e1.
[52]
Hahn RT, Kodali S, Fam N, et al. Early multinational experience of transcatheter tricuspid valve replacement for treating severe tricuspid regurgitation[J]. JACC Cardiovasc Interv, 2020, 13(21):2482-2493.
[53]
Buğan B, Çekirdekçi Eİ, Onar LÇ, et al. Transcatheter tricuspid valve replacement for tricuspid regurgitation: a systematic review and Meta-analysis[J]. Anatol J Cardiol,2022, 26(7):505-519.
[54]
Kodali S, Hahn RT, George I, et al. Transfemoral tricuspid valve replacement in patients with tricuspid regurgitation: TRISCEND study 30-day results[J]. JACC Cardiovasc Interv, 2022, 15(5):471-480.
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