Department of Cardiology, University Hospital Amiens, Amiens, France; INSERM U-1088, Jules Verne University of Picardie, Amiens, France.
Department of Cardiology, University Hospital Amiens, Amiens, France; Department of Cardiology, Hospital of Saint Quentin, Saint Quentin, France.
J Am Coll Cardiol. 2015 Jan 6;65(1):55-66. doi: 10.1016/j.jacc.2014.09.080.
BACKGROUND: Severe low-gradient, low-flow (LG/LF) aortic stenosis with preserved left ventricular ejection fraction (EF) has been described as a more advanced form of aortic stenosis. However, the natural history and need for surgery in patients with LG/LF aortic stenosis remain subjects of intense debate. OBJECTIVES: We sought to investigate the outcome of LG/LF aortic stenosis in comparison with moderate aortic stenosis and with high-gradient (HG) aortic stenosis in a real-world study, in the context of routine practice. METHODS: This analysis included 809 patients (ages 75 ± 12 years) diagnosed with aortic stenosis and preserved EF (≥50%). Patients were divided into 4 groups: mild-to-moderate aortic stenosis; HG aortic stenosis; LG/LF aortic stenosis; and low-gradient, normal-flow (LG/NF) aortic stenosis. RESULTS: Compared with mild-to-moderate aortic stenosis patients, LG/LF aortic stenosis patients had smaller valve areas and stroke volumes, higher mean gradients, and comparable degrees of ventricular hypertrophy. Under medical management (22.8 months; range 7 to 53 months), compared with mild-to-moderate aortic stenosis patients, HG aortic stenosis patients were at higher risk of death (adjusted hazard ratio [HR]: 1.47; 95% confidence interval [CI]: 1.03 to 2.07), whereas LG/LF aortic stenosis patients did not have an excess mortality risk (adjusted HR: 0.88; 95% CI: 0.53 to 1.48). During the entire (39.0 months; range 11 to 69 months) follow-up (with medical and surgical management), the mortality risk associated with LG/LF aortic stenosis was close to that of mild-to-moderate aortic stenosis (adjusted HR: 0.96; 95% CI: 0.58 to 1.53), whereas the excess risk of death associated with HG aortic stenosis was confirmed (adjusted HR: 1.74; 95% CI: 1.27 to 2.39). The benefit associated with aortic valve replacement was confined to the HG aortic stenosis group (adjusted HR: 0.29; 95% CI: 0.18 to 0.46) and was not observed for LG/LF aortic stenosis (adjusted HR: 0.75; 95% CI: 0.14 to 4.05). CONCLUSIONS: In this study, the outcome of severe LG/LF aortic stenosis with preserved EF was similar to that of mild-to-moderate aortic stenosis and was not favorably influenced by aortic surgery. Further research is needed to better understand the natural history and the progression of LG/LF aortic stenosis.
背景：严重低梯度、低流量（LG/LF）伴射血分数保留的主动脉瓣狭窄（AS）被描述为更严重的主动脉瓣狭窄形式。然而，LG/LF 主动脉瓣狭窄患者的自然病程和手术需求仍然是激烈争论的话题。
目的：我们旨在在常规实践背景下，通过真实世界研究比较 LG/LF 主动脉瓣狭窄与中度主动脉瓣狭窄和高梯度（HG）主动脉瓣狭窄患者的预后。
方法：本分析纳入 809 例（年龄 75±12 岁）诊断为主动脉瓣狭窄且射血分数保留（≥50%）的患者。患者被分为 4 组：轻度至中度主动脉瓣狭窄；HG 主动脉瓣狭窄；LG/LF 主动脉瓣狭窄；低梯度、正常流量（LG/NF）主动脉瓣狭窄。
结果：与轻度至中度主动脉瓣狭窄患者相比，LG/LF 主动脉瓣狭窄患者的瓣口面积和每搏输出量更小，平均梯度更高，心室肥厚程度相似。在药物治疗（22.8 个月；范围 7 至 53 个月）期间，与轻度至中度主动脉瓣狭窄患者相比，HG 主动脉瓣狭窄患者死亡风险更高（校正风险比[HR]：1.47；95%置信区间[CI]：1.03 至 2.07），而 LG/LF 主动脉瓣狭窄患者的死亡风险没有增加（校正 HR：0.88；95% CI：0.53 至 1.48）。在整个（39.0 个月；范围 11 至 69 个月）随访期间（包括药物和手术治疗），LG/LF 主动脉瓣狭窄患者的死亡风险与轻度至中度主动脉瓣狭窄患者相近（校正 HR：0.96；95% CI：0.58 至 1.53），而 HG 主动脉瓣狭窄患者的死亡风险仍较高（校正 HR：1.74；95% CI：1.27 至 2.39）。主动脉瓣置换的获益仅限于 HG 主动脉瓣狭窄组（校正 HR：0.29；95% CI：0.18 至 0.46），而在 LG/LF 主动脉瓣狭窄患者中未观察到（校正 HR：0.75；95% CI：0.14 至 4.05）。
结论：在这项研究中，严重 LG/LF 伴射血分数保留的主动脉瓣狭窄的预后与轻度至中度主动脉瓣狭窄相似，主动脉瓣手术并不能改善其预后。需要进一步研究以更好地了解 LG/LF 主动脉瓣狭窄的自然病程和进展。
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