Ibrahim Hossam, Thaden Jeremy J, Fabre Katarina L, Scott Christopher G, Greason Kevin L, Pislaru Sorin V, Nkomo Vuyisile T
Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota.
Am J Cardiol. 2023 Feb 15;189:64-69. doi: 10.1016/j.amjcard.2022.11.031. Epub 2022 Dec 9.
The prevalence and impact of atrial fibrillation (AF) versus sinus rhythm (SR) on outcomes in very severe aortic stenosis (vsAS) of the native valve is unknown. The aim of the study was to determine the prognostic significance of AF in vsAS. A total of 563 patients with vsAS (transaortic valve peak velocity ≥5 m/s) and left ventricular ejection fraction ≥50% were identified retrospectively. Patients were divided by rhythm at the time of index transthoracic echocardiogram (AF: n = 50 [9%] vs SR: n = 513 [91%]). Patients with AF were older (83.1 ± 7.5 vs 72.5 ± 12.2 y, p <0.001) and had no difference in gender distribution (p = 0.49) but had a higher Charlson co-morbidity index (2 [1,3] vs 1 [0,2], p = 0.01). There was no difference in transaortic peak velocity (5.3 ± 0.3 m/s vs 5.4 ± 0.4 m/s, p = 0.13) and left ventricular ejection fraction was comparable (63 ± 7 vs 66 ± 7%, p = 0.01). Age-, gender-, Charlson co-morbidity index-, and time-dependent aortic valve replacement (AVR)-adjusted overall mortality at 5 years was significantly higher in patients with AF than patients with SR (hazard ratio [HR] 1.88 [1.23 to 2.85], p = 0.003). AVR was associated with improved survival (HR = 0.30 [0.22 to 0.42], p <0.001), with no statistically significant interaction of AVR and rhythm (p = 0.36). Outcomes were also compared in the 2 SR:1 AF propensity-matched analyses (100 SR: 50 AF), with matching done according to age, gender, clinical co-morbidities, and year of echocardiogram. In the propensity-matched analysis, age-, gender-, and time-dependent AVR-adjusted all-cause mortality was higher in AF (HR 2.32 [1.41 to 3.82], p <0.001). In conclusion, AF was not uncommon in vsAS and identified a subset of patients at a much higher risk of mortality without AVR.
在重度主动脉瓣狭窄（vsAS）的天然瓣膜中，心房颤动（AF）与窦性心律（SR）的患病率及其对预后的影响尚不清楚。本研究的目的是确定AF在vsAS中的预后意义。回顾性纳入了563例vsAS（经主动脉瓣峰值流速≥5 m/s）且左心室射血分数≥50%的患者。根据首次经胸超声心动图检查时的心律将患者分组（AF组：n = 50例[9%]，SR组：n = 513例[91%]）。AF患者年龄更大（83.1±7.5岁 vs 72.5±12.2岁，p<0.001），性别分布无差异（p = 0.49），但Charlson合并症指数更高（2[1,3] vs 1[0,2]，p = 0.01）。经主动脉峰值流速无差异（5.3±0.3 m/s vs 5.4±0.4 m/s，p = 0.13），左心室射血分数相当（63±7% vs 66±7%，p = 0.01）。校正年龄、性别、Charlson合并症指数和时间依赖性主动脉瓣置换（AVR）后，AF患者5年时的全因死亡率显著高于SR患者（风险比[HR] 1.88[1.23至2.85]，p = 0.003）。AVR与生存率提高相关（HR = 0.30[0.22至0.42]，p<0.001），AVR与心律之间无统计学显著交互作用（p = 0.36）。还在2:1倾向匹配分析（100例SR:50例AF）中比较了结局，根据年龄、性别、临床合并症和超声心动图年份进行匹配。在倾向匹配分析中，校正年龄、性别和时间依赖性AVR后的AF组全因死亡率更高（HR 2.32[1.41至3.82]，p<0.001）。总之，AF在vsAS中并不少见，且确定了一组未进行AVR时死亡风险高得多的患者。
