Borer J S, Hochreiter C, Herrold E M, Supino P, Aschermann M, Wencker D, Devereux R B, Roman M J, Szulc M, Kligfield P, Isom O W
The New York Hospital-Cornell Medical Center, New York 10021, USA.
Circulation. 1998 Feb 17;97(6):525-34. doi: 10.1161/01.cir.97.6.525.
Optimal criteria for valve replacement are unclear in asymptomatic/minimally symptomatic patients with aortic regurgitation (AR) and normal left ventricular (LV) performance at rest. Moreover, previous studies have not assessed the prognostic capacity of load-adjusted LV performance ("contractility") variables, which may be fundamentally related to clinical state. Therefore, 18 years ago, we set out to test prospectively the hypothesis that objective noninvasive measures of LV size and performance and, specifically, of load-adjusted variables, assessed at rest and during exercise (ex), could predict the development of currently accepted indications for operation for AR.
Clinical variables and measures of LV size, performance, and end-systolic wall stress (ESS) were assessed annually in 104 patients by radionuclide cineangiography at rest and maximal ex and by echocardiography at rest; ESS was derived during ex. During an average 7.3-year follow-up among patients who had not been operated on, 39 of 104 patients either died suddenly (n = 4) or developed operable symptoms only (n = 22) or subnormal LV performance with or without symptoms (n = 13) (progression rate=6.2%/y). By multivariate Cox model analysis, change (delta) in LV ejection fraction (EF) from rest to ex, normalized for deltaESS from rest to ex (deltaLVEF-deltaESS index), was the strongest predictor of progression to any end point or to sudden cardiac death alone. Unadjusted deltaLVEF was almost as efficient. Symptom status modified prediction on the basis of the deltaLVEF-deltaESS index. The population tercile at highest risk by deltaLVEF-deltaESS progressed to end points at a rate of 13.3%/y, and the lowest-risk tercile progressed at 1.8%/y.
Currently accepted symptom and LV performance indications for valve replacement, as well as sudden cardiac death, can be predicted in asymptomatic/minimally symptomatic patients with AR by load-adjusted deltaLVEF-deltaESS index, which includes data obtained during exercise.
对于无症状/症状轻微的主动脉瓣反流（AR）且静息时左心室（LV）功能正常的患者，瓣膜置换的最佳标准尚不清楚。此外，既往研究未评估负荷调整后的LV功能（“收缩性”）变量的预后能力，而这些变量可能与临床状态存在根本关联。因此，18年前，我们着手前瞻性地检验以下假设：静息和运动（ex）时评估的LV大小和功能的客观非侵入性测量指标，特别是负荷调整后的变量，能够预测目前公认的AR手术指征的发展。
通过静息和最大运动时的放射性核素心血管造影以及静息时的超声心动图，每年对104例患者的临床变量、LV大小、功能和收缩末期壁应力（ESS）进行评估；运动时计算ESS。在未接受手术的患者平均7.3年的随访期间，104例患者中有39例要么突然死亡（n = 4），要么仅出现可手术治疗的症状（n = 22），要么出现LV功能低于正常水平且伴有或不伴有症状（n = 13）（进展率 = 6.2%/年）。通过多变量Cox模型分析，静息到运动时LV射血分数（EF）的变化（delta），经静息到运动时deltaESS标准化（deltaLVEF-deltaESS指数），是进展至任何终点或单独进展至心源性猝死的最强预测因子。未调整的deltaLVEF几乎同样有效。症状状态基于deltaLVEF-deltaESS指数改变预测结果。根据deltaLVEF-deltaESS处于最高风险的人群三分位数进展至终点的速率为13.3%/年，而最低风险三分位数的进展速率为1.8%/年。
对于无症状/症状轻微的AR患者，通过负荷调整后的deltaLVEF-deltaESS指数（包括运动时获得的数据）可以预测目前公认的瓣膜置换症状和LV功能指征以及心源性猝死。
