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Abstract：
Background: Few data exist on the comparative long-term outcomes of severe aortic stenosis (AS) patients with different flow-gradient patterns undergoing transcatheter aortic valve implantation (TAVI). This study sought to evaluate the impact of the pre-TAVI flow-gradient pattern on long-term clinical outcomes after TAVI and assess changes in the left ventricular ejection fraction (LVEF) of different subtypes of AS patients following TAVI. Methods: Consecutive patients with severe AS undergoing TAVI in our institution were screened and prospectively enrolled. Patients were divided into four subgroups according to pre-TAVI flow/gradient pattern: (i) low flow-low gradient (LF-LG): stroke volume indexed (SVi) ≤ 35 mL/m2 and mean gradient (MG) < 40 mmHg); (ii) normal flow-low gradient (NF-LG): SVi > 35 mL/m2 and MG < 40 mmHg; (iii) low flow-high gradient (LF-HG): Svi 35 mL/m2 and MG ≥ 40 mmHg and (iv) normal flow-high gradient (NF-HG): SVi > 35 mL/m2 and MG ≥ 40 mmHg. Transthoracic echocardiography was repeated at 1-year follow-up. Clinical follow-up was obtained at 12 months, and yearly thereafter until 5-year follow-up was complete for all patients. Results: A total of 272 patients with complete echocardiographic and clinical follow-up were included in our analysis. Their mean age was 80 ± 7 years and the majority of patients (N = 138, 50.8%) were women. 62 patients (22.8% of the study population) were distributed in the LF-LG group, 98 patients (36%) were LF-HG patients, 95 patients (34.9%) were NF-HG, and 17 patients (6.3%) were NF-LG. There was a greater prevalence of comorbidities among LF-LG AS patients. One-year all-cause mortality differed significantly between the four subgroups of AS patients (log-rank p: 0.022) and was more prevalent among LF-LG patients (25.8%) compared to LF-HG (11.3%), NF-HG (6.3%) and NF-LG patients (18.8%). At 5-year follow-up, global mortality remained persistently higher among LF-LG patients (64.5%) compared to LF-HG (47.9%), NF-HG (42.9%), and NF-LG patients (58.8%) (log-rank p: 0.029). At multivariable Cox hazard regression analysis, baseline SVi (HR: 0.951, 95% C.I.; 0.918-0.984), the presence of at least moderate tricuspid regurgitation at baseline (HR: 3.091, 95% C.I: 1.645-5.809) and at least moderate paravalvular leak (PVL) post-TAVI (HR: 1.456, 95% C.I.: 1.106-1.792) were significant independent predictors of late global mortality. LF-LG patients and LF-HG patients exhibited a significant increase in LVEF at 1-year follow-up. A lower LVEF (p < 0.001) and a lower Svi (p < 0.001) at baseline were associated with LVEF improvement at 1-year. Conclusions: Patients with LF-LG AS have acceptable 1-year outcomes with significant improvement in LVEF at 1-year follow-up, but exhibit exceedingly high 5-year mortality following TAVI. The presence of low transvalvular flow and at least moderate tricuspid regurgitation at baseline and significant paravalvular leak post-TAVI were associated with poorer long-term outcomes in the entire cohort of AS patients. The presence of a low LVEF or a low SVi predicts LVEF improvement at 1-year.
摘要：
背景：关于不同血流梯度模式的严重主动脉瓣狭窄（AS）患者经导管主动脉瓣植入术（TAVI）的长期比较结果的数据很少。本研究旨在评估TAVI前血流梯度模式对TAVI后长期临床结果的影响，并评估TAVI后不同亚型AS患者的左心室射血分数（LVEF）的变化。方法：对我院接受TAVI治疗的重度AS患者进行连续筛查和前瞻性招募。根据TAVI前流量/梯度模式，将患者分为四个亚组：（i）低流量-低梯度（LF-LG）：每搏输出量指数（SVi）≤35mL/m2和平均梯度（MG）<40mmHg；（ii）正常流量-低梯度（NF-LG）：SVi>35mL/m2和MG<40mmHg；（iii）低流量-高梯度（NF-HG≥35mm/m2）在1年随访时重复经胸超声心动图检查。12个月时获得临床随访，所有患者均完成了每年的随访,直至5年.结果：我们的分析中包括了272例完整的超声心动图和临床随访患者。他们的平均年龄为80±7岁，大多数患者（N=138，50.8％）是女性。62例患者（占研究人群的22.8%）分布在LF-LG组中，98例（36%）为LF-HG患者，95例患者（34.9%）为NF-HG，17例(6.3%)为NF-LG。LF-LGAS患者的合并症患病率更高。一年全因死亡率在AS患者的四个亚组之间存在显着差异（log-rankp：0.022），并且与LF-HG（11.3％）相比，在LF-LG患者中更为普遍（25.8％），NF-HG(6.3%)和NF-LG(18.8%)患者。在5年的随访中，与LF-HG（47.9％）相比，LF-LG患者（64.5％）的全球死亡率仍然持续较高，NF-HG（42.9%），和NF-LG患者（58.8%）（log-rankp：0.029）。在多变量Cox风险回归分析中，基线SVi(HR:0.951,95%C.I.;0.918-0.984),基线时至少存在中度三尖瓣返流(HR:3.091,95%C.I:1.645~5.809)和TAVI后至少存在中度瓣周漏(PVL)(HR:1.456,95%C.I.:1.106~1.792)是晚期全球死亡率的重要独立预测因子.在1年的随访中，LF-LG患者和LF-HG患者的LVEF显着增加。基线时更低的LVEF(p<0.001)和更低的Svi(p<0.001)与1年时的LVEF改善相关。结论：LF-LGAS患者的1年结局可接受，1年随访LVEF明显改善，但在TAVI后表现出极高的5年死亡率。在整个AS患者队列中，基线时存在低经瓣膜血流和至少中度三尖瓣返流以及TAVI后显著的瓣周漏与较差的长期预后相关。低LVEF或低SVi的存在预测1年时LVEF的改善。
