静息和踏车运动超声心动图检查下射血分数保留的无症状重度主动脉瓣狭窄的转归。

Outcomes in Asymptomatic Severe Aortic Stenosis With Preserved Ejection Fraction Undergoing Rest and Treadmill Stress Echocardiography.

机构信息

Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH.

Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH

出版信息

J Am Heart Assoc. 2018 Apr 12;7(8):e007880. doi: 10.1161/JAHA.117.007880.

BACKGROUND

In asymptomatic patients with severe aortic stenosis and preserved left ventricular ejection fraction, we sought to assess the incremental prognostic value of resting valvuloarterial impedence (Zva) and left ventricular global longitudinal strain (LV-GLS) to treadmill stress echocardiography.

METHODS AND RESULTS

We studied 504 such patients (66±12 years, 78% men, 32% with coronary artery disease who underwent treadmill stress echocardiography between 2001 and 2012. Clinical and exercise variables (% of age-sex predicted metabolic equivalents [%AGP-METs]) were recorded. Resting Zva ([systolic arterial pressure+mean aortic valve gradient]/[LV-stroke volume index]) and LV-GLS (measured offline using Velocity Vector Imaging, Siemens) were obtained from the baseline resting echocardiogram. Death was the primary outcome. There were no major adverse cardiac events during treadmill stress echocardiography. Indexed aortic valve area, Zva, and LV-GLS were 0.46±0.1 cm/m, 4.5±0.9 mm Hg/mL per m and -16±4%, respectively; only 50% achieved >100% AGP-METs. Sixty-four percent underwent aortic valve replacement. Death occurred in 164 (33%) patients over 8.9±3.6 years (2 within 30 days of aortic valve replacement). On multivariable Cox survival analysis, higher Society of Thoracic Surgeons score (hazard ratio or HR 1.06), lower % AGP-METS (HR 1.16), higher Zva (HR 1.25) and lower LV-GLS (HR 1.12) were associated with higher longer-term mortality, while aortic valve replacement (HR 0.45) was associated with improved survival (all <0.01). Sequential addition of ZVa and LV-GLS to clinical model (Society of Thoracic Surgeons score and %AGP-METs) increased the c-statistic from 0.65 to 0.69 and 0.75, respectively, both <0.001); findings were similar in the subgroup of patients who underwent aortic valve replacement.

CONCLUSIONS

In asymptomatic patients with severe aortic stenosis undergoing treadmill stress echocardiography, LV-GLS and ZVa offer incremental prognostic value.

背景

在左心室射血分数正常的无症状重度主动脉瓣狭窄患者中，我们旨在评估静息时瓣-动脉阻抗（Zva）和左心室整体纵向应变（LV-GLS）对平板运动超声心动图的预后价值。

方法和结果

我们研究了 504 例此类患者（66±12 岁，78%为男性，32%患有冠心病，于 2001 年至 2012 年间接受平板运动超声心动图检查）。记录临床和运动变量（%年龄性别预测代谢当量[％AGP-METs]）。静息 Zva（[收缩期动脉压+平均主动脉瓣梯度]/[LV stroke volume index]）和 LV-GLS（使用西门子的 Velocity Vector Imaging 离线测量）从基线静息超声心动图获得。死亡是主要终点。平板运动超声心动图检查期间无重大不良心脏事件。索引主动脉瓣面积、Zva 和 LV-GLS 分别为 0.46±0.1cm/m、4.5±0.9mm Hg/mL per m 和-16±4%，仅 50%达到>100%AGP-METs。64%的患者接受了主动脉瓣置换术。504 例患者中有 164 例（33%）在 8.9±3.6 年（主动脉瓣置换术后 30 天内 2 例）后死亡。多变量 Cox 生存分析显示，更高的胸外科医师协会评分（风险比或 HR 1.06）、更低的%AGP-METS（HR 1.16）、更高的 Zva（HR 1.25）和更低的 LV-GLS（HR 1.12）与更高的长期死亡率相关，而主动脉瓣置换术（HR 0.45）与生存率提高相关（均<0.01）。ZVa 和 LV-GLS 依次加入临床模型（胸外科医师协会评分和%AGP-METs）后，C 统计量分别从 0.65 提高到 0.69 和 0.75，均<0.001；在接受主动脉瓣置换术的患者亚组中也发现了类似的结果。