3^(+)级以上二尖瓣反流患者的解剖分型及危险分层评估:基于超声核心实验室的初步研究结果

The echocardiographic characteristics and risk stratification of patients with above grade 3^(+) mitral regurgitation:Based on the preliminary findings of echo core-lab

目的通过三维经食管超声心动图(3D transesophageal echocardiography,3D-TEE)对3^(+)级以上二尖瓣反流(mitral regurgitation,MR)患者的二尖瓣装置进行形态学分型及危险度分层,比较不同分型患者的超声影像学特征以及不同危险分层患者的经导管缘对缘修复(transcatheter edge-to-edge repair,TEER)治疗干预率。方法回顾性分析2021年6月—2022年4月间因重度MR就诊于北京安贞医院91例3^(+)级以上MR患者的临床资料,男45例、女46例,平均年龄(66.5±15.9)岁。按发病机制将患者分为5组:单纯退行性变组(单纯DMR组)34例,复杂病变组(Complex组)28例,单纯室性功能性反流组(单纯VFMR组)14例,单纯房性功能性反流组(单纯AFMR组)9例,混合型功能性反流组(混合型FMR组)6例。所有患者行统一标准的经胸超声心动图(transthoracic echocardiography,TTE)及3D-TEE检查,比较各组患者特征性二尖瓣三维结构改变;按照TEER术前解剖学评估的三分区策略对入组患者进行危险分层,由轻到重划分为绿区-黄区-红区三个区域,比对不同危险分层患者的TEER治疗干预率。结果单纯DMR组及Complex组前纵角和后纵角为负值,瓣叶的非平面角度、脱垂高度和脱垂容积高于其它组(P=0.000)。单纯VFMR组及混合型FMR组瓣环前后径更大(P=0.036),瓣叶前纵角和后纵角为正值,穹窿高度和穹窿容积更高,瓣叶的非平面角度更低(P=0.000)。单纯AFMR组患者特征性改变不明显。本研究划分为黄区和红区患者在常规筛查出的3^(+)级以上MR患者中占62.6%,而其实际TEER干预率仅为28.1%。结论超声核心实验室规范化的超声检查对MR定性及定量诊断至关重要;3D-TEE所获得的二尖瓣装置参数可从不同维度帮助确定MR的确切发病机制,从而提高中高危MR患者介入干预率。

Objective To analyze the echocardiographic characteristics of above grade 3^(+)mitral regurgitation(MR)patients by 3D transesophageal echocardiography(3D-TEE)in transcatheter edge-to-edge repair(TEER)and compare the intervention rate of TEER treatment in patients with different risk stratification.Methods We retrospectively analyzed the clinical data of 91 patients with above grade 3^(+)MR in Anzhen Hospital between June 2021 and April 2022.There were 45 males and 46 females aged 66.5±15.9 years.According to pathogenesis,the patients were divided into different anatomical groups and risk stratification groups.There were 34 patients in a simple degenerative group(simple DMR group),28 patietns in a complex disease group(Complex group),14 patients in a simple ventricular functional reflux group(simple VFMR group),9 patients in a simple atrial functional reflux group(simple AFMR group)and 6 patients in a mixed functional reflux group(mixed FMR group).All patients were examined with a unified standard of transthoracic echocardiography(TTE)and 3D-TEE to compare the characteristic three-dimensional structural changes of the mitral valve in each group.According to the three partition strategy of preoperative anatomical evaluation of TEER the risk stratification was conducted for the enrolled patients,which was divided into three regions from light to heavy green area,yellow area,and red area.TEER treatment intervention rate of patients with different risk stratification was calculated.Results Ant leaf angle and post leaf angle were negative in the simple DMR and Complex groups,and nonplanar angle,prolapse height and prolapse volume were higher than those of the other groups(P=0.000).Ant leaf angle and post leaf angle were positive in the VFMR group and the mixed FMR group.Anterior and posterior(AP)diameter of valve ring(P=0.036),tenting height and tenting volume were higher than those of other groups(P=0.000).AP diameter tenting height and tenting volume were changed mildly in patients with simple AFMR.MR patients in red and yellow zone achieved a 28.1%TEER intervention rate.Conclusion Standardized TTE and TEE examinations are crucial for the qualitative and quantitative diagnosis of MR in the echo core-lab.3D-TEE mitral valve parameter can help determine the exact pathogenesis of MR and to improve the interventional rate of challenging MR patients.