Division of Cardiology, Department of Internal Medicine, Teikyo University Hospital, Tokyo, Japan.
Division of Cardiovascular Medicine, Toyohashi Heart Center, Aichi, Japan.
JACC Cardiovasc Imaging. 2018 May;11(5):659-669. doi: 10.1016/j.jcmg.2016.12.028. Epub 2017 May 17.
This study aimed to analyze the prognostic impact of low-flow (LF) severe aortic stenosis in small-body patients undergoing transcatheter aortic valve replacement (TAVR).
Western literature demonstrates a poor prognosis with paradoxical LF and low-flow low-gradient (LF-LG) severe aortic stenosis (AS), as defined by stroke volume index (SVi) <35 ml/m and mean pressure gradient <40 mm Hg with preserved left ventricular ejection fraction (LVEF). However, this poor prognosis is contested in Japan owing to the smaller body size of Japanese patients relative to that of Western patients. Additionally, there are no reports of the prognostic implication of paradoxical LF or LF-LG severe AS in small-body patients undergoing TAVR.
This was a retrospective analysis of 723 consecutive Japanese patients (median age 85 years; 32.6% male; median body surface area 1.4 m) who underwent TAVR for severe AS at 9 sites in Japan. The primary and secondary endpoints were cumulative all-cause and cardiovascular mortality after TAVR, respectively.
Ninety-seven (13.4%) patients had paradoxical LF severe AS whereas 38 (5.3%) had paradoxical LF-LG with severe AS. PLF was associated with a significant increase in all-cause (hazard ratio [HR]: 3.00; 95% confidence interval [CI]: 1.34 to 6.72; p < 0.001) and cardiovascular mortality (HR: 5.58; 95% CI: 1.19 to 26.2; p < 0.01), as compared with patients' normal flow and preserved LVEF. PLF-LG was associated with a significant increase in all-cause mortality (HR: 3.76; 95% CI: 1.09 to 13.73; p < 0.01), as compared with normal flow high gradient with preserved LVEF. SVi was an independent predictor of cardiovascular mortality on multivariate analysis after adjustments for age, sex, clinically relevant variables, and other echocardiographic parameters (HR: 1.96; 95% CI: 1.19 to 3.23; p < 0.01).
Among Japanese small-body patients with severe AS, both paradoxical LF and LF-LG severe AS were associated with poor outcomes following TAVR. SVi was an independent predictor of cardiovascular mortality after TAVR. (Optimised Transcatheter Valvular Intervention registry [OCEAN-TAVI]; UMIN000020423).
本研究旨在分析经导管主动脉瓣置换术（TAVR）中小体型患者中低流量（LF）重度主动脉瓣狭窄的预后影响。
西方文献表明，与 stroke volume index（SVi）<35 ml/m 和平均压力梯度 <40 mmHg 伴保留左心室射血分数（LVEF）的悖论性 LF 和低流量低梯度（LF-LG）重度主动脉瓣狭窄（AS）相比，悖论性 LF 和 LF-LG 重度 AS 患者预后较差。然而，由于日本患者的体型比西方患者小，这种不良预后在日本受到质疑。此外，尚无关于 TAVR 中小体型患者中悖论性 LF 或 LF-LG 重度 AS 的预后意义的报告。
这是一项在日本 9 个地点接受 TAVR 治疗重度 AS 的 723 例连续日本患者（中位年龄 85 岁；32.6%为男性；中位体表面积 1.4 m）的回顾性分析。主要和次要终点分别是 TAVR 后累积全因和心血管死亡率。
97 例（13.4%）患者存在悖论性 LF 重度 AS，38 例（5.3%）患者存在悖论性 LF-LG 重度 AS。与正常血流和保留的 LVEF 相比，PLF 与全因（风险比 [HR]：3.00；95%置信区间 [CI]：1.34 至 6.72；p<0.001）和心血管死亡率（HR：5.58；95%CI：1.19 至 26.2；p<0.01）显著增加相关。与正常血流高梯度伴保留的 LVEF 相比，PLF-LG 与全因死亡率显著增加相关（HR：3.76；95%CI：1.09 至 13.73；p<0.01）。多变量分析校正年龄、性别、临床相关变量和其他超声心动图参数后，SVi 是心血管死亡率的独立预测因子（HR：1.96；95%CI：1.19 至 3.23；p<0.01）。
在日本小体型重度 AS 患者中，悖论性 LF 和 LF-LG 重度 AS 均与 TAVR 后不良结局相关。SVi 是 TAVR 后心血管死亡率的独立预测因子。（优化经导管瓣膜干预登记处[OCEAN-TAVI]；UMIN000020423）。
