Department of Cardiovascular Diseases, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin and German Centre for Cardiovascular Research (DZHK) Berlin Site, Hindenburgdamm 30, 12200, Berlin, Germany.
Department of Internal Medicine and Cardiology, Zollernalbklinik, Balingen, Germany.
Clin Res Cardiol. 2022 Dec;111(12):1377-1386. doi: 10.1007/s00392-022-02067-2. Epub 2022 Aug 19.
Patients with severe aortic stenosis (AS) frequently presented mitral regurgitation (MR), which may interfere with the standard echocardiographic measurements of mean pressure gradient (MPG), flow velocity, and aortic valve area (AVA).
Herein we investigated the prevalence and severity of MR in patients with severe AS and its role on the accuracy of the standard echocardiographic parameters of AS quantification.
Of all patients with severe AS undergoing transcatheter or surgical aortic valve replacement enrolled in the German Aortic Registry from 2011 to 2017, 119,641 were included in this study. The population was divided based on the values of left ventricular ejection fraction ([LVEF] > 50%, LVEF 31-50%, and LVEF ≤ 30%] and AVA (0.80 to ≤ 1.00 cm, 0.60 to < 0.80 cm, 0.40 to < 0.60 cm, and 0.20 to < 0.40 cm).
Overall, 77,890 (65%) patients with mild to-moderate and 4262 (4%) with severe MR were compared with 37,489 (31%) patients without MR. Patients with mild-to-moderate and severe MR presented significantly lower mPG (ΔmPG [95%CI] - 1.694 mmHg [- 2.123 to - 1.265], p < 0.0001 and - 6.954 mmHg [- 7.725 to - 6.183], p < 0.0001, respectively), that increased with LVEF impairment. Conversely, AVA did not differ (severe versus no MR: ΔAVA [95%CI]: - 0.007cm [- 0.023 to 0.009], p = 0.973). Increasing MR severity was associated with significant mPG reduction throughout all AVA strata, causing a low-gradient pattern, that manifested since the early stages of severe AS (LVEF > 50%: AVA 0.80 to 1.00 cm; LVEF 31-50%: AVA 0.60 to 0.80 cm).
In patients with severe AS, concomitant MR is common, contributes to the onset of a low-gradient AS pattern, and affects the diagnostic accuracy of flow-dependent AVA measurements. In this setting, a multimodality, AVA-centric approach should be implemented. In patients with severe aortic stenosis, concomitant mitral regurgitation contributes to the onset of a low-gradient pattern, warranting a multimodality, and AVA-centric diagnostic approach.
严重主动脉瓣狭窄（AS）患者常伴有二尖瓣反流（MR），这可能会影响平均压力梯度（MPG）、流速和主动脉瓣面积（AVA）的标准超声心动图测量。
本研究旨在探讨严重 AS 患者 MR 的发生率和严重程度及其对 AS 定量标准超声心动图参数准确性的影响。
本研究纳入了 2011 年至 2017 年期间在德国主动脉注册中心接受经导管或手术主动脉瓣置换的所有严重 AS 患者，共 119641 例。根据左心室射血分数（LVEF>50%、LVEF 31-50%和 LVEF≤30%）和 AVA（0.80 至≤1.00cm、0.60 至<0.80cm、0.40 至<0.60cm 和 0.20 至<0.40cm）值对人群进行了分组。
总体而言，77890 例（65%）患者为轻度至中度 MR 和 4262 例（4%）患者为重度 MR，并与 37489 例（31%）无 MR 患者进行了比较。轻度至中度 MR 和重度 MR 患者的平均压力梯度（MPG）明显降低（MPG 差值[95%CI]：-1.694mmHg[-2.123 至-1.265]，p<0.0001 和-6.954mmHg[-7.725 至-6.183]，p<0.0001），且随左心室射血分数（LVEF）降低而增加。相反，AVA 并无差异（重度 MR 与无 MR：AVA 差值[95%CI]：-0.007cm[-0.023 至 0.009]，p=0.973）。随着 MR 严重程度的增加，整个 AVA 分层的 MPG 显著降低，导致低梯度模式，这在严重 AS 的早期阶段就已经表现出来（LVEF>50%：AVA 0.80 至 1.00cm；LVEF 31-50%：AVA 0.60 至 0.80cm）。
在严重 AS 患者中，并存的 MR 很常见，导致低梯度 AS 模式的发生，并影响流量依赖性 AVA 测量的诊断准确性。在这种情况下，应采用多模态、以 AVA 为中心的方法。在严重主动脉瓣狭窄患者中，并存的二尖瓣反流导致低梯度模式的发生，需要采用多模态和以 AVA 为中心的诊断方法。
