O'Sullivan Crochan J, Stortecky Stefan, Bütikofer Anne, Heg Dik, Zanchin Thomas, Huber Christoph, Pilgrim Thomas, Praz Fabien, Buellesfeld Lutz, Khattab Ahmed A, Blöchlinger Stefan, Carrel Thierry, Meier Bernhard, Zbinden Stephan, Wenaweser Peter, Windecker Stephan
From the Department of Cardiology (C.J.O., S.S., A.B., T.Z., T.P., F.P., L.B., A.A.K., S.B., B.M., S.Z., P.W., S.W.), Department of Cardiovascular Surgery (C.H., T.C.), and Clinical Trials Unit (D.H.), Bern University Hospital, Bern, Switzerland; and Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland (D.H.).
Circ Cardiovasc Interv. 2015 Feb;8(2):e001895. doi: 10.1161/CIRCINTERVENTIONS.114.001895.
Up to 1 in 6 patients undergoing transcatheter aortic valve implantation (TAVI) present with low-ejection fraction, low-gradient (LEF-LG) severe aortic stenosis and concomitant relevant mitral regurgitation (MR) is present in 30% to 55% of these patients. The effect of MR on clinical outcomes of LEF-LG patients undergoing TAVI is unknown.
Of 606 consecutive patients undergoing TAVI, 113 (18.7%) patients with LEF-LG severe aortic stenosis (mean gradient ≤40 mm Hg, aortic valve area <1.0 cm(2), left ventricular ejection fraction <50%) were analyzed. LEF-LG patients were dichotomized into ≤mild MR (n=52) and ≥moderate MR (n=61). Primary end point was all-cause mortality at 1 year. No differences in mortality were observed at 30 days (P=0.76). At 1 year, LEF-LG patients with ≥moderate MR had an adjusted 3-fold higher rate of all-cause mortality (11.5% versus 38.1%; adjusted hazard ratio, 3.27 [95% confidence interval, 1.31-8.15]; P=0.011), as compared with LEF-LG patients with ≤mild MR. Mortality was mainly driven by cardiac death (adjusted hazard ratio, 4.62; P=0.005). As compared with LEF-LG patients with ≥moderate MR assigned to medical therapy, LEF-LG patients with ≥moderate MR undergoing TAVI had significantly lower all-cause mortality (hazard ratio, 0.38; 95% confidence interval, 0.019-0.75) at 1 year.
Moderate or severe MR is a strong independent predictor of late mortality in LEF-LG patients undergoing TAVI. However, LEF-LG patients assigned to medical therapy have a dismal prognosis independent of MR severity suggesting that TAVI should not be withheld from symptomatic patients with LEF-LG severe aortic stenosis even in the presence of moderate or severe MR.
在接受经导管主动脉瓣植入术（TAVI）的患者中，高达六分之一的患者存在低射血分数、低跨瓣压差（LEF-LG）的重度主动脉瓣狭窄，且这些患者中有30%至55%伴有相关的二尖瓣反流（MR）。MR对接受TAVI的LEF-LG患者临床结局的影响尚不清楚。
在连续606例接受TAVI的患者中，分析了113例（18.7%）LEF-LG重度主动脉瓣狭窄患者（平均跨瓣压差≤40 mmHg，主动脉瓣面积<1.0 cm²，左心室射血分数<50%）。LEF-LG患者被分为轻度MR组（n = 52）和中度及以上MR组（n = 61）。主要终点是1年时的全因死亡率。30天时未观察到死亡率差异（P = 0.76）。1年时，与轻度MR组的LEF-LG患者相比，中度及以上MR组的LEF-LG患者全因死亡率调整后高出3倍（11.5%对38.1%；调整后风险比，3.27 [95%置信区间，1.31 - 8.15]；P = 0.011）。死亡率主要由心源性死亡驱动（调整后风险比，4.62；P = 0.005）。与接受药物治疗的中度及以上MR组的LEF-LG患者相比，接受TAVI的中度及以上MR组的LEF-LG患者1年时全因死亡率显著更低（风险比，0.38；95%置信区间，0.019 - 0.75）。
中度或重度MR是接受TAVI的LEF-LG患者晚期死亡的有力独立预测因素。然而，接受药物治疗的LEF-LG患者预后不佳，与MR严重程度无关，这表明即使存在中度或重度MR，对于有症状的LEF-LG重度主动脉瓣狭窄患者也不应拒绝行TAVI。
