Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota.
JACC Cardiovasc Imaging. 2020 Feb;13(2 Pt 1):357-369. doi: 10.1016/j.jcmg.2019.01.009. Epub 2019 Mar 13.
This study sought to determine the prevalence of reduced contractility and uncompensated wall stress in patients with aortic stenosis (AS) with preserved or reduced left ventricular ejection fraction (LVEF) and their impact on survival.
LVEF in AS is determined not only by contractility but also by loading conditions.
Patients with first diagnosis (time 0) of severe AS (aortic valve area [AVA]≤1 cm) with prior echo study (-3±1 years) were identified. Contractility was evaluated by plotting midwall fractional shortening (mFS) against circumferential end-systolic wall stress (cESS), stratified by LVEF of 60% at time 0. The temporal changes (from -3 years to time 0) and prognostic value of LVEF, contractility, and wall stress were assessed.
Of 445 patients, 290 (65%) had LVEF ≥60% (median: 66% [interquartile range {IQR}: 63% to 69%]) and 155 patients (35%) had LVEF <60% (median: 47% [IQR: 34% to 55%]). Median AVA was 1.27 cm (IQR: 1.13 to 1.43 cm) at -3 years and 0.90 cm (IQR: 0.83 to 0.96 cm) at time 0. Decreased contractility was already present at -3 years (49 [17%] vs. 59 [38%]; LVEF ≥60% vs. <60%; p < 0.001) and became more prevalent at time 0 (69 [24%] vs. 106 [68%]; p < 0.001). Overall, wall stress was well controlled in both groups at -3 years (1 [0%] vs. 12 [8%]; p < 0.001) but deteriorated over time in patients with LVEF <60% (time 0: 0 [0%] vs. 26 [17%]; p < 0.001). During a median follow-up of 3.4 years, LVEF <60%, decreased contractility and high wall stress were associated with worse survival (p < 0.01 for all). Decreased contractility remained incremental to LVEF in patients with LVEF ≥60% (p < 0.01), but less so when LVEF was <60% (p = 0.11).
In patients with severe AS, LVEF <60% is associated with a poor prognosis, being linked with decreased contractility and/or high wall stress. Decreased contractility is also present in a subset of patients with LVEF ≥60% and provides incremental prognostic value. These abnormalities already exist before AVA reaches 1.0 cm.
本研究旨在确定左心室射血分数（LVEF）保留或降低的主动脉瓣狭窄（AS）患者收缩功能降低和壁应力失代偿的患病率及其对生存率的影响。
AS 中的 LVEF 不仅取决于收缩功能，还取决于负荷条件。
确定首次诊断（时间 0）为严重 AS（主动脉瓣口面积[AVA]≤1cm）且之前有超声心动图研究（-3±1 年）的患者。通过绘制中膜节段缩短率（mFS）与周向收缩末期壁应力（cESS）之间的关系，按时间 0 时的 LVEF 分层评估收缩功能。评估 LVEF、收缩功能和壁应力的时间变化及其预后价值。
445 例患者中，290 例（65%）LVEF≥60%（中位数：66%[四分位距 {IQR}：63%至 69%]），155 例（35%）LVEF<60%（中位数：47%[IQR：34%至 55%]）。-3 年时 AVA 中位数为 1.27cm（IQR：1.13 至 1.43cm），时间 0 时为 0.90cm（IQR：0.83 至 0.96cm）。收缩功能降低在-3 年时已经存在（49 例[17%]与 59 例[38%]；LVEF≥60%与<60%；p<0.001），并在时间 0 时变得更为普遍（69 例[24%]与 106 例[68%]；p<0.001）。总体而言，两组在-3 年时壁应力控制良好（1 例[0%]与 12 例[8%]；p<0.001），但 LVEF<60%的患者随时间恶化（时间 0：0 例[0%]与 26 例[17%]；p<0.001）。在中位随访 3.4 年期间，LVEF<60%、收缩功能降低和高壁应力与较差的生存率相关（p<0.01）。在 LVEF≥60%的患者中，收缩功能降低比 LVEF 更具增量预后价值（p<0.01），但在 LVEF<60%的患者中则不明显（p=0.11）。
在严重 AS 患者中，LVEF<60%与预后不良相关，与收缩功能降低和/或高壁应力相关。LVEF≥60%的患者中也存在收缩功能降低亚组，并提供了额外的预后价值。这些异常在 AVA 达到 1.0cm 之前就已经存在。
