Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec, Canada.
Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart & Lung Institute, Laval University, Québec, Canada.
JACC Cardiovasc Imaging. 2016 Jul;9(7):797-805. doi: 10.1016/j.jcmg.2015.09.026. Epub 2016 May 18.
This study sought to assess the survival benefit associated with aortic valve replacement (AVR) according to different strata of echocardiographic parameters of aortic stenosis (AS) severity, and especially in patients with an aortic valve area (AVA) comprised between 0.8 cm(2) and 1 cm(2).
Discordant findings between AVA (≤1.0 cm(2)) and mean gradient (MG) (<40 mm Hg) raise uncertainty regarding the actual severity of AS. Some studies suggested that the AVA threshold value to define severe AS should be decreased to 0.8 cm(2) to reconcile these discordances.
A total of 1,710 patients with documented moderate to severe AS by Doppler echocardiography were separated into 4 strata of AS severity based alternatively on AVA, indexed AVA, MG, or peak aortic jet velocity (Vpeak). We compared the survival rates of medically versus surgically treated patients. To eliminate covariate differences that may lead to biased estimates of treatment effect, a propensity matching with a greedy 5-to-1 digit-matching algorithm was used.
Mean AVA was 0.9 ± 0.3 cm(2), mean MG 33 ± 18 mm Hg, and mean Vpeak 3.6 ± 0.9 m/s. A total of 1,030 (60%) patients underwent AVR within 3 months following echocardiographic evaluation. During a mean follow-up of 4.4 ± 3.0 years there were 469 deaths. Patients with an AVA between 0.8 cm(2) and 1.0 cm(2) had a significant observed survival benefit with AVR (hazard ratio: 0.37 [95% confidence interval: 0.21 to 0.63]; p = 0.0002). AVR was also associated with improved survival in patients with MG between 25 mm Hg and 40 mm Hg or Vpeak between 3 m/s and 4 m/s, but only in patients with concomitant AVA ≤1 cm(2) (p = 0.001 vs. p = 0.46 in patients with AVA >1 cm(2)).
These results do not support decreasing the AVA threshold value for severity to 0.8 cm(2) and they confirm that AVR is associated with improved survival in a substantial number of patients with discordant aortic grading.
本研究旨在评估根据不同主动脉瓣狭窄（AS）严重程度的超声心动图参数分层，以及在主动脉瓣口面积（AVA）介于 0.8 cm(2) 和 1 cm(2)之间的患者中，主动脉瓣置换（AVR）的生存获益。
AVA（≤1.0 cm(2)）和平均梯度（MG）（<40 mmHg）之间的不一致结果使得 AS 的实际严重程度存在不确定性。一些研究表明，为了协调这些差异，应将定义严重 AS 的 AVA 阈值降低至 0.8 cm(2)。
共有 1710 例经多普勒超声心动图证实为中重度 AS 的患者，根据 AVA、指数化 AVA、MG 或峰值主动脉射流速度（Vpeak），分为 4 个 AS 严重程度分层。我们比较了药物治疗与手术治疗患者的生存率。为了消除可能导致治疗效果估计偏倚的协变量差异，使用贪婪的 5 对 1 数字匹配算法进行了倾向匹配。
平均 AVA 为 0.9 ± 0.3 cm(2)，平均 MG 为 33 ± 18 mmHg，平均 Vpeak 为 3.6 ± 0.9 m/s。共有 1030 例（60%）患者在超声心动图评估后 3 个月内接受了 AVR。平均随访 4.4±3.0 年后，共有 469 例死亡。AVA 在 0.8 cm(2)至 1.0 cm(2)之间的患者行 AVR 后具有显著的生存获益（风险比：0.37 [95%置信区间：0.21 至 0.63]；p=0.0002）。MG 在 25 mmHg 至 40 mmHg 之间或 Vpeak 在 3 m/s 至 4 m/s 之间的患者，行 AVR 后也可提高生存率，但仅在 AVA 同时≤1 cm(2)的患者中（p=0.001 与 AVA>1 cm(2)的患者相比 p=0.46）。
这些结果不支持将 AVA 严重程度的阈值降低至 0.8 cm(2)，并证实 AVR 与大量主动脉分级不一致的患者的生存改善相关。
