Bohbot Yohann, Rusinaru Dan, Delpierre Quentin, Marechaux Sylvestre, Tribouilloy Christophe
From the Department of Cardiology, Amiens University Hospital, France (Y.B., D.R., Q.D., C.T.); INSERM U-1088, Jules Verne University of Picardie, Amiens, France (D.R., S.M., C.T.); and Groupement des Hôpitaux de l'Institut Catholique de Lille/Faculté libre de médecine, Université Lille Nord de France (S.M.).
Circ Cardiovasc Imaging. 2017 Oct;10(10). doi: 10.1161/CIRCIMAGING.117.006760.
Current guidelines consider aortic valve replacement reasonable in asymptomatic patients with very severe aortic stenosis (AS); however, the definition of very severe AS based on peak aortic jet velocity (Vmax) remains unclear with a 5-m/s cutoff in US guidelines and 5.5 m/s in European guidelines. Because ≈20% of patients with severe AS and preserved left ventricular ejection fraction have Vmax in this range, we aimed to assess the relationship between Vmax and mortality and determine the best threshold to define very severe AS.
A total of 1140 patients with severe AS (aortic valve area ≤1 cm, Vmax ≥4 m/s) and preserved left ventricular ejection fraction were included. The population was divided into 4 groups according to Vmax (4-4.49, 4.5-4.99, 5-5.49, and ≥5.5 m/s). After adjustment for covariates (including surgery), there was no difference in all-cause mortality between Vmax 4 to 4.49 m/s and Vmax 4.5 to 4.99 m/s (=0.64). Both Vmax 5 to 5.49 m/s and Vmax ≥5.5 m/s exhibited significant excess mortality compared with Vmax 4 to 4.49 m/s (adjusted hazard ratio=1.34 [1.18-1.52]; <0.001, and 1.28 [1.16-1.41]; <0.001, respectively). Mortality risk was similar for Vmax 5 to 5.49 m/s and Vmax ≥5.5 m/s (=0.93). Compared with Vmax <5 m/s, patients with Vmax ≥5 m/s had greater mortality risk (adjusted hazard ratio=1.86 [1.55-2.54]; <0.001), even in the subgroup of asymptomatic even in the subgroup of asymptomatic patients (adjusted hazard ratio=2.08 [1.25-3.46]; =0.005).
Our results demonstrate the strong relationship between Vmax and mortality in patients with severe AS and preserved left ventricular ejection fraction irrespective of symptoms. Vmax ≥5 m/s at the time of AS diagnosis identifies patients with very severe AS at high risk of death.
当前指南认为，对于无症状的极重度主动脉瓣狭窄（AS）患者，主动脉瓣置换术是合理的；然而，基于主动脉峰值流速（Vmax）定义极重度AS仍不明确，美国指南的截断值为5 m/s，欧洲指南为5.5 m/s。由于约20%左心室射血分数保留的重度AS患者的Vmax在此范围内，我们旨在评估Vmax与死亡率之间的关系，并确定定义极重度AS的最佳阈值。
共纳入1140例左心室射血分数保留的重度AS患者（主动脉瓣面积≤1 cm²，Vmax≥4 m/s）。根据Vmax将患者分为4组（4 - 4.49、4.5 - 4.99、5 - 5.49和≥5.5 m/s）。在对协变量（包括手术）进行调整后，Vmax 4至4.49 m/s组与Vmax 4.5至4.99 m/s组的全因死亡率无差异（P = 0.64）。与Vmax 4至4.49 m/s相比，Vmax 5至5.49 m/s组和Vmax≥5.5 m/s组均显示出显著更高的死亡率（调整后风险比分别为1.34[1.18 - 1.52]；P < 0.001和1.28[1.16 - 1.41]；P < 0.001）。Vmax 5至5.49 m/s组和Vmax≥5.5 m/s组的死亡风险相似（P = 0.93）。与Vmax < 5 m/s相比，Vmax≥5 m/s的患者死亡风险更高（调整后风险比 = 1.86[1.55 - 2.54]；P < 0.001），即使在无症状亚组中也是如此（调整后风险比 = 2.08[1.25 - 3.46]；P = 0.005）。
我们的结果表明，在左心室射血分数保留的重度AS患者中，无论有无症状，Vmax与死亡率之间都存在密切关系。AS诊断时Vmax≥5 m/s可识别出死亡风险高的极重度AS患者。
