Regurgitação tricúspide funcional em pacientes com cardiopatia reumática: fatores asociados, impacto prognóstico e preditores de progressão

• Ano de defesa: 2022
• Autor(a) principal: Mônica Maria Costa Caldas
• Tipo de documento: Tese
• Tipo de acesso: Acesso aberto
• Idioma: por
• Instituição de defesa: Universidade Federal de Minas Gerais; Brasil; Programa de Pós-Graduação em Ciências da Saúde - Infectologia e Medicina Tropical; UFMG
• Palavras-chave em Português: regurgitação tricúspide funcional; cardiopatia reumática crônica; Insuficiência da Valva Tricúspide; Cardiopatia Reumática; Valva Mitral; Ecocardiografia; Progressão da Doença; Dissertação Acadêmica
• Link de acesso: http://hdl.handle.net/1843/69616

Background: Rheumatic heart disease (RHD) remains a major health problem, particularly in low- and middle-income countries, where it accounts for over a million premature deaths annually. Although the mitral valve is affected predominantly, a substantial proportion of patients manifest significant tricuspid regurgitation (TR) secondary to mitral valve disease, which lead to right-sided heart failure and ultimately death. Functional TR is mostly consequent to pulmonary hypertension in patients with RHD. However, there are limited data regarding the clinical implications of TR in the setting of RHD. This prospective study was designed to identify the determinants of significant functional TR, the impact of TR on clinical outcomes and the predictors of TR progression in a large population of RHD patients. Methods: Patients with RHD who were referred for management of heart valve disease between 2011 and 2021 were enrolled. A comprehensive echocardiogram was performed, with careful tricuspid valve examination and special attention to optimize the right heart acquisitions. Patients with rheumatic involvement of tricuspid valve were excluded. At baseline, functional TR was graded according to guidelines, as absent, mild, moderate, and severe. TR progression was defined either as worsening of TR degree from baseline to the last follow-up echocardiogram or severe TR at baseline that required surgery or cardiac death. Clinical outcomes were defined as the composite of cardiac death or the need for surgical mitral valve replacement (MVR). Risk of TR progression was estimated accounting for competing risks. Results: A total of 645 were enrolled, mean age of 47 ± 12 years, 85% female. Functional TR was absent in 3.4%, mild in 83.7%, moderate in 8.5% and severe in 4.3%. In the overall population, mixed mitral valve disease was the most common pattern of valve involvement with mitral stenosis as a predominant lesion associated with mild mitral regurgitation. At enrollment, atrial fibrillation was diagnosed in 205 patients (32%). Clinical and echocardiographic features associated with more severe TR were age, right atrial (RA) area, and systolic pulmonary artery pressure (SPAP), and the presence of right ventricular (RV) dysfunction, with C statistic of the model of 0.888 (95% CI 0.844-0.932). Functional TR degree compared with no or mild TR was associated with adverse outcome (hazard ratio [HR] 1.91 (95% CI 1.15-3.2) for moderate TR, and 2.30 (95% CI 1.28-4.13) for severe TR, independently of age, NYHA functional class, left ventricular ejection fraction, net atrioventricular compliance (Cn) and mitral valvuloplasty. Event-free survival rates decreased with increasing severity of functional TR, with survival rate at 3-years follow-up of 91%, 72% and 62% in patients with no or mild, moderate and severe TR, respectively. During mean follow-up of 4.1 years (median 3.4, IQR 1.0 to 6.6 years), TR progression occurred in 83 patients (13%) with an overall incidence of progression rate of 3.7 events (95% CI 2.9-4.5) per 100 patient-years. Predictors of TR progression were age (HR 1.06, 95% CI 1.04-1.08, P<0.001), RA area (HR 1.05, 95% CI 1.02-1.08, P<0.001), the presence of RV dysfunction (HR 2.36, 95% CI 1.40-4.01, P=0.001), and NYHA functional class III/IV (HR 2.48, 95% CI 1.50-4.08, P<0.001), after adjusted by AF, mitral valvuloplasty, and SPAP. Conclusions: In patients with RHD, functional TR was frequent and associated with age, pulmonary artery pressure, RA dimension, and RV dysfunction. Functional TR was predictor of adverse outcomes, independently of RV dysfunction and SPAP. TR may progress over time, mainly related to right-sided remodeling. Assessing of functional TR grade is essential in RHD patient for risk stratification and decisions regarding tricuspid valve intervention.