Department of Cardiology, Heart Valve Disease Clinic, University Hospital Sart Tilman, University of Liège, Belgium.
Circulation. 2010 Jul 6;122(1):33-41. doi: 10.1161/CIRCULATIONAHA.110.938241. Epub 2010 Jun 21.
Current guidelines recommend mitral valve surgery for asymptomatic patients with severe degenerative mitral regurgitation and preserved left ventricular systolic function when exercise pulmonary hypertension (PHT) is present. However, the determinants of exercise PHT have not been evaluated. The aim of this study was to identify the echocardiographic predictors of exercise PHT and the impact on symptoms.
Comprehensive resting and exercise transthoracic echocardiography was performed in 78 consecutive patients (age, 61+/-13 years; 56% men) with at least moderate degenerative mitral regurgitation (effective regurgitant orifice area =43+/-20 mm(2); regurgitant volume =71+/-27 mL). Exercise PHT was defined as a systolic pulmonary arterial pressure (SPAP) >60 mm Hg. Exercise PHT was present in 46% patients. In multivariable analysis, exercise effective regurgitant orifice was an independent determinant of exercise SPAP (P<0.0001) and exercise PHT (P=0.002). Resting PHT and exercise PHT were associated with markedly reduced 2-year symptom-free survival (36+/-14% versus 59+/-7%, P=0.04; 35+/-8% versus 75+/-7%, P<0.0001). After adjustment, although the impact of resting PHT was no longer significant, exercise PHT was identified as an independent predictor of the occurrence of symptoms (hazard ratio=3.4; P=0.002). Receiver-operating characteristics curves revealed that exercise PHT (SPAP >56 mm Hg) was more accurate than resting PHT (SPAP >36 mm Hg) in predicting the occurrence of symptoms during follow-up (P=0.032).
Exercise PHT is frequent in patients with asymptomatic degenerative mitral regurgitation. Exercise mitral regurgitation severity is a strong independent predictor of both exercise SPAP and exercise PHT. Exercise PHT is associated with markedly low 2-year symptom-free survival, emphasizing the use of exercise echocardiography. An exercise SPAP >56 mm Hg accurately predicts the occurrence of symptoms.
目前的指南建议，对于无症状的退行性二尖瓣反流且左心室收缩功能正常的患者，如果存在运动性肺动脉高压（PHT），则行二尖瓣手术。然而，运动性 PHT 的决定因素尚未得到评估。本研究旨在确定运动性 PHT 的超声心动图预测指标及其对症状的影响。
对 78 例连续的退行性二尖瓣中重度反流患者（年龄 61+/-13 岁；56%为男性）进行了全面的静息和运动经胸超声心动图检查，有效反流口面积=43+/-20mm²；反流容积=71+/-27mL）。运动性 PHT 定义为收缩期肺动脉压（SPAP）>60mmHg。46%的患者存在运动性 PHT。多变量分析显示，运动性有效反流口是运动性 SPAP（P<0.0001）和运动性 PHT（P=0.002）的独立决定因素。静息性 PHT 和运动性 PHT 与 2 年无症状生存显著降低相关（36+/-14%比 59+/-7%，P=0.04；35+/-8%比 75+/-7%，P<0.0001）。调整后，尽管静息性 PHT 的影响不再显著，但运动性 PHT 被确定为症状发生的独立预测因素（风险比=3.4；P=0.002）。受试者工作特征曲线显示，运动性 PHT（SPAP>56mmHg）比静息性 PHT（SPAP>36mmHg）更能准确预测随访期间症状的发生（P=0.032）。
无症状退行性二尖瓣反流患者中运动性 PHT 很常见。运动性二尖瓣反流严重程度是运动性 SPAP 和运动性 PHT 的强独立预测因素。运动性 PHT 与 2 年无症状生存明显降低相关，强调了运动超声心动图的应用。运动性 SPAP>56mmHg 可准确预测症状的发生。
