Dahan Shani, Dal-Bianco Jacob P, Plakht Ygal, Namasivayam Mayooran, Capoulade Romain, Zeng Xin, Passeri Jonathan, Yucel Evin, Picard Michael H, Levine Robert A, Hung Judy
Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston (S.D., J.P.D.-B., X.Z., J.P., E.Y., M.H.P., R.A.L., J.H.).
Department of Nursing, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel (Y.P.).
Circ Cardiovasc Imaging. 2025 May;18(5):e017598. doi: 10.1161/CIRCIMAGING.124.017598. Epub 2025 Mar 21.
Patients with paradoxical low-flow, low-gradient severe aortic stenosis exhibit low transvalvular flow rate (Q), while maintaining preserved left ventricular ejection fraction. Severe mitral regurgitation (MR) also causes a low-flow state, adding complexity to diagnosis and management. This study aimed to examine the impact of severe MR on outcomes in paradoxical low-flow, low-gradient severe aortic stenosis.
Data from an institutional echo database identified 1189 patients with adjudicated severe aortic stenosis (aortic valve area ≤1.0 cm), low transaortic gradients (mean gradient <40 mm Hg), preserved left ventricular ejection fraction (≥50%), and low-flow rate (Q ≤210 mL/s) to confirm paradoxical low-flow, low-gradient severe aortic stenosis. Subgroups were based on MR severity (severe and non-severe). Clinical outcomes included all-cause mortality, aortic valve replacement, heart failure hospitalizations, and a composite outcome.
In the severe MR group (n=80), patients had lower flow rates, increased left ventricular dimensions, and a more eccentric hypertrophy pattern compared with non-severe MR (n=1109). Over a follow-up of up to 5 years, severe MR correlated with higher all-cause mortality (=0.02) and aortic valve replacement rates (=0.012). After multivariable adjustment, severe MR was independently associated with increased all-cause mortality risk (hazard ratio=1.43; =0.011) and composite outcome (hazard ratio=1.64; <0.001). Aortic valve replacement significantly reduced mortality at every MR degree, with the most substantial impact in severe MR (hazard ratio=0.18; <0.001). Propensity-adjusted models demonstrated a stronger aortic valve replacement impact with increasing MR degree (=0.044).
Severe MR in paradoxical low-flow, low-gradient severe aortic stenosis is associated with adverse outcomes and distinctive left ventricular remodeling. Aortic valve replacement improves survival across all MR grades, with greater impact in severe MR.
矛盾性低流量、低跨瓣压差的重度主动脉瓣狭窄患者表现为跨瓣血流速率（Q）降低，同时左心室射血分数保持正常。重度二尖瓣反流（MR）也会导致低流量状态，增加了诊断和管理的复杂性。本研究旨在探讨重度MR对矛盾性低流量、低跨瓣压差的重度主动脉瓣狭窄患者预后的影响。
从机构超声心动图数据库中提取数据，确定1189例经判定为重度主动脉瓣狭窄（主动脉瓣面积≤1.0 cm²）、低跨主动脉压差（平均压差<40 mmHg）、左心室射血分数正常（≥50%）且血流速率低（Q≤210 mL/s）的患者，以确诊矛盾性低流量、低跨瓣压差的重度主动脉瓣狭窄。根据MR严重程度（重度和非重度）进行分组。临床结局包括全因死亡率、主动脉瓣置换术、心力衰竭住院以及复合结局。
在重度MR组（n = 80）中，与非重度MR组（n = 1109）相比，患者的血流速率更低，左心室尺寸更大，且左心室肥厚模式更偏心。在长达5年的随访中，重度MR与更高的全因死亡率（P = 0.02）和主动脉瓣置换率（P = 0.012）相关。多变量调整后，重度MR与全因死亡风险增加（风险比 = 1.43；P = 0.011）和复合结局（风险比 = 1.64；P < 0.001）独立相关。在每个MR程度下，主动脉瓣置换术均显著降低死亡率，对重度MR的影响最为显著（风险比 = 0.18；P < 0.001）。倾向评分调整模型显示，随着MR程度增加，主动脉瓣置换术的影响更强（P = 0.044）。
矛盾性低流量、低跨瓣压差的重度主动脉瓣狭窄合并重度MR与不良结局及独特的左心室重构相关。主动脉瓣置换术可改善所有MR分级患者的生存率，对重度MR患者的影响更大。
