Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Canada (E.S., H.M., F.D., P.V., S.M., D.K., R.P., N.C., J.R.-C., P.M., M.-A.C., P.P.).
Centre de Résonance Magnétique Biologique et Médicale, Centre National de la Recherche Scientifique, Aix-Marseille Université, France (E.S.).
Circulation. 2018 Sep 4;138(10):971-985. doi: 10.1161/CIRCULATIONAHA.118.035150.
The incidence of structural valve deterioration after bioprosthesis (BP) aortic valve replacement (AVR) established on the basis of reoperation may substantially underestimate the true incidence. The objective is to determine the rate, timing, correlates, and association between hemodynamic valve deterioration (HVD) and outcomes assessed by Doppler echocardiography after surgical BP AVR.
A total of 1387 patients (62.2% male, 70.5±7.8 years of age) who underwent BP AVR were included in this retrospective study. Baseline echocardiography was performed at a median time of 4.1 (1.3-6.5) months after AVR. All patients had an echocardiographic follow-up ≥2 years after AVR (926 at least 5 years and 385 at least 10 years). HVD was defined by Doppler assessment as a ≥10 mm Hg increase in mean gradient or worsening of transprosthetic regurgitation ≥1/3 class. HVD was classified according to the timing after AVR: "very early," during the first 2-years; "early," between 2 and 5 years; "midterm," between 5 and 10 years; and "long-term," >10 years.
A total of 428 patients (30.9%) developed HVD. Among these patients, 52 (12.0%) were classified as "very early," 129 (30.1%) as "early," 158 (36.9%) as "midterm," and 89 (20.8%) as "long-term" HVD. Factors independently associated with HVD occurring within the first 5 years after AVR were diabetes mellitus ( P=0.01), active smoking ( P=0.01), renal insufficiency ( P=0.01), baseline postoperative mean gradient ≥15 mm Hg ( P=0.04) or transprosthetic regurgitation ≥mild ( P=0.04), and type of BP (stented versus stentless, P=0.003). Factors associated with HVD occurring after the fifth year after AVR were female sex ( P=0.03), warfarin use ( P=0.007), and BP type ( P<0.001). HVD was independently associated with mortality (hazard ratio, 2.18; 95% CI, 1.86-2.57; P<0.001).
HVD as identified by Doppler echocardiography occurred in one third of patients and was associated with a 2.2-fold higher adjusted mortality. Diabetes mellitus and renal insufficiency were associated with early HVD, whereas female sex, warfarin use, and stented BPs (versus stentless) were associated with late HVD.
基于再次手术的生物瓣（BP）主动脉瓣置换（AVR）后结构性瓣恶化的发生率可能严重低估了真实的发生率。本研究的目的是确定在外科 BP AVR 后通过多普勒超声心动图评估的血流动力学瓣恶化（HVD）的发生率、时间、相关性以及与结果之间的关联。
本回顾性研究纳入了 1387 例（62.2%为男性，70.5±7.8 岁）接受 BP AVR 的患者。基线超声心动图在 AVR 后中位时间 4.1（1.3-6.5）个月时进行。所有患者均在 AVR 后至少 2 年（926 例至少 5 年，385 例至少 10 年）进行了超声心动图随访。HVD 通过多普勒评估定义为平均梯度增加≥10mmHg 或跨瓣反流恶化≥1/3 级。根据 AVR 后的时间将 HVD 进行分类：“非常早期”，发生在最初 2 年内；“早期”，发生在 2 至 5 年内；“中期”，发生在 5 至 10 年内；“晚期”，发生在 10 年以上。
共有 428 例患者（30.9%）发生 HVD。其中 52 例（12.0%）患者被归类为“非常早期”，129 例（30.1%）为“早期”，158 例（36.9%）为“中期”，89 例（20.8%）为“晚期”HVD。发生在 AVR 后 5 年内的 HVD 的独立相关因素包括糖尿病（P=0.01）、主动吸烟（P=0.01）、肾功能不全（P=0.01）、术后基线平均梯度≥15mmHg（P=0.04）或跨瓣反流≥轻度（P=0.04），以及 BP 类型（带支架与无支架，P=0.003）。发生在 AVR 后第 5 年以后的 HVD 的相关因素包括女性（P=0.03）、华法林使用（P=0.007）和 BP 类型（P<0.001）。HVD 与死亡率独立相关（风险比，2.18；95%置信区间，1.86-2.57；P<0.001）。
通过多普勒超声心动图发现的 HVD 发生在三分之一的患者中，与调整后的死亡率增加 2.2 倍相关。糖尿病和肾功能不全与早期 HVD 相关，而女性、华法林使用和带支架的 BP（而非无支架）与晚期 HVD 相关。
