Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.
Department of Cardiology, National Heart Centre, Singapore.
Open Heart. 2021 Jun;8(1). doi: 10.1136/openhrt-2021-001639.
The criteria to define the grade of aortic stenosis (AS)-aortic valve area (AVA) and mean gradient (MG) or peak jet velocity-do not always coincide into one grade. Although in severe AS, this discrepancy is well characterised, in moderate AS, the phenomenon of discordant grading has not been investigated and its prognostic implications are unknown.
To investigate the occurrence of discordant grading in patients with moderate AS (defined by an AVA between 1.0 cm² and 1.5 cm² but with an MG <20 mm Hg) and how these patients compare with those with concordant grading moderate AS (AVA between 1.0 cm² and 1.5 cm² and MG ≥20 mm Hg) in terms of clinical outcomes.
From an ongoing registry of patients with AS, patients with moderate AS based on AVA were selected and classified into discordant or concordant grading (MG <20 mm Hg or ≥20 mm Hg, respectively). The clinical endpoint was all-cause mortality.
Of 790 patients with moderate AS, 150 (19.0%) had discordant grading, moderate AS. Patients with discordant grading were older, had higher prevalence of previous myocardial infarction and left ventricular (LV) hypertrophy, larger LV end-diastolic and end-systolic volume index, higher LV filling pressure and lower LV ejection fraction and stroke volume index as compared with their counterparts. After a median follow-up of 4.9 years (IQR 3.0-8.2), patients with discordant grading had lower aortic valve replacement rates (26.7% vs 44.1%, p<0.001) and higher mortality rates (60.0% vs 43.1%, p<0.001) as compared with patients with concordant grading. Discordant grading moderate AS, combined with low LV ejection fraction, presented the higher risk of mortality (HR 2.78 (2.00-3.87), p<0.001).
Discordant-grading moderate AS is not uncommon and, when combined with low LV ejection fraction, is associated with high risk of mortality.
定义主动脉瓣狭窄（AS）的严重程度的标准——主动脉瓣面积（AVA）和平均梯度（MG）或峰值射流速度——并不总是对应一个等级。虽然在严重 AS 中，这种差异得到了很好的描述，但在中度 AS 中，这种不一致的分级现象尚未得到研究，其预后意义尚不清楚。
研究中度 AS 患者（AVA 在 1.0cm²和 1.5cm²之间但 MG<20mmHg）中不一致分级的发生情况，并比较这些患者与具有一致分级中度 AS（AVA 在 1.0cm²和 1.5cm²之间且 MG≥20mmHg）在临床结局方面的差异。
从正在进行的 AS 患者注册中，选择基于 AVA 的中度 AS 患者，并将其分为不一致或一致分级（MG<20mmHg 或≥20mmHg，分别）。临床终点为全因死亡率。
在 790 例中度 AS 患者中，150 例（19.0%）存在不一致分级。与对照组相比，不一致分级患者年龄更大，既往心肌梗死和左心室（LV）肥厚的发生率更高，LV 舒张末期和收缩末期容积指数更大，LV 充盈压更高，LV 射血分数和每搏输出量指数更低。中位随访 4.9 年后（IQR 3.0-8.2），不一致分级患者的主动脉瓣置换率（26.7% vs 44.1%，p<0.001）和死亡率（60.0% vs 43.1%，p<0.001）均低于一致分级患者。与具有一致分级的患者相比，不一致分级的中度 AS 合并低 LV 射血分数与更高的死亡率相关（HR 2.78（2.00-3.87），p<0.001）。
不一致分级的中度 AS 并不少见，当合并低 LV 射血分数时，与高死亡率相关。
