Maes Frédéric, Boulif Jamila, Piérard Sophie, de Meester Christophe, Melchior Julie, Gerber Bernhard, Vancraeynest David, Pouleur Anne-Catherine, Lazam Siham, Pasquet Agnès, Vanoverschelde Jean-Louis
From Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium, and Division of Cardiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium.
Circ Cardiovasc Imaging. 2014 Jul;7(4):714-22. doi: 10.1161/CIRCIMAGING.113.001695. Epub 2014 Apr 28.
Up to 30% of patients with severe aortic stenosis (SAS; indexed aortic valve area <0.6 cm(2)/m(2)) present with low transvalvular gradient despite a normal left ventricular ejection fraction. Presently, there is intense controversy as to the prognostic implications of such findings. Accordingly, the aim of the present work was to compare the natural history of patients with paradoxical low-gradient (PLG) or high-gradient (HG) SAS.
We prospectively studied 349 patients with SAS and preserved left ventricular ejection fraction. Patients were categorized into HG-SAS (n=144) and PLG-SAS (n=205) according to mean transvalvular gradient (mean gradient >40 or ≤40 mm Hg). Primary end points were all-cause mortality and echocardiographic disease progression. To evaluate natural history, patients undergoing aortic valve replacement were censored at the time of surgery (n=92). During a median follow-up of 28 months, 148 patients died. Kaplan-Meier survival curves showed better survival in PLG-SAS than in HG-SAS, both in the overall population (48% versus 31%; P<0.01) and in the asymptomatic subgroup (59% versus 35%; P<0.02). In asymptomatic patients, Cox analysis identified age, diabetes mellitus, left atrial volume, and mean gradient as independent predictors of death. Finally, at last echocardiographic follow-up, PLG-SAS demonstrated significant increases in mean gradient (from 29±6 to 38±11 mm Hg; P<0.001).
Our study indicates that PLG-SAS is a less malignant form of AS compared with HG-SAS, because their spontaneous outcome is better. We further demonstrated that patients with PLG-SAS are en route toward the more severe HG-SAS form, because the majority of them evolve into HG-SAS over time.
高达30%的重度主动脉瓣狭窄（SAS；主动脉瓣面积指数<0.6 cm²/m²）患者尽管左心室射血分数正常，但跨瓣压差较低。目前，关于这些发现的预后意义存在激烈争议。因此，本研究的目的是比较矛盾性低压差（PLG）或高压差（HG）SAS患者的自然病程。
我们前瞻性研究了349例SAS且左心室射血分数保留的患者。根据平均跨瓣压差（平均压差>40或≤40 mmHg）将患者分为HG-SAS组（n = 144）和PLG-SAS组（n = 205）。主要终点是全因死亡率和超声心动图疾病进展。为评估自然病程，接受主动脉瓣置换术的患者在手术时被剔除（n = 92）。在中位随访28个月期间，148例患者死亡。Kaplan-Meier生存曲线显示，PLG-SAS患者的生存率在总体人群中（48%对31%；P<0.01）和无症状亚组中（59%对35%；P<0.02）均优于HG-SAS患者。在无症状患者中，Cox分析确定年龄、糖尿病、左心房容积和平均压差是死亡的独立预测因素。最后，在末次超声心动图随访时，PLG-SAS患者的平均压差显著增加（从29±6 mmHg增至38±11 mmHg；P<0.001）。
我们的研究表明，与HG-SAS相比，PLG-SAS是一种恶性程度较低的AS形式，因为其自发转归更好。我们进一步证明，PLG-SAS患者正朝着更严重的HG-SAS形式发展，因为随着时间的推移，他们中的大多数会演变为HG-SAS。
