Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, UK (T.A.M., L.E.D., J.R.J.F., P.B., G.R.L., J.P.G.).
Barts Health National Health Service Trust and University College London, UK (T.A.T., G.C., S.P., J.C.M.).
Circulation. 2018 Oct 30;138(18):1935-1947. doi: 10.1161/CIRCULATIONAHA.117.032839.
Aortic valve replacement (AVR) for aortic stenosis is timed primarily on the development of symptoms, but late surgery can result in irreversible myocardial dysfunction and additional risk. The aim of this study was to determine whether the presence of focal myocardial scar preoperatively was associated with long-term mortality.
In a longitudinal observational outcome study, survival analysis was performed in patients with severe aortic stenosis listed for valve intervention at 6 UK cardiothoracic centers. Patients underwent preprocedural echocardiography (for valve severity assessment) and cardiovascular magnetic resonance for ventricular volumes, function and scar quantification between January 2003 and May 2015. Myocardial scar was categorized into 3 patterns (none, infarct, or noninfarct patterns) and quantified with the full width at half-maximum method as percentage of the left ventricle. All-cause mortality and cardiovascular mortality were tracked for a minimum of 2 years.
Six hundred seventy-four patients with severe aortic stenosis (age, 75±14 years; 63% male; aortic valve area, 0.38±0.14 cm/m; mean gradient, 46±18 mm Hg; left ventricular ejection fraction, 61.0±16.7%) were included. Scar was present in 51% (18% infarct pattern, 33% noninfarct). Management was surgical AVR (n=399) or transcatheter AVR (n=275). During follow-up (median, 3.6 years), 145 patients (21.5%) died (52 after surgical AVR, 93 after transcatheter AVR). In multivariable analysis, the factors independently associated with all-cause mortality were age (hazard ratio [HR], 1.50; 95% CI, 1.11-2.04; P=0.009, scaled by epochs of 10 years), Society of Thoracic Surgeons score (HR, 1.12; 95% CI, 1.03-1.22; P=0.007), and scar presence (HR, 2.39; 95% CI, 1.40-4.05; P=0.001). Scar independently predicted all-cause (26.4% versus 12.9%; P<0.001) and cardiovascular (15.0% versus 4.8%; P<0.001) mortality, regardless of intervention (transcatheter AVR, P=0.002; surgical AVR, P=0.026 [all-cause mortality]). Every 1% increase in left ventricular myocardial scar burden was associated with 11% higher all-cause mortality hazard (HR, 1.11; 95% CI, 1.05-1.17; P<0.001) and 8% higher cardiovascular mortality hazard (HR, 1.08; 95% CI, 1.01-1.17; P<0.001).
In patients with severe aortic stenosis, late gadolinium enhancement on cardiovascular magnetic resonance was independently associated with mortality; its presence was associated with a 2-fold higher late mortality.
主动脉瓣置换术（AVR）治疗主动脉瓣狭窄主要取决于症状的发展，但晚期手术可能导致心肌不可逆功能障碍和增加风险。本研究旨在确定术前是否存在局灶性心肌瘢痕与长期死亡率之间是否存在关联。
在一项纵向观察性结局研究中，对英国 6 家心胸中心接受瓣膜介入治疗的严重主动脉瓣狭窄患者进行生存分析。患者在 2003 年 1 月至 2015 年 5 月期间接受了术前超声心动图（用于评估瓣膜严重程度）和心血管磁共振成像，以评估心室容积、功能和瘢痕定量。心肌瘢痕分为 3 种模式（无、梗死或非梗死模式），并采用半峰全宽法以左心室的百分比表示瘢痕程度。对所有原因死亡率和心血管死亡率进行至少 2 年的跟踪。
共纳入 674 例严重主动脉瓣狭窄患者（年龄 75±14 岁；63%为男性；主动脉瓣口面积 0.38±0.14 cm/m；平均梯度 46±18 mm Hg；左心室射血分数 61.0±16.7%）。51%的患者存在瘢痕（18%为梗死模式，33%为非梗死模式）。管理方法为外科 AVR（n=399）或经导管 AVR（n=275）。在随访期间（中位数为 3.6 年），145 例患者（52 例经外科 AVR 治疗，93 例经经导管 AVR 治疗）死亡。多变量分析显示，全因死亡率的独立相关因素为年龄（危险比[HR]，1.50；95%置信区间[CI]，1.11-2.04；P=0.009，按每 10 年为一个时间段进行分段）、胸外科医师协会评分（HR，1.12；95%CI，1.03-1.22；P=0.007）和瘢痕存在（HR，2.39；95%CI，1.40-4.05；P=0.001）。瘢痕独立预测全因（26.4%与 12.9%；P<0.001）和心血管（15.0%与 4.8%；P<0.001）死亡率，与干预措施无关（经导管 AVR，P=0.002；外科 AVR，P=0.026[全因死亡率]）。左心室心肌瘢痕负担每增加 1%，全因死亡率的风险就会增加 11%（HR，1.11；95%CI，1.05-1.17；P<0.001），心血管死亡率的风险增加 8%（HR，1.08；95%CI，1.01-1.17；P<0.001）。
在严重主动脉瓣狭窄患者中，心血管磁共振成像上的晚期钆增强与死亡率独立相关；其存在与晚期死亡率增加 2 倍相关。
