Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
Department of Radiology, Mayo Clinic, Rochester, Minnesota.
J Am Soc Echocardiogr. 2022 Jan;35(1):116-123. doi: 10.1016/j.echo.2021.08.024. Epub 2021 Sep 8.
BACKGROUND: Doppler mean gradient (MG) may underestimate aortic stenosis (AS) severity when obtained during atrial fibrillation (AF) because of lower forward flow compared with sinus rhythm (SR). Whether AS is more advanced at the time of referral for aortic valve intervention in AF compared with SR is unknown. The aim of this study was to examine flow-independent computed tomographic aortic valve calcium scores (AVCS) and their concordance to MG in AF versus SR in patients undergoing transcatheter aortic valve replacement (TAVR). METHODS: Patients who underwent TAVR from 2016 to 2020 for native valve severe AS with left ventricular ejection fraction ≥ 50% were identified from an institutional TAVR database. MGs during AF and SR in high-gradient AS (HGAS) and low-gradient AS (LGAS) were compared with AVCS (AVCS/MG ratio). AVCS were obtained within 90 days of pre-TAVR echocardiography. RESULTS: Six hundred thirty-three patients were included; median age was 82 years (interquartile range [IQR], 76-86 years), and 46% were women. AF was present in 109 (17%) and SR in 524 (83%) patients during echocardiography. Aortic valve area index was slightly smaller in AF versus SR (0.43 cm/m [IQR, 0.39-0.47 cm/m] vs 0.46 cm/m [IQR, 0.41-0.51 cm/m], P = .0003). Stroke volume index, transaortic flow rate, and MG were lower in AF (P < .0001 for all). AVCS were higher in men with AF compared with SR (3,510 Agatston units [AU] [IQR, 2,803-4,030 AU] vs 2,722 AU [IQR, 2,180-3,467 AU], P < .0001) in HGAS but not in LGAS. AVCS were not different in women with AF versus SR. Overall AVCS/MG ratios were higher in AF versus SR in HGAS and LGAS (P < .03 for all), except in women with LGAS. CONCLUSIONS: AVCS were higher than expected by MG in AF compared with SR. The very high AVCS in men with AF and HGAS at the time of TAVR suggests late diagnosis of severe AS because of underestimated AS severity during progressive AS and/or late referral to TAVR. Additional studies are needed to examine the extent to which echocardiography may be underestimating AS severity in AF.
背景：与窦性心律（SR）相比，心房颤动（AF）时的平均跨瓣梯度（MG）可能因前向血流较低而低估主动脉瓣狭窄（AS）的严重程度。在 AF 中进行主动脉瓣介入治疗时，AS 是否比 SR 更严重尚不清楚。本研究旨在检查经导管主动脉瓣置换术（TAVR）患者中 AF 与 SR 时与 MG 无关的计算断层扫描主动脉瓣钙评分（AVCS）及其一致性。
方法：从机构 TAVR 数据库中确定了 2016 年至 2020 年期间因左心室射血分数≥50%的原发性瓣膜严重 AS 而接受 TAVR 的患者。比较了 AF 和 SR 时高梯度 AS（HGAS）和低梯度 AS（LGAS）中的 MG 与 AVCS（AVCS/MG 比值）。AVCS 在 TAVR 前超声心动图检查后 90 天内获得。
结果：共纳入 633 例患者；中位年龄为 82 岁（四分位距 [IQR]，76-86 岁），46%为女性。在超声心动图检查中，109 例（17%）为 AF，524 例（83%）为 SR。AF 时的主动脉瓣面积指数略小于 SR（0.43 cm/m [IQR，0.39-0.47 cm/m] 比 0.46 cm/m [IQR，0.41-0.51 cm/m]，P =.0003）。AF 时的每搏量指数、跨瓣流量和 MG 均较低（所有 P <.0001）。与 SR 相比，AF 中男性的 AVCS 更高（3510 个 Agatston 单位 [AU] [IQR，2803-4030 AU] 比 2722 AU [IQR，2180-3467 AU]，P <.0001）在 HGAS 中，但在 LGAS 中并非如此。AF 中女性的 AVCS 与 SR 无差异。HGAS 和 LGAS 中，AF 时的 AVCS/MG 比值均高于 SR（所有 P <.03），LGAS 中的女性除外。
结论：与 SR 相比，AF 时的 AVCS 高于 MG 预期。在 TAVR 时，AF 中 HGAS 的男性 AVCS 非常高，这表明由于 AS 进行性加重和/或晚期转诊至 TAVR 导致 AS 严重程度被低估，导致严重 AS 的诊断延迟。需要进一步研究来检查超声心动图在多大程度上可能低估 AF 中的 AS 严重程度。
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