Okuno Taishi, Corpataux Noé, Spano Giancarlo, Gräni Christoph, Heg Dik, Brugger Nicolas, Lanz Jonas, Praz Fabien, Stortecky Stefan, Siontis George C M, Windecker Stephan, Pilgrim Thomas
Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland.
CTU, University of Bern, Bern, Switzerland.
Eur Heart J Qual Care Clin Outcomes. 2021 Jul 21;7(4):366-377. doi: 10.1093/ehjqcco/qcab010.
The ESC/EACTS guidelines propose criteria that determine the likelihood of true-severe aortic stenosis (AS). We aimed to investigate the impact of the guideline-based criteria of the likelihood of true-severe AS in patients with low-flow low-gradient (LFLG) AS with preserved ejection fraction (pEF) on outcomes following transcatheter aortic valve replacement (TAVR).
In a prospective TAVR registry, LFLG-AS patients with pEF were retrospectively categorized into high (criteria ≥6) and intermediate (criteria <6) likelihood of true-severe AS. Haemodynamic, functional, and clinical outcomes were compared with high-gradient AS patients with pEF. Among 632 eligible patients, 202 fulfilled diagnostic criteria for LFLG-AS. Significant haemodynamic improvement after TAVR was observed in LFLG-AS patients, irrespective of the likelihood. Although >70% of LFLG-AS patients had functional improvement, impaired functional status [New York Heart Association (NYHA III/IV)] persisted more frequently at 1 year in LFLG-AS than in high-gradient AS patients (7.8%), irrespective of the likelihood (high: 17.4%, P = 0.006; intermediate: 21.1%, P < 0.001). All-cause death at 1 year occurred in 6.6% of high-gradient AS patients, 10.9% of LFLG-AS patients with high likelihood [hazard ratio (HR)adj 1.43, 95% confidence interval (CI) 0.68-3.02], and in 7.2% of those with intermediate likelihood (HRadj 0.92, 95% CI 0.39-2.18). Among the criteria, only the absence of aortic valve area ≤0.8 cm2 emerged as an independent predictor of treatment futility, a combined endpoint of all-cause death or NYHA III/IV at 1 year (OR 2.70, 95% CI 1.14-6.25).
Patients with LFLG-AS with pEF had comparable survival but worse functional status at 1 year than high-gradient AS with pEF, irrespective of the likelihood of true-severe AS.
https://www.clinicaltrials.gov. NCT01368250.
欧洲心脏病学会/欧洲心胸外科学会（ESC/EACTS）指南提出了确定真正重度主动脉瓣狭窄（AS）可能性的标准。我们旨在研究基于指南的真正重度AS可能性标准对射血分数保留（pEF）的低流量低梯度（LFLG）AS患者经导管主动脉瓣置换术（TAVR）后结局的影响。
在一项前瞻性TAVR注册研究中，对pEF的LFLG-AS患者进行回顾性分类，分为真正重度AS可能性高（标准≥6）和中度（标准<6）两组。将血流动力学、功能和临床结局与pEF的高梯度AS患者进行比较。在632例符合条件的患者中，202例符合LFLG-AS的诊断标准。LFLG-AS患者TAVR后观察到显著的血流动力学改善，与可能性无关。尽管>70%的LFLG-AS患者有功能改善，但与高梯度AS患者相比，LFLG-AS患者在1年时功能状态受损[纽约心脏协会（NYHA III/IV）]持续更频繁（7.8%），与可能性无关（高：17.4%，P = 0.006；中度：21.1%，P < 0.001）。1年时全因死亡在高梯度AS患者中发生率为6.6%，真正重度AS可能性高的LFLG-AS患者中为10.9%[调整后风险比（HR）1.43，95%置信区间（CI）0.68 - 3.02]，真正重度AS可能性中度的患者中为7.2%（调整后HR 0.92，95% CI 0.39 - 2.18）。在这些标准中，只有主动脉瓣面积≤0.8 cm²不存在是治疗无效的独立预测因素，治疗无效是1年时全因死亡或NYHA III/IV的联合终点（比值比2.70，95% CI 1.14 - 6.25）。
与pEF的高梯度AS患者相比，pEF的LFLG-AS患者在1年时生存率相当，但功能状态更差，与真正重度AS的可能性无关。
