Eleid Mackram F, Michelena Hector I, Nkomo Vuyisile T, Nishimura Rick A, Malouf Joseph F, Scott Christopher G, Pellikka Patricia A
Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA.
Eur Heart J Cardiovasc Imaging. 2015 Nov;16(11):1270-5. doi: 10.1093/ehjci/jev091. Epub 2015 Apr 20.
Reduced stroke volume index (SVI) in patients with severe aortic stenosis (AS) and preserved ejection fraction (EF) is associated with adverse outcomes even after aortic valve replacement (AVR), although specific reasons for impaired survival in this group are unknown. We investigated predictors of post-AVR survival and specific cause of death in patients with AS according to SVI.
Among 1120 consecutive patients with severe AS (aortic valve area <1.0 cm(2)) and preserved EF (≥50%) using 2-D and Doppler echocardiography who had AVR, 61 (5%) patients had reduced SVI [<35 mL/m(2) (low flow, LF)] and 1059 (95%) had normal SVI [≥35 mL/m(2) (normal flow, NF)]. Survival post-AVR was lower in patients with LF compared with NF [3-year survival in LF group 76% (95% CI 70-82) vs. 89% (95% CI 88-90%), P = 0.03] primarily due to higher cardiac mortality [3-year event rate 13% (95% CI 8-18%) in LF vs. 5% (95% CI 5-7%) in NF, P = 0.02]. Congestive heart failure (CHF) was the most common cause of cardiac death in the LF group (57% of post-AVR cardiac deaths) and was a more frequent cause of death in LF compared with NF (3-year risk 7 vs. 2%, P = 0.008). Multivariable predictors of post-AVR mortality included age, creatinine, haemoglobin, right ventricular systolic pressure, SVI, and cognitive impairment.
Reduced SVI is associated with higher cardiac mortality after AVR. CHF is the predominant cause of cardiac mortality after AVR in patients with LF, suggesting the presence of persistent myocardial impairment in this population.
重度主动脉瓣狭窄（AS）且射血分数（EF）保留的患者，即使在进行主动脉瓣置换术（AVR）后，其每搏量指数（SVI）降低仍与不良预后相关，尽管该组患者生存受损的具体原因尚不清楚。我们根据SVI调查了AS患者AVR术后生存的预测因素及具体死因。
在1120例连续接受AVR的重度AS（主动脉瓣面积<1.0 cm²）且EF保留（≥50%）的患者中，使用二维和多普勒超声心动图检查，61例（5%）患者SVI降低[<35 mL/m²（低流量，LF）]，1059例（95%）患者SVI正常[≥35 mL/m²（正常流量，NF）]。与NF组相比，LF组患者AVR术后生存率较低[LF组3年生存率为76%（95%CI 70 - 82），而NF组为89%（95%CI 88 - 90%），P = 0.03]，主要是因为心脏死亡率较高[LF组3年事件发生率为13%（95%CI 8 - 18%），NF组为5%（95%CI 5 - 7%），P = 0.02]。充血性心力衰竭（CHF）是LF组心脏死亡的最常见原因（占AVR术后心脏死亡的57%），且与NF组相比，LF组中CHF作为死亡原因更为常见（3年风险分别为7%和2%，P = 0.008）。AVR术后死亡的多变量预测因素包括年龄、肌酐、血红蛋白、右心室收缩压、SVI和认知障碍。
SVI降低与AVR术后较高的心脏死亡率相关。CHF是LF患者AVR术后心脏死亡的主要原因，提示该人群存在持续性心肌损伤。
