Department of Cardiovascular Medicine, Mayo Clinic, Rochester.
Circ Cardiovasc Imaging. 2021 Dec;14(12):1100-1108. doi: 10.1161/CIRCIMAGING.121.013075. Epub 2021 Dec 8.
Chronic elevation of left heart filling pressure causes pulmonary vascular remodeling, pulmonary hypertension, and right heart dysfunction. Although diastolic dysfunction is relatively common in patients with coarctation of aorta, there are limited data about the prevalence and prognostic implications of pulmonary hypertension and right heart dysfunction in this population. The purpose of the study was to assess right heart function and hemodynamics in patients with coarctation of aorta and to determine the relationship between right heart indices and cardiovascular events defined as heart failure hospitalization, heart transplant, or cardiovascular death.
Right heart structure, function, and hemodynamics were assessed with these indices: right atrial volume, right atrial pressure, right atrial reservoir strain, right ventricular global longitudinal strain, right ventricular end-diastolic area, right ventricular systolic pressure, and tricuspid regurgitation severity. Right heart hemodynamic score, range 0 to 5, was generated based on the correlation between the right heart indices and cardiovascular events, using half of the cohort (derivation cohort, n=411), and then tested on the validation cohort (n=410). The goodness of fit and discrimination power was compared using C statistics and risk score.
The median follow-up in the derivation cohort was 8.2 (4.0-11.1) years, and 59 (14%) patients had cardiovascular events during this period. Right heart hemodynamic score was independently associated with cardiovascular events (hazard ratio, 1.64 [95% CI, 1.38-2.17]) for every unit increase in right heart hemodynamic score after adjustment for clinical and echocardiographic indices (C statistic, 0.718 [95% CI, 0.682-0.746]). The right heart hemodynamic score was also independently associated with cardiovascular events in the validation cohort (C statistic, 0.711 [95% CI, 0.679-0.741]). The C statistic difference (0.007 [95% CI, 0.014-0.022]) and risk score (0.86 [95% CI, 0.54-1.17]) suggest a good model fit.
The current study underscores the prognostic importance of right heart dysfunction in patients with coarctation of aorta and suggests that right heart indices should be used for risks stratification in this population.
慢性左心充盈压升高可导致肺血管重塑、肺动脉高压和右心功能障碍。虽然在主动脉缩窄患者中，舒张功能障碍较为常见，但有关该人群肺动脉高压和右心功能障碍的患病率和预后意义的数据有限。本研究的目的是评估主动脉缩窄患者的右心功能和血流动力学，并确定右心指数与心血管事件（定义为心力衰竭住院、心脏移植或心血管死亡）之间的关系。
使用右心房容积、右心房压力、右心房储备应变、右心室整体纵向应变、右心室舒张末期面积、右心室收缩压和三尖瓣反流严重程度等指标评估右心结构、功能和血流动力学。根据右心指数与心血管事件的相关性，使用半队列（推导队列，n=411）生成右心血流动力学评分（范围 0-5），然后在验证队列（n=410）中进行检验。使用 C 统计量和风险评分比较拟合优度和区分能力。
推导队列的中位随访时间为 8.2（4.0-11.1）年，在此期间 59 名（14%）患者发生心血管事件。右心血流动力学评分与心血管事件独立相关（风险比，1.64[95%CI，1.38-2.17]），在调整临床和超声心动图指标后，每增加一个单位的右心血流动力学评分（C 统计量，0.718[95%CI，0.682-0.746]）。右心血流动力学评分在验证队列中也与心血管事件独立相关（C 统计量，0.711[95%CI，0.679-0.741]）。C 统计量差异（0.007[95%CI，0.014-0.022]）和风险评分（0.86[95%CI，0.54-1.17]）表明模型拟合良好。
本研究强调了右心功能障碍在主动脉缩窄患者中的预后重要性，并表明右心指数应用于该人群的风险分层。
