重度二尖瓣反流对评估主动脉瓣狭窄严重程度的影响。
Impact of Significant Mitral Regurgitation on Assessing the Severity of Aortic Stenosis.
机构信息
Department of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
Division of Cardiology, School of Medicine, Chungnam National University, Daejeon, Korea.
出版信息
J Am Soc Echocardiogr. 2018 Jan;31(1):26-33. doi: 10.1016/j.echo.2017.09.012. Epub 2017 Nov 20.
BACKGROUND
Significant mitral regurgitation (MR) may reduce a pressure gradient of aortic stenosis (AS) by decreasing forward stroke volume. The study objective was to evaluate whether significant MR can cause inconsistency when assessing the severity of AS.
METHODS
Among 5,355 patients diagnosed with AS from 2000 to 2015, 68 were retrospectively found to have concomitant significant (moderate or greater) MR and normal left ventricular ejection fractions in normal sinus rhythm (AS with MR). As a control group, 136 patients with trivial or no MR were selected who were matched by age, gender, and left ventricular end-systolic volume (AS without MR). Nonlinear regression was performed for data pairs (aortic valve area [AVA] vs mean pressure gradient [MPG]) using the formula AVA = a + b/√MPG. Composite clinical events were defined as aortic valve surgery warranted by the development of symptoms or left ventricular dysfunction, admission because of heart failure, and death.
RESULTS
The forward stroke volume index was significantly lower in the AS with MR group than in the AS without MR group (43.8 ± 8.3 vs 49.2 ± 10.2 mL/m, P < .004). A significant group difference was found with respect to the relationship between (indexed) AVA and MPG (AVA, 0.02 + 4.43/√MPG vs -0.06 + 5.60/√MPG [P for interaction = .04]; indexed AVA, 0.03 + 2.66/√MPG vs -0.03 + 3.47/√MPG [P for interaction = .01]). An AVA of 1.0 cm corresponded to MPGs of 20.3 and 28.2 mm Hg for the groups with and without MR, respectively. Conversely, an MPG of 40 mm Hg corresponded to AVAs of 0.72 and 0.83 cm for the groups with and without MR, respectively. Among patients with MPGs < 40 mm Hg, clinical event rates were significantly higher in those with MR compared with those without MR (P = .009).
CONCLUSIONS
This quantitative analysis demonstrated that AS severity assessed by MPG measurement may be underestimated, and thus AVA measurement is essential in patients with combined significant MR.
背景
严重的二尖瓣反流（MR）可通过降低前向心搏量而降低主动脉瓣狭窄（AS）的压力梯度。本研究旨在评估严重 MR 是否会导致 AS 严重程度评估出现不一致性。
方法
2000 年至 2015 年期间共诊断出 5355 例 AS 患者，其中 68 例患者被回顾性地发现存在同时存在严重（中度或更严重）MR 和窦性心律下正常左心室射血分数（AS 伴 MR）。作为对照组，选择了 136 例 MR 为轻度或无的患者，这些患者通过年龄、性别和左心室收缩末期容积（AS 无 MR）进行匹配。使用公式 AVA= a+b/√MPG 对数据对（主动脉瓣瓣口面积[AVA]与平均压力梯度[MPG]）进行非线性回归。复合临床事件定义为由于症状或左心室功能障碍而需要进行主动脉瓣手术、因心力衰竭入院和死亡。
结果
AS 伴 MR 组的前向心搏量指数明显低于 AS 无 MR 组（43.8±8.3 比 49.2±10.2 mL/m，P<.004）。（指数化的）AVA 与 MPG 之间的关系存在显著组间差异（AVA，0.02+4.43/√MPG 比-0.06+5.60/√MPG[P 交互=0.04]；指数化 AVA，0.03+2.66/√MPG 比-0.03+3.47/√MPG[P 交互=0.01]）。AVA 为 1.0 cm 时，MR 组和无 MR 组的 MPG 分别为 20.3 和 28.2 mmHg。相反，MPG 为 40 mmHg 时，MR 组和无 MR 组的 AVA 分别为 0.72 和 0.83 cm。在 MPG<40mmHg 的患者中，MR 组的临床事件发生率明显高于无 MR 组（P=0.009）。
结论
本定量分析表明，通过 MPG 测量评估的 AS 严重程度可能被低估，因此在合并严重 MR 的患者中，AVA 测量至关重要。
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