Wasfy Jason H, Etiwy Muhammad, Zhao Yunong, Gustus Sarah K, Berman Adam N, Fraccaro Chiara, Karam Nicole, Wasfy Meagan M, Hsu John, Picard Michael H
Heart and Vascular Institute and Department of Medicine, Mass General Brigham, Harvard Medical School, 55 Fruit Street, Boston, Massachusetts, 02138, USA.
Dartmouth Geisel School of Medicine, 1 Rope Ferry Rd, Hanover, New Hampshire, 03755, USA.
Eur J Cardiothorac Surg. 2025 Sep 2;67(9). doi: 10.1093/ejcts/ezaf211.
Indications for aortic valve replacement (AVR) in severe asymptomatic aortic stenosis (AS) differ for individuals with normal versus low or decreasing left ventricular ejection fraction (LVEF). Conceptually, the development of left ventricular hypertrophy (LVH) could also indicate ventricular injury and potential need for earlier AVR.
Initially, 1 232 492 echocardiography reports from 12 hospitals were identified; then previously validated, open-source natural language processing modules were applied to identify aortic gradients, LVEF, and the presence of LVH. These reports were linked to mortality data, key comorbidities, and date of any AVR. We then performed physician chart reviews, identified asymptomatic individuals with normal flow severe AS, LVEF ≥ 55%, and LVH, and confirmed key clinical data manually. To assess the association between AVR and mortality, Cox proportional hazards models considering treatment status (i.e., AVR or not considered as a time-dependent covariate) were used with the index echocardiogram as time zero.
After application of eligibility criteria, 607 unique, confirmed asymptomatic individuals remained for the primary analysis. After adjustment, and accounting for the time-dependence of AVR, AVR was associated with reduced mortality (hazard ratio 0.37; 95% confidence interval 0.25-0.55, P < 0.0001).
AVR was associated with reduced mortality for patients with severe asymptomatic AS, preserved LVEF, and LVH. This is the largest known analysis of aortic valve replacement outcomes in individuals with severe aortic stenosis and left ventricular hypertrophy. As clinical guidelines for intervention in asymptomatic severe aortic stenosis expand, left ventricular hypertrophy is easier to assess than myocardial fibrosis and may be a useful marker for patients who need to be prioritized. These results raise the potential of more proactive AVR in individuals with LVH, even among asymptomatic individuals with normal LVEF.
对于左心室射血分数（LVEF）正常与低或降低的严重无症状主动脉瓣狭窄（AS）患者，主动脉瓣置换术（AVR）的指征有所不同。从概念上讲，左心室肥厚（LVH）的出现也可能表明心室损伤以及可能需要更早进行AVR。
首先，从12家医院识别出1232492份超声心动图报告；然后应用先前经过验证的开源自然语言处理模块来识别主动脉瓣压差、LVEF以及LVH的存在情况。这些报告与死亡率数据、关键合并症以及任何AVR的日期相关联。随后，我们进行了医生病历审查，识别出无症状且血流正常的严重AS、LVEF≥55%且有LVH的个体，并手动确认关键临床数据。为了评估AVR与死亡率之间的关联，使用了考虑治疗状态（即AVR或未考虑作为时间依赖性协变量）的Cox比例风险模型，将首次超声心动图检查作为时间零点。
应用纳入标准后，607名独特的、确诊的无症状个体留作主要分析。经过调整并考虑到AVR的时间依赖性后，AVR与死亡率降低相关（风险比0.37；95%置信区间0.25 - 0.55，P < 0.0001）。
对于严重无症状AS、LVEF保留且有LVH的患者，AVR与死亡率降低相关。这是已知的对严重主动脉瓣狭窄和左心室肥厚个体进行主动脉瓣置换术结果的最大规模分析。随着无症状严重主动脉瓣狭窄干预临床指南的扩展，左心室肥厚比心肌纤维化更容易评估，可能是需要优先考虑的患者的有用标志物。这些结果提高了对于有LVH的个体，甚至是LVEF正常的无症状个体更积极进行AVR的可能性。
