Tribouilloy Christophe, Lévy Franck, Rusinaru Dan, Guéret Pascal, Petit-Eisenmann Hélène, Baleynaud Serge, Jobic Yannick, Adams Catherine, Lelong Bernard, Pasquet Agnès, Chauvel Christophe, Metz Damien, Quéré Jean-Paul, Monin Jean-Luc
Department of Cardiology, INSERM, ERI-12, Amiens and University Hospital Amiens, Amiens, France.
J Am Coll Cardiol. 2009 May 19;53(20):1865-73. doi: 10.1016/j.jacc.2009.02.026.
This study investigated whether aortic valve replacement (AVR) is associated with improved survival in patients with severe low-flow/low-gradient aortic stenosis (LF/LGAS) without contractile reserve (CR) on dobutamine stress echocardiography (DSE).
Patients with LF/LGAS without CR have a high mortality rate with conservative therapy. The benefit of AVR in this subset of patients remains controversial.
Eighty-one consecutive patients with symptomatic calcified LF/LGAS (valve area <or=1 cm(2), left ventricular ejection fraction <or=40%, mean pressure gradient [MPG] <or=40 mm Hg) without CR on DSE were enrolled. Absence of CR was defined as the absence of increase in stroke volume of >or=20% compared with the baseline value. Multivariable analysis and propensity scores were used to compare survival according to whether or not AVR was performed (n = 55).
Five-year survival was higher in AVR patients compared with medically managed patients (54 +/- 7% vs. 13 +/- 7%, p = 0.001) despite a high operative mortality of 22% (n = 12). An AVR was independently associated with lower 5-year mortality (adjusted hazard ratio from 0.16 to 5.21 varying with time [95% confidence interval: 0.12-3.16 to 0.21-8.50], p = 0.00026). In 42 propensity-matched patients, 5-year survival was markedly improved by AVR (65 +/- 11% vs. 11 +/- 7%, p = 0.019). Associated bypass surgery (p = 0.007) and MPG <or=20 mm Hg (p = 0.035) were independently predictive of operative mortality. Late survival after AVR (excluding operative death) was 69 +/- 8% at 5 years.
In patients with LF/LGAS without CR on DSE, AVR is associated with better outcome compared with medical management. Surgery should not be withheld from this subset of patients solely on the basis of lack of CR on DSE.
本研究调查了在多巴酚丁胺负荷超声心动图（DSE）上无收缩储备（CR）的重度低流量/低梯度主动脉瓣狭窄（LF/LGAS）患者中，主动脉瓣置换术（AVR）是否与生存率提高相关。
无CR的LF/LGAS患者采用保守治疗时死亡率很高。AVR对这部分患者的益处仍存在争议。
连续纳入81例有症状的钙化性LF/LGAS患者（瓣口面积≤1 cm²，左心室射血分数≤40%，平均压力阶差[MPG]≤40 mmHg），这些患者在DSE上无CR。无CR定义为与基线值相比，每搏量增加未达到或超过20%。采用多变量分析和倾向评分，根据是否进行AVR（n = 55）比较生存率。
尽管手术死亡率高达22%（n = 12），但AVR患者的5年生存率高于接受药物治疗的患者（54±7% 对 13±7%，p = 0.001）。AVR与较低的5年死亡率独立相关（校正风险比随时间从0.16至5.21变化[95%置信区间：0.12 - 3.16至0.21 - 8.50]，p = 0.00026）。在42例倾向匹配患者中，AVR使5年生存率显著提高（65±11% 对 11±7%，p = 0.019）。相关的搭桥手术（p = 0.007）和MPG≤20 mmHg（p = 0.035）是手术死亡率的独立预测因素。AVR术后（不包括手术死亡）5年的晚期生存率为69±8%。
在DSE上无CR的LF/LGAS患者中，与药物治疗相比，AVR与更好的预后相关。不应仅基于DSE上无CR而拒绝为这部分患者进行手术。
