Department of Cardiology, Swiss Cardiovascular Center, Bern University Hospital, Bern, Switzerland.
Institute of Social and Preventive Medicine and Clinical Trials Unit, University of Bern, Bern, Switzerland.
JACC Cardiovasc Interv. 2018 Mar 26;11(6):593-601. doi: 10.1016/j.jcin.2018.01.240. Epub 2018 Mar 2.
This study sought to determine the impact of left ventricular diastolic dysfunction (LVDD) on clinical outcomes in patients undergoing transcatheter aortic valve replacement (TAVR).
Left ventricular (LV) hypertrophy in response to afterload increase promotes the development of LVDD and represents an early stage in the progression to valvular heart failure.
In a consecutive cohort of 777 aortic stenosis patients undergoing TAVR, LVDD was categorized according to the latest guidelines. The primary endpoint was 1-year all-cause mortality.
There were 545 (70.1%) patients with LVDD. Ninety-eight (18.0%), 198 (36.3%), and 104 (19.1%) patients were classified as LVDD grades I, II, and III, respectively. In 145 (26.6%) patients, LVDD grade could not be determined because of only 1 or 2 discrepant variables. One-year all-cause mortality was higher in patients with LVDD grades I (16.3%; adjusted hazard ratio [HR]: 2.32; 95% confidence interval [CI]: 1.15 to 4.66), II (17.9%; HR: 2.58; 95% CI: 1.43 to 4.67), and III (27.6%; HR: 4.21; 95% CI: 2.25 to 7.86) than in those with normal diastolic function (6.9%). The difference in clinical outcome emerged within 30 days, was driven by cardiovascular death, and maintained in a sensitivity analysis of patients with normal systolic LV function. Furthermore, LVDD grades I (HR: 2.36; 95% CI: 1.17 to 4.74), II (HR: 2.58; 95% CI: 1.42 to 4.66), and III (HR: 4.41; 95% CI: 2.37 to 8.20) were independent predictors of 1-year mortality.
Advancing stages of LVDD are associated with an incremental risk of all-cause mortality after TAVR, driven by cardiovascular death and taking effect as early as 30 days after the intervention.
本研究旨在探讨左心室舒张功能障碍（LVDD）对行经导管主动脉瓣置换术（TAVR）患者临床结局的影响。
左心室（LV）顺应性降低是导致 LVDD 的主要原因，LVDD 是瓣膜性心力衰竭发生的早期阶段。
在连续纳入的 777 例主动脉瓣狭窄患者中，根据最新指南对 LVDD 进行分类。主要终点为 1 年全因死亡率。
545 例（70.1%）患者存在 LVDD。98 例（18.0%）、198 例（36.3%）和 104 例（19.1%）患者分别被归类为 LVDD Ⅰ级、Ⅱ级和Ⅲ级。145 例（26.6%）患者由于只有 1 或 2 项不一致的变量而无法确定 LVDD 分级。LVDD Ⅰ级（16.3%；调整后的危险比[HR]：2.32；95%置信区间[CI]：1.15 至 4.66）、Ⅱ级（17.9%；HR：2.58；95% CI：1.43 至 4.67）和Ⅲ级（27.6%；HR：4.21；95% CI：2.25 至 7.86）患者的 1 年全因死亡率高于无 LVDD 功能正常的患者（6.9%）。这种临床结局的差异在术后 30 天内出现，主要由心血管死亡导致，并在 LV 收缩功能正常患者的敏感性分析中得以维持。此外，LVDD Ⅰ级（HR：2.36；95% CI：1.17 至 4.74）、Ⅱ级（HR：2.58；95% CI：1.42 至 4.66）和Ⅲ级（HR：4.41；95% CI：2.37 至 8.20）是 1 年死亡率的独立预测因素。
LVDD 进展程度与 TAVR 后全因死亡率的增加相关，主要由心血管死亡驱动，且在术后 30 天内即可显现。
