Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.
Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany.
Am Heart J. 2020 Jul;225:138-148. doi: 10.1016/j.ahj.2020.03.013. Epub 2020 Apr 8.
Compared to high gradient aortic stenosis (AS), patients with low-flow, low-gradient AS have higher mortality after transcatheter aortic valve replacement (TAVR), but distinct outcome predictors in this patient subset are yet to be determined. The present study investigated the prognostic impact of aortic valve calcification (AVC) in patients with low-flow, low-gradient AS undergoing TAVR.
This retrospective single-center analysis includes all patients undergoing TAVR for severe low-flow, low-gradient AS (n = 526), ie, low EF low gradient AS (LEF-LG AS; n = 290) and paradoxical low-flow, low-gradient AS (PLF-LG AS; n = 236), in whom AVC was quantified from contrast-enhanced multislice computed tomography images. AVC was defined as calcium volume per annulus area. Patients were trichotomized according to sex-specific AVC tertiles in both subgroups. All-cause mortality was assessed by Kaplan-Meier analyses and independent outcome predictors were determined by multivariable analyses.
In both subgroups, patients with high AVC had higher mean transvalvular gradients at baseline and higher rates of PVL after TAVR. High AVC was associated with lowest 1- and 3-year mortality after TAVR in the LEF-LG AS but not in the PLF-LG AS group. According to multivariable analysis AVC was independently associated with better survival in LEF-LG AS patients (HR 0.73 [0.60-0.88], P = .0011), but not in those with PLF-LG AS (HR 0.91 [0.73-1.14], P = .42).
Quantification of AVC may not only be of diagnostic but also of prognostic value, as it facilitates the selection of LEF-LG AS patients with higher probability of beneficial outcome after TAVR.
与高梯度主动脉瓣狭窄（AS）相比，经导管主动脉瓣置换术（TAVR）后低流量、低梯度 AS 患者的死亡率更高，但该患者亚组中明确的预后预测因素尚未确定。本研究调查了 TAVR 治疗低流量、低梯度 AS 患者中主动脉瓣钙化（AVC）的预后影响。
本回顾性单中心分析包括所有因严重低流量、低梯度 AS（n=526），即低射血分数低梯度 AS（LEF-LG AS；n=290）和矛盾性低流量、低梯度 AS（PLF-LG AS；n=236）而行 TAVR 的患者，其中 AVC 从对比增强多层 CT 图像中定量。AVC 定义为每个瓣环面积的钙体积。根据两个亚组中性别特异性 AVC 三分位数，将患者分为三部分。通过 Kaplan-Meier 分析评估全因死亡率，并通过多变量分析确定独立的预后预测因素。
在两个亚组中，高 AVC 患者的基线跨瓣梯度更高，TAVR 后 PVL 发生率更高。在 LEF-LG AS 中，高 AVC 与 TAVR 后最低的 1 年和 3 年死亡率相关，但在 PLF-LG AS 组中则不然。根据多变量分析，AVC 与 LEF-LG AS 患者的生存获益独立相关（HR 0.73 [0.60-0.88]，P=0.0011），但与 PLF-LG AS 患者则无关（HR 0.91 [0.73-1.14]，P=0.42）。
AVC 的定量不仅具有诊断价值，而且具有预后价值，因为它有助于选择 TAVR 后具有更高获益可能性的 LEF-LG AS 患者。
