背景:诊断严重的主动脉瓣狭窄(AS)取决于流量和压力状况。怀疑伴随的主动脉瓣反流(AR)对AS严重程度的评估有影响。这项研究的目的是分析伴随AR对多普勒衍生的指南标准的影响。我们假设跨瓣膜流速(maxVAV)和平均压力梯度(mPGAV)都会受到AR的影响,而有效孔口面积(EOA)以及左心室流出道的最大速度与跨瓣流速(maxVLVOT/maxVAV)之间的比率则不会。此外,我们假设EOA(通过连续性方程),和几何孔口面积(GOA)(通过使用3D经食道超声心动图进行平面测量,TEE),不会受到AR的影响。
结果:在这项回顾性研究中,335名患者(平均年龄75.9±9.8岁,44%的男性)患有严重AS(定义为EOA<1.0cm2),接受了经胸和经食道超声心动图检查。排除左心室射血分数降低(LVEF<53%)的患者(n=97)。根据AR严重程度,其余238例患者分为四个亚组,并使用压力半衰期(PHT)方法进行评估:不,trace,轻度(PHT500-750ms),和中等AR(PHT250-500ms)。maxVAV,在所有亚组中评估mPGAV和maxVLVOT/maxVAV。在四个亚组中(否(n=101),trace(n=49),轻度(n=61)和中度AR(n=27),EOA(无AR:0.75cm2±0.15;痕量AR:0.74cm2±0.14;轻度AR:0.75cm2±0.14;中度AR:0.75cm2±0.15,p=0.998)和GOA(无AR:0.78cm2±0.20;痕量AR:0.79cm2±0.15;轻度AR:0.82cm2±0.19;中度AR:0.83cm2±424,p=0.14)。重度AS伴中度AR,与没有AR的患者相比,maxVAV(p=0.005)和mPGAV(p=0.022)较高,而EOA(p=0.998)和maxVLVOT/maxVAV(p=0.243)没有差异。有痕迹的AS患者的EOA小于GOA(0.74cm2±0.14vs.0.79cm2±0.15,p=0.024),轻度(0.75cm2±0.14vs.0.82cm2±0.19,p=0.021),和中等AR(0.75cm2±0.15vs.0.83cm2±0.14,p=0.024)。在40例(17%)重度AS患者中,根据EOA<1.0cm2,GOA≥1.0cm2。
结论:在重度AS伴中度AR中,maxVAV和mPGAV受AR显著影响,而EOA和maxVLVOT/maxVAV不是。这些结果强调了仅通过评估跨瓣流速和平均压力梯度来高估合并主动脉瓣疾病中AS严重程度的潜在风险。此外,在边缘EOA的情况下,约1.0cm2,AS的严重程度应通过确定GOA来验证。
BACKGROUND: Diagnosing severe aortic stenosis (AS) depends on flow and pressure conditions. It is suspected that concomitant aortic regurgitation (AR) has an impact on the assessment of AS severity. The aim of this study was to analyze the impact of concomitant AR on Doppler-derived guideline criteria. We hypothesized that both transvalvular flow velocity (maxVAV) and the mean pressure gradient (mPGAV) will be affected by AR, whereas the effective orifice area (EOA) and the ratio between maximum velocity of the left ventricular outflow tract and transvalvular flow velocity (maxVLVOT/maxVAV) will not. Furthermore, we hypothesized that EOA (by continuity equation), and the geometric orifice area (GOA) (by planimetry using 3D transesophageal echocardiography, TEE), will not be affected by AR.
RESULTS: In this retrospective study, 335 patients (mean age 75.9 ± 9.8 years, 44% male) with severe AS (defined by EOA < 1.0 cm2) who underwent a transthoracic and transesophageal echocardiography were analyzed. Patients with a reduced left ventricular ejection fraction (LVEF < 53%) were excluded (n = 97). The remaining 238 patients were divided into four subgroups depending on AR severity, and they were assessed using pressure half time (PHT) method: no, trace, mild (PHT 500-750 ms), and moderate AR (PHT 250-500 ms). maxVAV, mPGAV and maxVLVOT/maxVAV were assessed in all subgroups. Among the four subgroups (no (n = 101), trace (n = 49), mild (n = 61) and moderate AR (n = 27)), no differences were obtained for EOA (no AR: 0.75 cm2 ± 0.15; trace AR: 0.74 cm2 ± 0.14; mild AR: 0.75 cm2 ± 0.14; moderate AR: 0.75 cm2 ± 0.15, p = 0.998) and GOA (no AR: 0.78 cm2 ± 0.20; trace AR: 0.79 cm2 ± 0.15; mild AR: 0.82 cm2 ± 0.19; moderate AR: 0.83 cm2 ± 0.14, p = 0.424). In severe AS with moderate AR, compared with patients without AR, maxVAV (p = 0.005) and mPGAV (p = 0.022) were higher, whereas EOA (p = 0.998) and maxVLVOT/maxVAV (p = 0.243) did not differ. The EOA was smaller than the GOA in AS patients with trace (0.74 cm2 ± 0.14 vs. 0.79 cm2 ± 0.15, p = 0.024), mild (0.75 cm2 ± 0.14 vs. 0.82 cm2 ± 0.19, p = 0.021), and moderate AR (0.75 cm2 ± 0.15 vs. 0.83 cm2 ± 0.14, p = 0.024). In 40 (17%) patients with severe AS, according to an EOA < 1.0 cm2, the GOA was ≥ 1.0 cm2.
CONCLUSIONS: In severe AS with moderate AR, the maxVAV and mPGAV are significantly affected by AR, whereas the EOA and maxVLVOT/maxVAV are not. These results highlight the potential risk of overestimating AS severity in combined aortic valve disease by only assessing transvalvular flow velocity and the mean pressure gradient. Furthermore, in cases of borderline EOA, of approximately 1.0 cm2, AS severity should be verified by determining the GOA.