Scully Paul R, Patel Kush P, Treibel Thomas A, Thornton George D, Hughes Rebecca K, Chadalavada Sucharitha, Katsoulis Michail, Hartman Neil, Fontana Marianna, Pugliese Francesca, Sabharwal Nikant, Newton James D, Kelion Andrew, Ozkor Muhiddin, Kennon Simon, Mullen Michael, Lloyd Guy, Menezes Leon J, Hawkins Philip N, Moon James C
Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London EC1A 7BE, UK.
Institute of Cardiovascular Science, University College London, Gower Street, London WC1E 6BT, UK.
Eur Heart J. 2020 Aug 1;41(29):2759-2767. doi: 10.1093/eurheartj/ehaa170.
Cardiac amyloidosis is common in elderly patients with aortic stenosis (AS) referred for transcatheter aortic valve implantation (TAVI). We hypothesized that patients with dual aortic stenosis and cardiac amyloid pathology (AS-amyloid) would have different baseline characteristics, periprocedural and mortality outcomes.
Patients aged ≥75 with severe AS referred for TAVI at two sites underwent blinded bone scintigraphy prior to intervention (Perugini Grade 0 negative, 1-3 increasingly positive). Baseline assessment included echocardiography, electrocardiogram (ECG), blood tests, 6-min walk test, and health questionnaire, with periprocedural complications and mortality follow-up. Two hundred patients were recruited (aged 85 ± 5 years, 50% male). AS-amyloid was found in 26 (13%): 8 Grade 1, 18 Grade 2. AS-amyloid patients were older (88 ± 5 vs. 85 ± 5 years, P = 0.001), with reduced quality of life (EQ-5D-5L 50 vs. 65, P = 0.04). Left ventricular wall thickness was higher (14 mm vs. 13 mm, P = 0.02), ECG voltages lower (Sokolow-Lyon 1.9 ± 0.7 vs. 2.5 ± 0.9 mV, P = 0.03) with lower voltage/mass ratio (0.017 vs. 0.025 mV/g/m2, P = 0.03). High-sensitivity troponin T and N-terminal pro-brain natriuretic peptide were higher (41 vs. 21 ng/L, P < 0.001; 3702 vs. 1254 ng/L, P = 0.001). Gender, comorbidities, 6-min walk distance, AS severity, prevalence of disproportionate hypertrophy, and post-TAVI complication rates (38% vs. 35%, P = 0.82) were the same. At a median follow-up of 19 (10-27) months, there was no mortality difference (P = 0.71). Transcatheter aortic valve implantation significantly improved outcome in the overall population (P < 0.001) and in those with AS-amyloid (P = 0.03).
AS-amyloid is common and differs from lone AS. Transcatheter aortic valve implantation significantly improved outcome in AS-amyloid, while periprocedural complications and mortality were similar to lone AS, suggesting that TAVI should not be denied to patients with AS-amyloid.
心脏淀粉样变性在因经导管主动脉瓣植入术（TAVI）而转诊的老年主动脉瓣狭窄（AS）患者中很常见。我们假设患有双重主动脉瓣狭窄和心脏淀粉样病变（AS-淀粉样变性）的患者会有不同的基线特征、围手术期情况和死亡率结果。
在两个地点因严重AS而转诊接受TAVI的≥75岁患者在干预前接受了盲法骨闪烁扫描（佩鲁吉尼分级0为阴性，1 - 3级阳性程度逐渐增加）。基线评估包括超声心动图、心电图（ECG）、血液检查、6分钟步行试验和健康问卷，并对围手术期并发症和死亡率进行随访。招募了200名患者（年龄85±5岁，50%为男性）。发现26例（13%）患有AS-淀粉样变性：8例为1级，18例为2级。AS-淀粉样变性患者年龄更大（88±5岁对85±5岁，P = 0.001），生活质量降低（EQ-5D-5L评分为50对65，P = 0.04）。左心室壁厚度更高（14mm对13mm，P = 0.02），心电图电压更低（索科洛夫-里昂电压1.9±0.7对2.5±0.9mV，P = 0.03），电压/质量比更低（0.017对0.025mV/g/m²，P = 0.03）。高敏肌钙蛋白T和N末端脑钠肽前体更高（41对21ng/L，P < 0.001；3702对1254ng/L，P = 0.001）。性别、合并症、6分钟步行距离、AS严重程度、不成比例肥厚的患病率以及TAVI后并发症发生率（38%对35%，P = 0.82）相同。在中位随访19（10 - 27）个月时，死亡率无差异（P = 0.71）。经导管主动脉瓣植入术显著改善了总体人群的结局（P < 0.001）以及患有AS-淀粉样变性患者的结局（P = 0.03）。
AS-淀粉样变性很常见且与单纯AS不同。经导管主动脉瓣植入术显著改善了AS-淀粉样变性患者的结局，而围手术期并发症和死亡率与单纯AS相似，这表明不应拒绝AS-淀粉样变性患者接受TAVI。
