背景:在主动脉瓣狭窄(AS)和结构性瓣膜变性(SVD)中,超声心动图在从经主动脉速度推导经瓣膜平均梯度中的作用已被明确。然而,外科主动脉瓣置换术后的报告,经导管主动脉瓣置换术(TAVR)后,和瓣膜-瓣膜-TAVR(ViV-TAVR)提醒人们,由于在一种称为不一致的现象中,与侵入性措施相比存在差异,因此不要使用超声心动图得出的平均梯度来评估正常功能的生物假体.
方法:在一项多中心研究中,术中超声心动图和AS的侵入性平均梯度,SVD,后原生TAVR,和后ViV-TAVR进行了比较,当同时获得时,并记录出院超声心动图梯度。计算绝对不一致(术中超声心动图-侵入性平均梯度)和不一致百分比(术中超声心动图-侵入性平均梯度/超声心动图平均梯度)。进行多元回归分析以确定与术后侵入性梯度升高≥20mmHg独立相关的变量。绝对不一致>10mmHg,和出院超声心动图平均梯度≥20mmHg。
结果:共有5,027名患者被纳入登记:4,725个天然TAVR和302个ViV-TAVR。术中伴随超声心动图和侵入性平均梯度在AS患者的TAVR前获得(n=2,418),SVD中的ViV-TAVR前(n=101),在ViV-TAVR后(n=77),和后TAVR(n=823)。超声心动图和侵入性平均梯度显示出强相关性(r=0.69)和一致性(偏倚,0.11;95%CI,-0.4-0.62)在AS中,中等相关性(r=0.56)和一致性(偏差,1.08;95%CI,-2.53至4.59),以SVD计,中等相关性(r=0.61)和弱一致性(偏倚,6.47;95%CI,5.08-7.85)ViV-TAVR后,和弱相关性(r=0.18)和一致性(偏差,3.41;95%CI,3.16-3.65)TAVR后。绝对不一致主要发生在ViV-TVR中,不能通过窦管连接大小来解释,并且随着超声心动图平均梯度的增加而增加。AS和SVD的不一致百分比(1.3%和4%,分别)低于TAVR/ViV-TAVR后(66.7%和100%,分别)。与自膨胀阀相比,球囊扩张瓣膜独立地与排气超声心动图升高相关,但侵入性平均梯度较低(比值比=3.411,95%CI,1.482~7.852,P=.004;vs比值比=0.308,95%CI,0.130~0.731,P=.008).
结论:后TAVR/ViV-TAVR,超声心动图与侵入性平均梯度不一致,并且绝对不一致随着超声心动图平均梯度的增加而增加,并且不能通过窦管连接大小来解释。TAVR/ViV-TAVR后的不一致百分比明显高于AS和SVD。后TAVR/ViV-TAVR,相关性差和一致性界限广泛表明,超声心动图和侵入性平均梯度不可互换使用,在考虑进行任何额外"校正"梯度之前,应侵入性地确认高残余超声心动图平均梯度.经导管主动脉瓣置换瓣膜类型对超声心动图和侵入性平均梯度有不同的影响。
BACKGROUND: The role of echocardiography in deriving transvalvular mean gradients from transaortic velocities in aortic stenosis (AS) and in structural valve degeneration (SVD) is well established. However, reports following surgical aortic valve replacement, post-transcatheter aortic valve replacement (TAVR), and valve-in-valve-TAVR (ViV-TAVR) have cautioned against the use of echocardiography-derived mean gradients to assess normal functioning bioprosthesis due to discrepancy compared with invasive measures in a phenomenon called discordance.
METHODS: In a multicenter study, intraprocedural echocardiographic and invasive mean gradients in AS, SVD, post-native TAVR, and post-ViV-TAVR were compared, when obtained concomitantly, and discharge echocardiographic gradients were recorded. Absolute discordance (intraprocedural echocardiographic - invasive mean gradient) and percent discordance (intraprocedural echocardiographic - invasive mean gradient/echocardiographic mean gradient) were calculated. Multivariable regression analysis was performed to determine variables independently associated with elevated postprocedure invasive gradients ≥20 mm Hg, absolute discordance >10 mm Hg, and discharge echocardiographic mean gradient ≥20 mm Hg.
RESULTS: A total of 5,027 patients were included in the registry: 4,725 native TAVR and 302 ViV-TAVR. Intraprocedural concomitant echocardiographic and invasive mean gradients were obtained pre-TAVR in AS (n = 2,418), pre-ViV-TAVR in SVD (n = 101), in post-ViV-TAVR (n = 77), and in post-TAVR (n = 823). Echocardiographic and invasive mean gradients demonstrated strong correlation (r = 0.69) and agreement (bias, 0.11; 95% CI, -0.4-0.62) in AS, moderate correlation (r = 0.56) and agreement (bias, 1.08; 95% CI, -2.53 to 4.59) in SVD, moderate correlation (r = 0.61) and weak agreement (bias, 6.47; 95% CI, 5.08-7.85) post-ViV-TAVR, and weak correlation (r = 0.18) and agreement (bias, 3.41; 95% CI, 3.16-3.65) post-TAVR. Absolute discordance occurs primarily in ViV-TVR and is not explained by sinotubular junction size and increases with increasing echocardiographic mean gradient. Percent discordance in AS and SVD (1.3% and 4%, respectively) was lower compared with post-TAVR/ViV-TAVR (66.7% and 100%, respectively). Compared with self-expanding valves, balloon expanding valves were independently associated with elevated discharge echocardiographic but lower invasive mean gradient (odds ratio = 3.411, 95% CI, 1.482-7.852, P = .004; vs odds ratio = 0.308, 95% CI, 0.130-0.731, P = .008, respectively).
CONCLUSIONS: Post-TAVR/ViV-TAVR, echocardiography is discordant from invasive mean gradients, and absolute discordance increases with increasing echocardiographic mean gradient and is not explained by sinotubular junction size. Percent discordance is significantly higher post-TAVR/ViV-TAVR than in AS and SVD. Post-TAVR/ViV-TAVR, poor correlation and wide limits of agreement suggest echocardiographic and invasive mean gradients may not be used interchangeably and a high residual echocardiographic mean gradient should be confirmed invasively before considering any additional procedure to \"correct\" the gradient. Transcatheter aortic valve replacement valve types have variable impact on echocardiographic and invasive mean gradients.