Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada.
Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Muenster, Germany.
J Am Coll Cardiol. 2016 Aug 9;68(6):577-585. doi: 10.1016/j.jacc.2016.05.059.
Residual aortic regurgitation (AR) following transcatheter aortic valve replacement (TAVR) is associated with greater mortality; yet, determining AR severity post-TAVR using Doppler echocardiography remains challenging. Cardiovascular magnetic resonance (CMR) is purported as a more accurate means of quantifying AR; however, no data exist regarding the prognostic value of AR as assessed by CMR post-TAVR.
This study sought to evaluate the effect of AR assessed with CMR on clinical outcomes post-TAVR.
We included 135 patients from 3 centers. AR was quantified using regurgitant fraction (RF) measured by phase-contrast velocity mapping CMR at a median of 40 days post-TAVR, and using Doppler echocardiography at a median of 6 days post-TAVR. Median follow-up was 26 months. Clinical outcomes included mortality and rehospitalization for heart failure.
Moderate-severe AR occurred in 17.1% and 12.8% of patients as measured by echocardiography and CMR, respectively. Higher RF post-TAVR was associated with increased mortality (hazard ratio: 1.18 for each 5% increase in RF [95% confidence interval: 1.08 to 1.30]; p < 0.001) and the combined endpoint of mortality and rehospitalization for heart failure (hazard ratio: 1.19 for each 5% increase in RF; 95% confidence interval: 1.15 to 1.23; p < 0.001). Prediction models yielded significant incremental predictive value; CMR performed a median of 40 days post-TAVR had a greater association with post-TAVR clinical events compared with early echocardiography (p < 0.01). RF ≥30% best predicted poorer clinical outcomes (p < 0.001 for either mortality or the combined endpoint of mortality and heart failure rehospitalization).
Worse CMR-quantified AR was associated with increased mortality and poorer clinical outcomes following TAVR. Quantifying AR with CMR may identify patients with AR who could benefit from additional treatment measures.
经导管主动脉瓣置换术（TAVR）后残余主动脉瓣反流（AR）与死亡率增加相关；然而，使用多普勒超声心动图来确定 TAVR 后的 AR 严重程度仍然具有挑战性。心血管磁共振（CMR）被认为是一种更准确的 AR 定量方法；然而，关于 TAVR 后 CMR 评估的 AR 的预后价值尚无数据。
本研究旨在评估 CMR 评估的 AR 对 TAVR 后临床结局的影响。
我们纳入了来自 3 个中心的 135 名患者。使用相位对比速度映射 CMR 在 TAVR 后中位数 40 天测量反流分数（RF）来定量 AR，在 TAVR 后中位数 6 天使用多普勒超声心动图来定量 AR。中位随访时间为 26 个月。临床结局包括死亡率和心力衰竭再住院。
在超声心动图和 CMR 测量中，分别有 17.1%和 12.8%的患者发生中度至重度 AR。TAVR 后 RF 较高与死亡率增加相关（风险比：RF 每增加 5%，风险增加 1.18[95%置信区间：1.08 至 1.30]；p<0.001），以及死亡率和心力衰竭再住院的联合终点（风险比：RF 每增加 5%，风险增加 1.19[95%置信区间：1.15 至 1.23]；p<0.001）。预测模型产生了显著的增量预测价值；TAVR 后中位数 40 天进行的 CMR 与 TAVR 后临床事件的相关性大于早期超声心动图（p<0.01）。RF≥30% 最佳预测临床结局较差（死亡率或死亡率和心力衰竭再住院的联合终点的预测均 p<0.001）。
CMR 定量评估的 AR 更严重与 TAVR 后死亡率增加和临床结局较差相关。使用 CMR 定量 AR 可能可以识别出需要额外治疗措施的 AR 患者。
