Prakash Yash, Chopra Lakshay, Mannina Carlo, Galvani Eileen, Akinmolayemi Oludamilola, Singh Ranbir, Argulian Edgar, Melarcode-Krishnamoorthy Parasuram, Dangas George, Halperin Jonathan L, Sharma Samin K, Kini Annapoorna S, Lerakis Stamatios
Samuel Bronfman Department of Medicine, Mount Sinai Hospital, New York, New York.
Mount Sinai Fuster Heart Hospital, New York, New York.
Am J Cardiol. 2025 May 28;252:30-39. doi: 10.1016/j.amjcard.2025.05.018.
Transcatheter aortic valve replacement (TAVR) is a standard treatment for severe aortic stenosis (AS), but outcomes vary based on flow state. Low-flow, low-gradient aortic stenosis (LFLG AS) is a heterogenous condition and growing evidence suggests that response to TAVR differs by subtype. However, the generalizability of these studies to U.S. populations remains uncertain. This single-center, US-based retrospective study compared mortality outcomes from TAVR versus conservative management strategies in patients with classical (cLFLG) and paradoxical (pLFLG) LFLG AS. Adults with severe LFLG AS (valve area ≤1.0 cm, stroke volume index ≤35 mL/m, and mean pressure gradient <40 mmHg) evaluated for TAVR between 2019 and 2021 were included. Patients were stratified by subtype (cLFLG: left ventricular ejection fraction [LVEF] <50%; pLFLG: LVEF ≥50%) and treatment strategy (TAVR or conservative management). Of 490 patients included (207 cLFLG, 283 pLFLG), 67% underwent TAVR. Median follow-up was 19 months. TAVR was associated with lower mortality than conservative management (adjusted hazard ratio [HR] 0.47; 95% CI 0.33 to 0.69; p <0.001). In cLFLG AS, TAVR significantly reduced mortality (adjusted HR 0.37; 95% CI 0.23 to 0.60; p <0.001). In pLFLG AS, a nonsignificant trend towards benefit was observed (adjusted HR 0.62; 95% CI 0.33 to 1.15; p = 0.127). Among patients managed conservatively, those with pLFLG AS had lower mortality than cLFLG AS (adjusted HR 0.50; 95% CI 0.25 to 0.99; p = 0.046). In conclusion, TAVR is associated with improved survival in LFLG AS, particularly in patients with cLFLG AS. Comparable outcomes in conservatively managed pLFLG AS patients support a more individualized, phenotype-driven treatment approach.
经导管主动脉瓣置换术（TAVR）是重度主动脉瓣狭窄（AS）的标准治疗方法，但治疗效果因血流状态而异。低流量、低梯度主动脉瓣狭窄（LFLG AS）是一种异质性疾病，越来越多的证据表明，TAVR的反应因亚型而异。然而，这些研究在美国人群中的普遍性仍不确定。这项基于美国的单中心回顾性研究比较了经典型（cLFLG）和矛盾型（pLFLG）LFLG AS患者TAVR与保守治疗策略的死亡率结果。纳入了2019年至2021年间接受TAVR评估的重度LFLG AS（瓣口面积≤1.0 cm，每平方米体表面积心搏量指数≤35 mL/m，平均压力阶差<40 mmHg）的成年人。患者按亚型（cLFLG：左心室射血分数[LVEF]<50%；pLFLG：LVEF≥50%）和治疗策略（TAVR或保守治疗）进行分层。在纳入的490例患者中（207例cLFLG，283例pLFLG），67%接受了TAVR。中位随访时间为19个月。与保守治疗相比，TAVR与更低的死亡率相关（调整后风险比[HR]0.47；95%置信区间0.33至0.69；p<0.001）。在cLFLG AS中，TAVR显著降低了死亡率（调整后HR 0.37；95%置信区间0.23至0.60；p<0.001）。在pLFLG AS中，观察到有获益的非显著趋势（调整后HR 0.62；95%置信区间0.33至1.15；p=0.127）。在接受保守治疗的患者中，pLFLG AS患者的死亡率低于cLFLG AS患者（调整后HR 0.50；95%置信区间0.25至0.99；p=0.046）。总之，TAVR与LFLG AS患者生存率的提高相关，尤其是cLFLG AS患者。保守治疗的pLFLG AS患者具有可比的结果，支持采用更个体化的、表型驱动的治疗方法。
