保留左心室射血分数的血流动力学显著主动脉狭窄患者的侵入性血流动力学运动反应。

摘要(中文译文)

指南承认，不一致的低梯度（LG）主动脉瓣狭窄（AS）可能很严重，但验证这一点可能具有挑战性。运动时右心导管插入术被认为是评估心室血流动力学的金标准。没有侵入性研究比较运动期间不一致LG和严重AS的血流动力学反应。这项观察性研究的目的是描述无症状不一致AS和左心室射血分数≥50%患者的运动血流动力学。主动脉瓣面积≤1.5cm的患者在休息和最大运动时接受了右心导管插入术，测量了肺毛细血管楔压（PCWP）、心输出量（CO）和PCWP/CO斜率。患者被分为3组：不一致的LG AS（主动脉瓣面积≤1.0 cm，平均压差<40 mm Hg);中度主动脉瓣狭窄（主动脉瓣面积>1.0cm）；高梯度（HG）重度AS（主动脉瓣面积≤1.0 cm，平均梯度≥40 mm Hg).在86名患者中，17名（20%）患有不一致的LG，49名（57%）患有中度AS，20名（23%）患有HG重度AS。不一致LG的PCWP/CO斜率中值明显更陡（3.3[四分位数间距，2.1-4.3]mm Hg/L/min）和Hg重度AS（2.7[1.9-3.4]mm 每分钟汞柱/升）与中度AS（1.9[0.7-2.8]毫米）相比 Hg/L每分钟），=0.004。在根据年龄、性别和静息PCWP调整的回归模型中，全身动脉顺应性和AS严重程度与PCWP/CO斜率显著相关。此外，LG AS不一致的患者PCWP/CO曲线向左向上偏移。不一致的LG和HG重度AS对运动的血流动力学反应相似，PCWP/CO斜率比中度AS更陡，表明不一致的LG-AS是一种严重的AS。此外，与HG-重度AS相比，不一致的LG的PCWP/CO曲线左上偏移表明该组也有心力衰竭，射血分数生理学保持不变。网址：https://www.clinicaltrials.gov；唯一标识符：NCT04913870和NCT02395107。

Abstract

Guidelines acknowledge that discordant low-gradient (LG) aortic stenosis (AS) may be severe, but verifying this can be challenging. Right heart catheterization during exercise is considered the gold standard for evaluating ventricular hemodynamics. No invasive studies have compared the hemodynamic response of discordant LG and severe AS during exercise. The aim of this observational study was to describe exercise hemodynamics in patients with asymptomatic discordant AS and left ventricular ejection fraction ≥50%. Patients with aortic valve area ≤1.5 cm underwent right heart catheterization at rest and during maximal exercise, measuring pulmonary capillary wedge pressure (PCWP), cardiac output (CO), and the PCWP/CO-slope. Patients were stratified into 3 groups: discordant LG AS (aortic valve area ≤1.0 cm and mean gradient <40 mm Hg); moderate AS (aortic valve area >1.0 cm); and high-gradient (HG) severe AS (aortic valve area ≤1.0 cm and mean gradient ≥40 mm Hg). Among 86 patients, 17 (20%) had discordant LG, 49 (57%) moderate, and 20 (23%) HG severe AS. The median PCWP/CO-slope was significantly steeper in discordant LG (3.3 [interquartile range, 2.1-4.3] mm Hg/L/min) and HG severe AS (2.7 [1.9-3.4] mm Hg/L per minute) compared with moderate AS (1.9 [0.7-2.8] mm Hg/L per minute), =0.004. In a regression model adjusted for age, sex, and rest PCWP, systemic arterial compliance and AS severity were significantly associated with the PCWP/CO-slope. Furthermore, patients with discordant LG AS had a leftward-upward shift in the PCWP/CO-curve. Discordant LG and HG severe AS had similar hemodynamic responses to exercise with steeper PCWP/CO-slope than in moderate AS, suggesting that discordant LG AS is a severe form of AS. In addition, the left upwards shift in PCWP/CO-curve for discordant LG compared with HG severe AS indicates that this group also has heart failure with preserved ejection fraction physiology. URL: https://www.clinicaltrials.gov; Unique identifier: NCT04913870 and NCT02395107.

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