GCS-Groupement des Hôpitaux de l'Institut Catholique de Lille (GHICL), Cardiology department and Heart Valve Center, Faculté libre de médecine/Université Catholique de Lille, France (S.M., A.A.).
Centre Universitaire de Recherche en Santé, Laboratoire MP3CV - EA 7517, Université de Picardie, Amiens, France (S.M., D.R., C.T.).
Circ Cardiovasc Imaging. 2019 Oct;12(10):e009299. doi: 10.1161/CIRCIMAGING.119.009299. Epub 2019 Oct 10.
Grading of severe (aortic valve area ≤1 cm) aortic stenosis with preserved left ventricular ejection fraction is based on a classification depending on flow (normal flow versus low flow) and pressure gradient (low gradient versus high gradient). The aim of the present study was to compare the outcome of patients with normal flow high gradient and low flow high gradient severe aortic stenosis (SAS) with no or minimal symptoms.
This multicenter study enrolled 983 consecutive patients (mean age 75±11 years, 459 women) with asymptomatic or minimally symptomatic HG (mean pressure gradient ≥40 mm Hg) SAS with preserved left ventricular ejection fraction. Low flow was defined by Doppler echocardiography as a stroke volume index <30 mL/m (n=131) or a stroke volume <55 mL (n=136). The end point was all-cause mortality.
During a median follow-up period of 48 (45-52) months, 225 patients (23%) died. The 60-month mortality was higher in low flow high gradient SAS compared with normal flow high gradient SAS (36±5% versus 22±2% and 38±5% versus 21±2% for stroke volume index and stroke volume, respectively, both <0.0001). After adjustment for outcome predictors including aortic valve replacement as time-dependent covariate, low flow high gradient SAS displayed considerable mortality risk during follow up compared with normal flow high gradient SAS (adjusted HR 2.17 [1.51-3.13]; <0.0001 for stroke volume index <30 mL/m and adjusted HR 1.86 [1.29-2.68]; =0.001, for stroke volume <55 mL). The prognostic impact of low flow was consistent in subgroups of patients.
Asymptomatic or minimally symptomatic patients with low flow high gradient SAS and preserved left ventricular ejection fraction have a considerable increased risk of mortality during follow-up. These patients should be promptly considered for aortic valve replacement.
对于射血分数保留的重度主动脉瓣狭窄（主动脉瓣口面积≤1cm），其严重程度分级基于流量（正常流量与低流量）和压力梯度（低梯度与高梯度）的分类。本研究旨在比较无或轻度症状的正常流量高梯度和低流量高梯度重度主动脉瓣狭窄（SAS）患者的预后。
这项多中心研究纳入了 983 例连续的无症状或轻度症状的 HG（平均压力梯度≥40mmHg）SAS 合并保留左心室射血分数的患者（平均年龄 75±11 岁，459 例女性）。低流量通过多普勒超声心动图定义为每搏量指数<30mL/m（n=131）或每搏量<55mL（n=136）。终点是全因死亡率。
在中位数为 48（45-52）个月的随访期间，225 例患者（23%）死亡。与正常流量高梯度 SAS 相比，低流量高梯度 SAS 的 60 个月死亡率更高（每搏量指数和每搏量分别为 36±5%与 22±2%和 38±5%与 21±2%，均<0.0001）。在校正了包括主动脉瓣置换作为时变协变量在内的预后预测因素后，与正常流量高梯度 SAS 相比，低流量高梯度 SAS 在随访期间显示出相当大的死亡风险（校正 HR 2.17[1.51-3.13]；每搏量指数<30mL/m 时<0.0001，校正 HR 1.86[1.29-2.68]；=0.001，每搏量<55mL）。低流量的预后影响在患者亚组中是一致的。
对于射血分数保留的低流量高梯度 SAS 合并无症状或轻度症状的患者，在随访期间其死亡率显著增加。这些患者应及时考虑进行主动脉瓣置换。
