Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria.
Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria.
JACC Cardiovasc Imaging. 2019 Feb;12(2):225-232. doi: 10.1016/j.jcmg.2018.09.020. Epub 2018 Dec 12.
Decision making in severe aortic stenosis (AS) requires a comprehensive pre-operative evaluation of the risk-to-benefit ratio. The aim of this study was to assess whether certain pre-operative symptoms are associated with outcome after surgical aortic valve replacement (SAVR).
The cardinal symptoms of AS indicating a need for intervention are angina, symptoms of heart failure, and syncope. Nevertheless, it remains unknown whether the presence of these more advanced symptoms conveys an increased risk after SAVR and whether the detection of early symptoms in patients with asymptomatic AS should be emphasized more in routine clinical practice.
A total of 625 patients with isolated severe AS undergoing elective SAVR were prospectively enrolled in this long-term observational study.
Patients experiencing syncope had significantly smaller left ventricular diameters (p = 0.02), left atrial diameters (p = 0.043), right ventricular diameters (p = 0.04), and right atrial diameters (p = 0.001), smaller aortic valve areas (p = 0.048), and lower indexed stroke volumes (p = 0.043) compared with patients without syncope. Syncope conveyed an increased risk for mortality after SAVR that persisted after multivariate adjustment for a bootstrap-selected confounder model, with an adjusted hazard ratio of 2.27 (95% confidence interval: 1.04 to 4.95; p = 0.04) for 1-year short-term mortality and an adjusted hazard ratio of 2.11 (95% confidence interval: 1.39 to 3.21; p < 0.001) for 10-year long-term mortality. In contrast, pre-operative dyspnea, angina, and reduced left ventricular function were not significantly associated with outcomes.
This long-term observational study in a large contemporary cohort of patients with AS for the first time demonstrates that syncope represents an underestimated threat in aortic stenosis, associated with poor prognosis after SAVR. Importantly, other primary indications for SAVR (i.e., dyspnea, angina, and decreased left ventricular function) were associated with significantly better post-operative outcomes than syncope. Patients experiencing syncope displayed a specific pathophysiologic phenotype characterized by a smaller aortic valve area, smaller cardiac cavities, and lower stroke volumes.
严重主动脉瓣狭窄（AS）的决策需要综合评估风险获益比。本研究旨在评估术前某些症状与外科主动脉瓣置换术（SAVR）后的结果是否相关。
提示需要干预的 AS 的主要症状是心绞痛、心力衰竭症状和晕厥。然而，目前尚不清楚这些更晚期症状是否会增加 SAVR 后的风险，以及无症状 AS 患者的早期症状是否应该在常规临床实践中得到更多强调。
前瞻性纳入 625 例接受择期 SAVR 的孤立性严重 AS 患者，进行这项长期观察性研究。
发生晕厥的患者左心室直径（p=0.02）、左心房直径（p=0.043）、右心室直径（p=0.04）和右心房直径（p=0.001）更小，主动脉瓣面积（p=0.048）和指数化的每搏输出量（p=0.043）也更小。与无晕厥的患者相比，晕厥患者 SAVR 后死亡风险增加，且在 bootstrap 选择混杂因素模型的多变量校正后仍持续存在，校正后 1 年短期死亡率的危险比为 2.27（95%置信区间：1.04 至 4.95；p=0.04），10 年长期死亡率的危险比为 2.11（95%置信区间：1.39 至 3.21；p<0.001）。相比之下，术前呼吸困难、心绞痛和左心室功能降低与结果无显著相关性。
本研究为首次在大型当代 AS 患者队列中进行的长期观察性研究，首次表明晕厥是主动脉瓣狭窄的一个被低估的威胁，与 SAVR 后预后不良相关。重要的是，SAVR 的其他主要适应证（即呼吸困难、心绞痛和左心室功能降低）与术后结局显著相关，优于晕厥。发生晕厥的患者表现出一种特定的病理生理表型，其特征为主动脉瓣面积较小、心脏腔室较小和每搏输出量较低。
