背景:欧洲和美国关于退行性二尖瓣反流(DMR)中肺动脉高压(PHTN)的临床指南存在分歧。支撑这些分歧的知识差距会影响DMR中收缩压(SPAP)的风险评估和管理建议。
目的:这项研究试图定义PHTN与DMR严重程度的联系,预后阈值,以及大型定量DMR注册表中的独立结果影响。
方法:本研究收集了一项大型的多中心登记,该登记记录了患有孤立的中度至重度DMR的连续患者,在诊断时对DMR和SPAP进行前瞻性量化。
结果:在3,712名患者中(67±15岁,36%的女性)≥中度至重度DMR,有效反流口(ERO)为0.42±0.19cm2,反流体积为66±327mL/次/次,SPAP为41±16mmHg.样条曲线分析显示,在SPAP35mmHg附近出现医疗管理下的超额死亡率,在SPAP50mmHg附近增加了一倍。因此,在916例患者中检测到重度肺动脉高压(sPHTN)(SPAP≥50mmHg),中度肺动脉高压(mPHTN)(SPAP35-49mmHg)为1,128,无PHTN(SPAP<35mmHg)为1,668。而SPAP与DMR-ERO密切相关,然而,sPHTN(校正后HR:1.65;95%CI:1.24~2.20)和mPHTN(校正后HR:1.44;95%CI:1.11~1.85;P≤0.005)的超额死亡率与ERO和所有基线特征以及所有患者亚群无关.嵌套模型显示mPHTN和sPHTN的预后价值增加(所有P<0.0001)。尽管mPHTN和sPHTN的手术风险较高,在所有PHTN范围内,DMR手术矫正后的生存率更高,早期手术(<3个月)的生存率更高。术后,mPHTN取消了超额死亡率(P≥0.30),但只在sPHTN减弱。
结论:这个大型国际注册中心,通过前瞻性量化的DMR和SPAP,显示多普勒定义的PHTN对死亡率的影响,与DMR严重程度无关。至关重要的是,它客观地定义了新的和频繁的mPHTN范围,与医疗管理下的超额死亡率独立相关,由DMR更正废除。因此,在DMR诊断时,多普勒-SPAP测量定义了这些新的PHTN范围,对于指导DMR管理至关重要。
BACKGROUND: European and U.S. clinical guidelines diverge regarding pulmonary
hypertension (PHTN) in degenerative mitral regurgitation (DMR). Gaps in knowledge underpinning these divergences affect risk assessment and management recommendations attached to systolic pulmonary pressure (SPAP) in DMR.
OBJECTIVE: This study sought to define PHTN links to DMR severity, prognostic thresholds, and independent outcome impact in a large quantitative DMR registry.
METHODS: This study gathered a large multicentric registry of consecutive patients with isolated moderate-to-severe DMR, with DMR and SPAP quantified prospectively at diagnosis.
RESULTS: In 3,712 patients (67 ± 15 years, 36% women) with ≥ moderate-to-severe DMR, effective regurgitant orifice (ERO) was 0.42 ± 0.19 cm2, regurgitant volume 66 ± 327 mL/beat and SPAP 41 ± 16 mm Hg. Spline-curve analysis showed excess mortality under medical management emerging around SPAP 35 mm Hg and doubling around SPAP 50 mm Hg. Accordingly, severe pulmonary
hypertension (sPHTN) (SPAP ≥50 mm Hg) was detected in 916 patients, moderate pulmonary
hypertension (mPHTN) (SPAP 35-49 mm Hg) in 1,128, and no-PHTN (SPAP <35 mm Hg) in 1,668. Whereas SPAP was strongly associated with DMR-ERO, nevertheless excess mortality with sPHTN (adjusted HR: 1.65; 95% CI: 1.24-2.20) and mPHTN (adjusted HR: 1.44; 95% CI: 1.11-1.85; both P ≤ 0.005) was observed independently of ERO and all baseline characteristics and in all patient subsets. Nested models demonstrated incremental prognostic value of mPHTN and sPHTN (all P < 0.0001). Despite higher operative risk with mPHTN and sPHTN, DMR surgical correction was followed by higher survival in all PHTN ranges with strong survival benefit of early surgery (<3 months). Postoperatively, excess mortality was abolished (P ≥ 0.30) in mPHTN, but only abated in sPHTN.
CONCLUSIONS: This large international registry, with prospectively quantified DMR and SPAP, demonstrates a Doppler-defined PHTN impact on mortality, independent of DMR severity. Crucially, it defines objectively the new and frequent mPHTN range, independently linked to excess mortality under medical management, which is abolished by DMR correction. Thus, at DMR diagnosis, Doppler-SPAP measurement defining these new PHTN ranges, is crucial to guiding DMR management.