Clinical Outcomes and Revascularization Strategies in Patients With Low-Flow, Low-Gradient Severe Aortic Valve Stenosis According to the Assigned Treatment Modality

被引：35

作者：

O'Sullivan, Crochan J. ^{[1
,2
]}

Englberger, Lars ^{[3
]}

Hosek, Nicola ^{[1
]}

Heg, Dik ^{[4
,5
]}

Cao, Davide ^{[1
]}

Stefanini, Giulio G. ^{[1
]}

Stortecky, Stefan ^{[1
]}

Gloekler, Steffen ^{[1
]}

Spitzer, Ernest ^{[1
]}

Tueller, David ^{[2
]}

Huber, Christoph ^{[3
]}

Pilgrim, Thomas ^{[1
]}

Praz, Fabien ^{[1
]}

Buellesfeld, Lutz ^{[1
]}

Khattab, Ahmed A. ^{[1
]}

Carrel, Thierry ^{[3
]}

Meier, Bernhard ^{[1
]}

Windecker, Stephan ^{[1
,4
]}

Wenaweser, Peter ^{[1
]}

机构：

[1] Univ Hosp Bern, Dept Cardiol, CH-3010 Bern, Switzerland

[2] Stadtspital Triemli, Dept Cardiol, Zurich, Switzerland

[3] Univ Hosp Bern, Dept Cardiovasc Surg, CH-3010 Bern, Switzerland

[4] Univ Hosp Bern, Clin Trials Unit, CH-3010 Bern, Switzerland

[5] Univ Bern, Inst Social & Prevent Med, Bern, Switzerland

来源：

JACC-CARDIOVASCULAR INTERVENTIONS | 2015年 / 8卷 / 05期

关键词：

aortic stenosis; coronary artery disease; surgical aortic valve replacement; transcatheter aortic valve replacement; LEFT-VENTRICULAR DYSFUNCTION; TRANSVALVULAR PRESSURE-GRADIENTS; OPERATIVE RISK STRATIFICATION; CORONARY-ARTERY-DISEASE; EJECTION FRACTION; SYNTAX SCORE; DOBUTAMINE ECHOCARDIOGRAPHY; CONTRACTILE RESERVE; REPLACEMENT; TRANSCATHETER;

D O I：

10.1016/j.jcin.2014.11.020

中图分类号：

R5 [内科学];

学科分类号：

1002 ; 100201 ;

摘要：

OBJECTIVES This study compared clinical outcomes and revascularization strategies among patients presenting with low ejection fraction, low-gradient (LEF-LG) severe aortic stenosis (AS) according to the assigned treatment modality. BACKGROUND The optimal treatment modality for patients with LEF-LG severe AS and concomitant coronary artery disease (CAD) requiring revascularization is unknown. METHODS Of 1,551 patients, 204 with LEF-LG severe AS (aortic valve area <1.0 cm(2), ejection fraction <50%, and mean gradient <40 mm Hg) were allocated to medical therapy (MT) (n = 44), surgical aortic valve replacement (SAVR) (n = 52), or transcatheter aortic valve replacement (TAVR) (n = 108). CAD complexity was assessed using the SYNTAX score (SS) in 187 of 204 patients (92%). The primary endpoint was mortality at 1 year. RESULTS LEF-LG severe AS patients undergoing SAVR were more likely to undergo complete revascularization (17 of 52, 35%) compared with TAVR (8 of 108, 8%) and MT (0 of 44, 0%) patients (p < 0.001). Compared with MT, both SAVR (adjusted hazard ratio [adj HR]: 0.16; 95% confidence interval [CI]: 0.07 to 0.38; p < 0.001) and TAVR (adj HR: 0.30; 95% CI: 0.18 to 0.52; p < 0.001) improved survival at 1 year. In TAVR and SAVR patients, CAD severity was associated with higher rates of cardiovascular death (no CAD: 12.2% vs. low SS [0 to 22], 15.3% vs. high SS [>22], 31.5%; p = 0.037) at 1 year. Compared with no CAD/complete revascularization, TAVR and SAVR patients undergoing incomplete revascularization had significantly higher 1-year cardiovascular death rates (adj HR: 2.80; 95% CI: 1.07 to 7.36; p = 0.037). CONCLUSIONS Among LEF-LG severe AS patients, SAVR and TAVR improved survival compared with MT. CAD severity was associated with worse outcomes and incomplete revascularization predicted 1-year cardiovascular mortality among TAVR and SAVR patients. (C) 2015 by the American College of Cardiology Foundation.

引用

页码：704 / 717

页数：14

共 27 条

[1] Results of aortic valve replacement for aortic stenosis with relatively low transvalvular pressure gradients [J].

Blitz, LR ;

Gorman, M ;

Herrmann, HC .

AMERICAN JOURNAL OF CARDIOLOGY, 1998, 81 (03) :358-362

[2] PROGNOSIS AFTER VALVE-REPLACEMENT IN PATIENTS WITH SEVERE AORTIC-STENOSIS AND A LOW TRANSVALVULAR PRESSURE-GRADIENT [J].

BROGAN, WC ;

GRAYBURN, PA ;

LANGE, RA ;

HILLS, LD .

JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, 1993, 21 (07) :1657-1660

[3] HEMODYNAMIC DETERMINANTS OF PROGNOSIS OF AORTIC-VALVE REPLACEMENT IN CRITICAL AORTIC-STENOSIS AND ADVANCED CONGESTIVE HEART-FAILURE [J].

