经导管主动脉瓣植入术治疗低流量、低梯度、重度主动脉瓣狭窄伴射血分数保留或降低患者的临床结局。
Clinical outcomes of patients with low-flow, low-gradient, severe aortic stenosis and either preserved or reduced ejection fraction undergoing transcatheter aortic valve implantation.
机构信息
Department of Cardiology, Swiss Cardiovascular Center Bern, Bern University Hospital, 3010 Bern, Switzerland.
出版信息
Eur Heart J. 2013 Nov;34(44):3437-50. doi: 10.1093/eurheartj/eht408. Epub 2013 Oct 3.
AIMS
Our aim was to evaluate the invasive haemodynamic indices of high-risk symptomatic patients presenting with 'paradoxical' low-flow, low-gradient, severe aortic stenosis (AS) (PLF-LG) and low-flow, low-gradient severe AS (LEF-LG) and to compare clinical outcomes following transcatheter aortic valve implantation (TAVI) among these challenging AS subgroups.
METHODS AND RESULTS
Of 534 symptomatic patients undergoing TAVI, 385 had a full pre-procedural right and left heart catheterization. A total of 208 patients had high-gradient severe AS [HGAS; mean gradient (MG) ≥40 mmHg], 85 had PLF-LG [MG ≤ 40 mmHg, indexed aortic valve area [iAVA] ≤0.6 cm(2) m(-2), stroke volume index ≤35 mL/m(2), ejection fraction (EF) ≥50%], and 61 had LEF-LG (MG ≤ 40 mmHg, iAVA ≤0.6 cm(2) m(-2), EF ≤40%). Compared with HGAS, PLF-LG and LEF-LG had higher systemic vascular resistances (HGAS: 1912 ± 654 vs.
PLF-LG: 2006 ± 586 vs.
LEF-LG: 2216 ± 765 dyne s m(-5), P = 0.007) but lower valvulo-arterial impedances (HGAS: 7.8 ± 2.7 vs.
PLF-LG: 6.9 ± 1.9 vs.
LEF-LG: 7.7 ± 2.5 mmHg mL(-1) m(-2), P = 0.027). At 30 days, no differences in cardiac death (6.5 vs. 4.9 vs. 6.6%, P = 0.90) or death (8.4 vs. 6.1 vs. 6.6%, P = 0.88) were observed among HGAS, PLF-LG, and LEF-LG groups, respectively. At 1 year, New York Heart Association functional improvement occurred in most surviving patients (HGAS: 69.2% vs.
PLF-LG: 71.7% vs.
LEF-LG: 89.3%, P = 0.09) and no significant differences in overall mortality were observed (17.6 vs. 20.5 vs. 24.5%, P = 0.67). Compared with HGAS, LEF-LG had a higher 1 year cardiac mortality (adjusted hazard ratio 2.45, 95% confidence interval 1.04-5.75, P = 0.04).
CONCLUSION
TAVI in PLF-LG or LEF-LG patients is associated with overall mortality rates comparable with HGAS patients and all groups profit symptomatically to a similar extent.
目的
本研究旨在评估出现“矛盾性”低流量低梯度重度主动脉瓣狭窄（AS）（PLF-LG）和低流量低梯度重度 AS（LEF-LG）症状的高危患者的侵入性血流动力学指数，并比较这些具有挑战性的 AS 亚组患者经导管主动脉瓣置换术（TAVI）后的临床结局。
方法和结果
在接受 TAVI 的 534 名有症状患者中，385 名患者进行了全面的术前右心和左心导管检查。共有 208 名患者为高梯度重度 AS [HGAS；平均梯度（MG）≥40mmHg]，85 名为 PLF-LG [MG≤40mmHg，指数主动脉瓣面积（iAVA）≤0.6cm²/m²，每搏量指数≤35mL/m²，射血分数（EF）≥50%]，61 名为 LEF-LG（MG≤40mmHg，iAVA≤0.6cm²/m²，EF≤40%）。与 HGAS 相比，PLF-LG 和 LEF-LG 的全身血管阻力（HGAS：1912±654 vs. PLF-LG：2006±586 vs. LEF-LG：2216±765 dyne s m⁻⁵，P=0.007）更高，但脉管阻抗（HGAS：7.8±2.7 vs. PLF-LG：6.9±1.9 vs. LEF-LG：7.7±2.5mmHg mL⁻¹ m⁻²，P=0.027）更低。在 30 天时，HGAS、PLF-LG 和 LEF-LG 组之间的心脏死亡（6.5% vs. 4.9% vs. 6.6%，P=0.90）或死亡（8.4% vs. 6.1% vs. 6.6%，P=0.88）无差异。在 1 年时，大多数幸存患者的纽约心脏协会功能得到改善（HGAS：69.2% vs. PLF-LG：71.7% vs. LEF-LG：89.3%，P=0.09），总死亡率无显著差异（17.6% vs. 20.5% vs. 24.5%，P=0.67）。与 HGAS 相比，LEF-LG 患者 1 年的心脏死亡率更高（调整后的危险比 2.45，95%置信区间 1.04-5.75，P=0.04）。
结论
PLF-LG 或 LEF-LG 患者的 TAVI 与 HGAS 患者的总体死亡率相当，所有患者在症状上均有相似程度的获益。
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