经导管主动脉瓣置换术治疗主动脉瓣狭窄后的血压和动脉负荷
Blood Pressure and Arterial Load After Transcatheter Aortic Valve Replacement for Aortic Stenosis.
作者信息
Lindman Brian R, Otto Catherine M, Douglas Pamela S, Hahn Rebecca T, Elmariah Sammy, Weissman Neil J, Stewart William J, Ayele Girma M, Zhang Feifan, Zajarias Alan, Maniar Hersh S, Jilaihawi Hasan, Blackstone Eugene, Chinnakondepalli Khaja M, Tuzcu E Murat, Leon Martin B, Pibarot Philippe
机构信息
From the Structural Heart and Valve Center, Vanderbilt University Medical Center, Nashville, TN (B.R.L.); Washington University School of Medicine, St. Louis, MO (B.R.L., A.Z., H.S.M.); University of Washington School of Medicine, Seattle (C.M.O.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (P.S.D.); Columbia University Medical Center, New York, NY (R.T.H., M.B.L.); Massachusetts General Hospital, Boston (S.E.); Medstar Health Research Institute, Georgetown University School of Medicine, Washington, DC (N.J.W.); Cleveland Clinic, OH (W.J.S., E.B., E.M.T.); Cardiovascular Research Foundation, New York, NY (G.M.A., F.Z., M.B.L.); Cedars-Sinai Medical Center, Los Angeles, CA (H.J.); Saint Luke's Mid America Heart Institute, Kansas City, MO (K.M.C.); and Department of Medicine, Laval University, Quebec City, Quebec, Canada (P.P.).
出版信息
Circ Cardiovasc Imaging. 2017 Jul;10(7). doi: 10.1161/CIRCIMAGING.116.006308.
BACKGROUND
After aortic valve replacement, left ventricular afterload is often characterized by the residual valve obstruction. Our objective was to determine whether higher systemic arterial afterload-as reflected in blood pressure, pulsatile and resistive load-is associated with adverse clinical outcomes after transcatheter aortic valve replacement (TAVR).
METHODS AND RESULTS
Total, pulsatile, and resistive arterial load were measured in 2141 patients with severe aortic stenosis treated with TAVR in the PARTNER I trial (Placement of Aortic Transcatheter Valve) who had systolic blood pressure (SBP) and an echocardiogram obtained 30 days after TAVR. The primary end point was 30-day to 1-year all-cause mortality. Lower SBP at 30 days after TAVR was associated with higher mortality (20.0% for SBP 100-129 mm Hg versus 12.0% for SBP 130-170 mm Hg; <0.001). This association remained significant after adjustment, was consistent across subgroups, and confirmed in sensitivity analyses. In adjusted models that included SBP, higher total and pulsatile arterial load were associated with increased mortality (<0.001 for all), but resistive load was not. Patients with low 30-day SBP and high pulsatile load had a 3-fold higher mortality than those with high 30-day SBP and low pulsatile load (26.1% versus 8.1%; hazard ratio, 3.62; 95% confidence interval, 2.36-5.55).
CONCLUSIONS
Even after relief of valve obstruction in patients with aortic stenosis, there is an independent association between post-TAVR blood pressure, systemic arterial load, and mortality. Blood pressure goals in patients with a history of aortic stenosis may need to be redefined. Increased pulsatile arterial load, rather than blood pressure, may be a target for adjunctive medical therapy to improve outcomes after TAVR.
CLINICAL TRIAL REGISTRATION
URL: http://www.clinicaltrials.gov. Unique identifier: NCT00530894.
背景
主动脉瓣置换术后，左心室后负荷常以残余瓣膜梗阻为特征。我们的目的是确定较高的体循环动脉后负荷（如血压、搏动性和阻力负荷所反映的）是否与经导管主动脉瓣置换术（TAVR）后的不良临床结局相关。
方法与结果
在 PARTNER I 试验（主动脉经导管瓣膜置入）中，对 2141 例接受 TAVR 治疗的重度主动脉瓣狭窄患者测量了总动脉负荷、搏动性动脉负荷和阻力性动脉负荷，这些患者在 TAVR 后 30 天测量了收缩压（SBP）并进行了超声心动图检查。主要终点是 30 天至 1 年的全因死亡率。TAVR 后 30 天较低的 SBP 与较高的死亡率相关（SBP 为 100 - 129 mmHg 的患者死亡率为 20.0%，而 SBP 为 130 - 170 mmHg 的患者死亡率为 12.0%；P < 0.001）。调整后这种关联仍然显著，在各亚组中一致，并在敏感性分析中得到证实。在包含 SBP 的调整模型中，较高的总动脉负荷和搏动性动脉负荷与死亡率增加相关（所有 P < 0.001），但阻力性动脉负荷与死亡率无关。TAVR 后 30 天 SBP 低且搏动性负荷高的患者死亡率比 SBP 高且搏动性负荷低的患者高 3 倍（26.1% 对 8.1%；风险比，3.62；95% 置信区间，2.36 - 5.55）。
结论
即使在主动脉瓣狭窄患者的瓣膜梗阻解除后，TAVR 后的血压、体循环动脉负荷与死亡率之间仍存在独立关联。主动脉瓣狭窄病史患者的血压目标可能需要重新定义。增加的搏动性动脉负荷而非血压，可能是改善 TAVR 后结局的辅助药物治疗靶点。
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