CARABELLO, BA ;

GREEN, LH ;

GROSSMAN, W ;

COHN, LH ;

KOSTER, JK ;

COLLINS, JJ .

CIRCULATION, 1980, 62 (01) :42-48

[4] Comparison Between Transcatheter and Surgical Prosthetic Valve Implantation in Patients With Severe Aortic Stenosis and Reduced Left Ventricular Ejection Fraction [J].

Clavel, M. A. ;

Webb, J. G. ;

Rodes-Cabau, J. ;

Masson, J. B. ;

Dumont, E. ;

De Larochelliere, R. ;

Doyle, D. ;

Bergeron, S. ;

Baumgartner, H. ;

Burwash, I. G. ;

Dumesnil, J. G. ;

Mundigler, G. ;

Moss, R. ;

Kempny, A. ;

Bagur, R. ;

Bergler-Klein, J. ;

Gurvitch, R. ;

Mathieu, P. ;

Pibarot, P. .

CIRCULATION, 2010, 122 (19) :1928-U89

[5] Predictors of outcomes in low-flow, low-gradient aortic stenosis - Results of the multicenter TOPAS study [J].

Clavel, Marie-Annick ;

Fuchs, Christina ;

Burwash, Ian G. ;

Mundigler, Gerald ;

Dumesnil, Jean G. ;

Baumgartner, Helmut ;

Bergler-Klein, Jutta ;

Beanlands, Rob S. ;

Mathieu, Patrick ;

Magne, Julien ;

Pibarot, Philippe .

CIRCULATION, 2008, 118 (14) :S234-S242

[6] Severe aortic stenosis with low transvalvular gradient and severe left ventricular dysfunction - Result of aortic valve replacement in 52 patients [J].

Connolly, HM ;

Oh, JK ;

Schaff, HV ;

Roger, VL ;

Osborn, SL ;

Hodge, DO ;

Tajik, AJ .

CIRCULATION, 2000, 101 (16) :1940-1946

[7] USEFULNESS OF DOBUTAMINE ECHOCARDIOGRAPHY IN DISTINGUISHING SEVERE FROM NONSEVERE VALVULAR AORTIC-STENOSIS IN PATIENTS WITH DEPRESSED LEFT-VENTRICULAR FUNCTION AND LOW TRANSVALVULAR GRADIENTS [J].

DEFILIPPI, CR ;

WILLETT, DL ;

BRICKNER, E ;

APPLETON, CP ;

YANCY, CW ;

EICHHORN, EJ ;

GRAYBURN, PA .

AMERICAN JOURNAL OF CARDIOLOGY, 1995, 75 (02) :191-194

[8] Outcomes of Transcatheter and Surgical Aortic Valve Replacement in High-Risk Patients With Aortic Stenosis and Left Ventricular Dysfunction Results From the Placement of Aortic Transcatheter Valves (PARTNER) Trial (Cohort A) [J].

Elmariah, Sammy ;

Palacios, Igor F. ;

McAndrew, Thomas ;

Hueter, Irene ;

Inglessis, Ignacio ;

Baker, Joshua N. ;

Kodali, Susheel ;

Leon, Martin B. ;

Svensson, Lars ;

Pibarot, Philippe ;

Douglas, Pamela S. ;

Fearon, William F. ;

Kirtane, Ajay J. ;

Maniar, Hersh S. ;

Passeri, Jonathan J. .

CIRCULATION-CARDIOVASCULAR INTERVENTIONS, 2013, 6 (06) :604-614

[9] The CABG SYNTAX Score - an angiographic tool to grade the complexity of coronary disease following coronary artery bypass graft surgery: from the SYNTAX Left Main Angiographic (SYNTAX-LE MANS) substudy [J].

Farooq, Vasim ;

Girasis, Chrysafios ;

Magro, Michael ;

Onuma, Yoshinobu ;

Morel, Marie Angele ;

Heo, Jung Ho ;

Garcia-Garcia, Hector ;

Kappetein, Arie Pieter ;

van den Brand, Marcel ;

Holmes, David R. ;

Mack, Michael ;

Feldman, Ted ;

Colombo, Antonio ;

Stahle, Elisabeth ;

James, Stefan ;

Carrie, Didier ;

Fournial, Gerard ;

van Es, Gerrit-Anne ;

Dawkins, Keith D. ;

Mohr, Friedrich W. ;

Morice, Marie-Claude ;

Serruys, Patrick W. .

EUROINTERVENTION, 2013, 8 (11) :1277-1285

[10] The Negative Impact of Incomplete Angiographic Revascularization on Clinical Outcomes and Its Association With Total Occlusions [J].

Farooq, Vasim ;

Serruys, Patrick W. ;

Garcia-Garcia, Hector M. ;

Zhang, Yaojun ;

Bourantas, Christos V. ;

Holmes, David R. ;

Mack, Michael ;

Feldman, Ted ;

Morice, Marie-Claude ;

Stahle, Elisabeth ;

James, Stefan ;

Colombo, Antonio ;

Diletti, Roberto ;

Papafaklis, Michail I. ;

de Vries, Ton ;

Morel, Marie-angele ;

van Es, Gerrit Anne ;

Mohr, Friedrich W. ;

Dawkins, Keith D. ;

Kappetein, Arie-Pieter ;

Sianos, Georgios ;

Boersma, Eric .

JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, 2013, 61 (03) :282-294

← 1 2 3 →