Department of Cardiology, Royal Perth Hospital, Perth, Australia.
School of Medicine, University of Western Australia, Perth, Australia; Royal Perth Hospital Research Foundation, Perth, Australia.
J Am Soc Echocardiogr. 2021 May;34(5):465-471. doi: 10.1016/j.echo.2020.12.017. Epub 2020 Dec 31.
Echocardiographic measures of elevated left ventricular filling pressures are associated with an adverse prognosis. The aim of this study was to determine the relationship between acute (ratio of early transmitral flow to mitral annular velocity [E/e']) and chronic (indexed left atrial volume) markers of left ventricular filling pressure and mortality in patients with nonsevere aortic stenosis (AS), within the National Echo Database Australia cohort, testing the hypothesis that they would reflect the early hemodynamic consequences of AS and be associated with increased mortality in this setting.
The first record for patients ≥18 years of age showing hemodynamically significant but nonsevere (mild or moderate) AS (mean pressure gradient ≥ 10 to <40 mm Hg and aortic valve area > 1 cm) was analyzed. Baseline demographics and echocardiographic variables were compared with those among patients without AS (mean pressure gradient < 10 mm Hg). Mortality linkage data were available for all patients.
Of 78,886 patients with aortic valve mean pressure gradients < 40 mm Hg and aortic valve areas > 1 cm, 13,768 (17%) were identified with nonsevere AS (aortic valve mean pressure gradient 10-40 mm Hg), of whom 57% were men (mean age, 73 ± 13.4 years) with a median follow-up of 3.4 years (interquartile range, 1.7-6.1 years). In unadjusted time-varying coefficient models, nonsevere AS and indexed left atrial volume > 34 mL/m (hazard ratio [HR], 2.29; 95% CI, 2.03-2.58), E/e' ratio > 14 (HR, 2.27; 95% CI, 2.08-2.49), left ventricular ejection fraction < 50% (HR, 2.82; 95% CI, 2.50-3.19), and tricuspid regurgitation peak velocity > 280 cm/sec (HR, 2.54; 95% CI, 2.30-2.80) were associated with increased mortality hazard at the time of echocardiography. All markers were significant when combined in a multivariate model.
Indices of elevated left ventricular filling pressure are independently associated with death in patients with nonsevere AS. Risk stratification models incorporating these variables may identify patients at risk for complications, warranting closer surveillance and possibly earlier intervention.
左心室充盈压升高的超声心动图指标与不良预后相关。本研究旨在确定澳大利亚国家超声心动图数据库队列中非严重主动脉瓣狭窄（AS）患者的急性（早期二尖瓣血流与二尖瓣环速度比[E/e']）和慢性（左心房容积指数）左心室充盈压标志物与死亡率之间的关系，检验它们反映 AS 的早期血液动力学后果并与该人群中死亡率增加相关的假设。
分析了年龄≥ 18 岁的血流动力学显著但非严重（轻度或中度）AS（平均压力梯度≥ 10 至 <40mmHg 和主动脉瓣面积> 1cm）患者的首次记录。比较了伴有 AS 患者的基线人口统计学和超声心动图变量（平均压力梯度< 10mmHg）。所有患者均有死亡关联数据。
在主动脉瓣平均压力梯度< 40mmHg 和主动脉瓣面积> 1cm 的 78886 例患者中，有 13768 例（17%）被诊断为非严重 AS（主动脉瓣平均压力梯度 10-40mmHg），其中 57%为男性（平均年龄 73 ± 13.4 岁），中位随访时间为 3.4 年（四分位距 1.7-6.1 年）。在未调整的时变系数模型中，非严重 AS 和左心房容积指数> 34mL/m（危险比[HR]，2.29；95%置信区间[CI]，2.03-2.58），E/e'比值> 14（HR，2.27；95%CI，2.08-2.49），左心室射血分数< 50%（HR，2.82；95%CI，2.50-3.19）和三尖瓣反流峰值速度> 280cm/sec（HR，2.54；95%CI，2.30-2.80）与超声心动图时的死亡率升高相关。当这些标志物在多变量模型中结合时，所有标志物均具有统计学意义。
升高的左心室充盈压指数与非严重 AS 患者的死亡独立相关。纳入这些变量的风险分层模型可能会识别出有并发症风险的患者，需要更密切的监测，可能需要更早的干预。
