Institut universitaire de cardiologie et de pneumologie, Université Laval, Québec, Québec, Canada.
Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands.
J Am Coll Cardiol. 2021 Jun 8;77(22):2796-2803. doi: 10.1016/j.jacc.2021.04.014.
The study investigators previously reported that moderate aortic stenosis (AS) is associated with a poor prognosis in patients with heart failure (HF) with reduced left ventricular ejection fraction (LVEF) (HFrEF). However, the respective contribution of moderate AS versus HFrEF to the outcomes of these patients is unknown.
This study sought to determine the impact of moderate AS on outcomes in patients with HFrEF.
The study included 262 patients with moderate AS (aortic valve area >1.0 and <1.5 cm; and peak aortic jet velocity >2 and <4 m/s, at rest or after dobutamine stress echocardiography) and HFrEF (LVEF <50%). These patients were matched 1:1 for sex, age, estimated glomerular filtration rate, New York Heart Association functional class III to IV, presence of diabetes, LVEF, and body mass index with patients with HFrEF but no AS (i.e., peak aortic jet velocity <2 m/s). The endpoints were all-cause mortality and the composite of death and HF hospitalization.
A total of 262 patients with HFrEF and moderate AS were matched with 262 patients with HFrEF and no AS. Mean follow-up was 2.9 ± 2.2 years. In the moderate AS group, mean aortic valve area was 1.2 ± 0.2 cm, and mean gradient was 14.5 ± 4.7 mm Hg. Moderate AS was associated with an increased risk of mortality (hazard ratio [HR]: 2.98; 95% confidence interval [CI]: 2.08 to 4.31; p < 0.0001) and of the composite of HF hospitalization and mortality (HR: 2.34; 95% CI: 1. 72 to 3.21; p < 0.0001). In the moderate AS group, aortic valve replacement (AVR) performed in 44 patients at a median follow-up time of 10.9 ± 16 months during follow-up was associated with improved survival (HR: 0.59; 95% CI: 0.35 to 0.98; p = 0.04). Notably, surgical AVR was not significantly associated with improved survival (p = 0.92), whereas transcatheter AVR was (HR: 0.43; 95% CI: 0.18 to 1.00; p = 0.05).
In this series of patients with HFrEF, moderate AS was associated with a marked incremental risk of mortality. AVR, and especially transcatheter AVR during follow-up, was associated with improved survival in patients with HFrEF and moderate AS. These findings provide support to the realization of a randomized trial to assess the effect of early transcatheter AVR in patients with HFrEF and moderate AS.
研究人员先前报告称，中重度主动脉瓣狭窄（AS）与射血分数降低的心力衰竭（HF）（HFrEF）患者的预后不良相关。然而，中重度 AS 与 HFrEF 对这些患者结局的各自贡献尚不清楚。
本研究旨在确定中重度 AS 对 HFrEF 患者结局的影响。
该研究纳入了 262 例中重度 AS 患者（主动脉瓣口面积>1.0 且<1.5cm；静息或多巴酚丁胺负荷超声心动图后峰值主动脉瓣口速度>2 且<4m/s）和 HFrEF（LVEF<50%）患者。这些患者按性别、年龄、估算肾小球滤过率、纽约心脏协会心功能 III 至 IV 级、是否合并糖尿病、LVEF 和体重指数与无 AS 的 HFrEF 患者（即峰值主动脉瓣口速度<2m/s）进行 1:1 匹配。终点为全因死亡率和死亡与 HF 住院的复合终点。
共纳入 262 例 HFrEF 合并中重度 AS 患者和 262 例 HFrEF 无 AS 患者进行匹配。平均随访时间为 2.9±2.2 年。中重度 AS 组的平均主动脉瓣口面积为 1.2±0.2cm，平均跨瓣压差为 14.5±4.7mmHg。中重度 AS 与死亡率增加相关（风险比[HR]：2.98；95%置信区间[CI]：2.08 至 4.31；p<0.0001）和 HF 住院和死亡率的复合终点（HR：2.34；95%CI：1.72 至 3.21；p<0.0001）。在中重度 AS 组中，44 例患者在中位随访时间 10.9±16 个月时接受了主动脉瓣置换术（AVR），随访期间的生存率有所提高（HR：0.59；95%CI：0.35 至 0.98；p=0.04）。值得注意的是，手术 AVR 与生存率的改善无显著相关性（p=0.92），而经导管 AVR 则有（HR：0.43；95%CI：0.18 至 1.00；p=0.05）。
在本系列 HFrEF 患者中，中重度 AS 与死亡率明显增加相关。AVR，尤其是在随访期间行经导管 AVR，与 HFrEF 和中重度 AS 患者的生存率提高相关。这些发现为评估早期经导管 AVR 在 HFrEF 和中重度 AS 患者中的效果的随机试验提供了支持。
