Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada.
Department of Cardiology, Amiens University Hospital Center, Amiens, France.
J Am Coll Cardiol. 2019 Jul 30;74(4):550-563. doi: 10.1016/j.jacc.2019.04.065.
The optimal timing of intervention in patients with asymptomatic severe aortic stenosis (AS) remains controversial.
This multicenter study sought to test and validate the prognostic value of the staging of cardiac damage in patients with asymptomatic moderate to severe AS.
This study retrospectively analyzed the clinical, Doppler echocardiographic, and outcome data that were prospectively collected in 735 asymptomatic patients (71 ± 14 years of age; 60% men) with at least moderate AS (aortic valve area <1.5 cm) and preserved left ventricular ejection fraction (≥50%) followed in the heart valve clinics of 4 high-volume centers. Patients were classified according to the following staging classification: no cardiac damage associated with the valve stenosis (Stage 0), left ventricular damage (Stage 1), left atrial or mitral valve damage (Stage 2), pulmonary vasculature or tricuspid valve damage (Stage 3), or right ventricular damage or subclinical heart failure (Stage 4). The primary endpoint was all-cause mortality.
At baseline, 89 (12%) patients were classified in Stage 0, 200 (27%) in Stage 1, 341 (46%) in Stage 2, and 105 (14%) in Stage 3 or 4. Median follow-up was 2.6 years (interquartile range: 1.1 to 5.2 years). There was a stepwise increase in mortality rates according to staging: 13% in Stage 0, 25% in Stage 1, 44% in Stage 2, and 58% in Stages 3 to 4 (p < 0.0001). The staging was significantly associated with excess mortality in multivariable analysis adjusted for aortic valve replacement as a time-dependent variable (hazard ratio: 1.31 per each increase in stage; 95% CI: 1.06 to 1.61; p = 0.01), and showed incremental value to several clinical variables (net reclassification index = 0.34; p = 0.003).
The new staging system characterizing the extra-aortic valve cardiac damage provides incremental prognostic value in patients with asymptomatic moderate to severe AS. This staging classification may be helpful to identify asymptomatic AS patients who may benefit from elective aortic valve replacement.
对于无症状重度主动脉瓣狭窄（AS）患者，干预的最佳时机仍存在争议。
这项多中心研究旨在验证和验证无症状中重度 AS 患者心脏损伤分期的预后价值。
这项研究回顾性分析了 735 例无症状患者（71±14 岁；60%为男性）的临床、多普勒超声心动图和结局数据，这些患者前瞻性收集于 4 个大容量中心的心脏瓣膜门诊，均至少患有中度 AS（主动脉瓣口面积<1.5cm）且左心室射血分数保留（≥50%）。患者根据以下分期分类：与瓣膜狭窄无关的心脏损伤（阶段 0）、左心室损伤（阶段 1）、左心房或二尖瓣损伤（阶段 2）、肺血管或三尖瓣损伤（阶段 3）或右心室损伤或亚临床心力衰竭（阶段 4）。主要终点是全因死亡率。
基线时，89（12%）例患者被分类为 0 期，200（27%）例患者为 1 期，341（46%）例患者为 2 期，105 例患者（14%）为 3 期或 4 期。中位随访时间为 2.6 年（四分位距：1.1 至 5.2 年）。死亡率根据分期呈阶梯式增加：0 期为 13%，1 期为 25%，2 期为 44%，3-4 期为 58%（p<0.0001）。多变量分析调整主动脉瓣置换作为时变变量后，分期与超额死亡率显著相关（每增加一个阶段的风险比：1.31；95%置信区间：1.06 至 1.61；p=0.01），并且比几个临床变量具有增量价值（净重新分类指数=0.34；p=0.003）。
描述主动脉瓣外心脏损伤的新分期系统为无症状中重度 AS 患者提供了额外的预后价值。这种分期分类可能有助于识别可能从择期主动脉瓣置换中获益的无症状 AS 患者。
