Bridonneau Valentin, Galli Elena, Auffret Vincent, Lederlin Mathieu, Campion Marine, Le Breton Herve, Boulmier Dominique, Hubert Arnaud, Lenz Pierre-Axel, Leclercq Christophe, Oger Emmanuel, Donal Erwan
Service de Cardiologie, Inserm LTSI-UMR1099, CHU Rennes, Université Rennes 1, Rennes, France.
Imagerie médicale, CHU Rennes, Rennes, France.
Echocardiography. 2019 Dec;36(12):2136-2144. doi: 10.1111/echo.14531. Epub 2019 Nov 8.
Treatment strategy for low-gradient (LG) aortic stenosis (AS) remains an unresolved issue. The presence of a low aortic gradient and preserved left ventricular ejection fraction (LVEF) might lead toward the underestimation of aortic stenosis severity and a more conservative management. We sought (a) to describe the nature and timing of intervention according to flow/gradient subgroups in patibents with LG-AS, (2) to determine the factors associated with the decision to intervene, and (c) to describe prognosis.
One hundred and ten patients prospectively included in this study underwent a standardized clinical and imaging evaluation at inclusion and at 1-year follow-up. According to aortic flow, gradient and LVEF, patients were divided into 4 groups: LG-normal flow [n = 27], LG-low flow-low LVEF [n = 27], LG-low flow-normal LVEF [n = 16], and high gradient (HG) [n = 40]). 73% of patients underwent AVR 86 ± 59 days after the initial assessment. The HG subgroup had significantly higher intervention rates (P < .001). In multivariable analysis, four parameters were associated with the AVR: aortic gradient (HR 1.52 [1.10-2.11], P = .012), LVEF (HR 0.58 [0.40-0.85], P = .006), atrial fibrillation (HR 0.43 [0.021-0.87], P = .019), and NT-proBNP (HR 0.92[0.86-0.98), P = .008]. Patients operated earlier had better outcomes than those having a delayed AVR (P = .042). LG-AS patients had worse outcomes than HG-AS patients (P < .001).
Compared to HG-AS, LG-AS is less likely to benefit from an AVR and had a significantly worse outcome. Further interventional studies are needed to investigate the timing of AVR in these patients.
低梯度（LG）主动脉瓣狭窄（AS）的治疗策略仍是一个未解决的问题。低主动脉梯度和保留的左心室射血分数（LVEF）的存在可能导致对主动脉瓣狭窄严重程度的低估以及更保守的治疗。我们旨在（a）根据LG-AS患者的血流/梯度亚组描述干预的性质和时机，（b）确定与干预决策相关的因素，以及（c）描述预后。
本研究前瞻性纳入的110例患者在纳入时和1年随访时接受了标准化的临床和影像学评估。根据主动脉血流、梯度和LVEF，患者分为4组：LG-正常血流[n = 27]、LG-低血流-低LVEF[n = 27]、LG-低血流-正常LVEF[n = 16]和高梯度（HG）[n = 40]）。73%的患者在初始评估后86±59天接受了主动脉瓣置换术（AVR）。HG亚组的干预率显著更高（P <.001）。在多变量分析中，四个参数与AVR相关：主动脉梯度（HR 1.52 [1.10 - 2.11]，P =.012）、LVEF（HR 0.58 [0.40 - 0.85]，P =.006）、心房颤动（HR 0.43 [0.021 - 0.87]，P =.019）和NT-脑钠肽（HR 0.92[0.86 - 0.98]，P =.008）。早期手术的患者比延迟进行AVR的患者预后更好（P =.042）。LG-AS患者的预后比HG-AS患者更差（P <.001）。
与HG-AS相比，LG-AS从AVR中获益的可能性较小，且预后明显更差。需要进一步的干预性研究来调查这些患者进行AVR的时机。
