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导语 LV射血分数保留，主狭无症状，治还是不治？ 作者：沿若 来源：医学论坛网 对于无症状的严重主动脉瓣狭窄(AS)患者，目前的指南建议，在出现症状或左室(LV)收缩功能障碍(即，LV射血分数[LVEF]<50%)进展之前，应采用冷处理策略，静观其变。对这些患者进行干预的最佳时机仍有争议。为了确定患者是否真的无症状，运动测试是一个重要的诊断工具。然而，对于无法进行这项测试的患者，需要额外的检测来更好地确定干预时间。通过超声心动图全心纵向拉伸(GLS)散斑跟踪表明，尽管左室射血分数正常，很大比例的患者的左心室纵向活动已经受损。症状严重AS的患者，受损的左心室纵向活动与较差的预后有关。然而，据我们所知，对于无症状的严重AS和LVEF正常的患者，左心室纵向活动（LV GLS）受损的发生率，以及LV GLS的自然病程和预后价值尚未被广泛阐明。因此，本研究旨在调查左室GLS受损的流行情况，并描述无症状的严重AS和保留射血分数的患者左室GLS连续变化的自然过程及其预后影响。
目的 探讨左室射血分数保留(LVEF)患者左室GLS受损的发生率、左室GLS的自然病程及其预后意义。
设计、设置和参与者
主要结果和措施: 左室GLS受损的流行情况、左室GLS的自然过程、左室GLS受损与症状的发生和主动脉瓣介入之间的关系。
结果 220例患者(平均[SD]68[13]岁;包括126名男性[57%]。尽管对照两组的左室射血分数保留，无症状严重AS患者组对比无AS患者组，左心室纵向活动明显受损(平均(SD)LV GLS,-17.9%(2.5%)VS.-19.6%(2.1%);P<0.001)。平均随访12个月(四分位范围后,7-23个月)后，平均(SD)LV GLS显著恶化(-18.0% [2.6%]VS.-16.3%(2.8%);P <0.001)，而LVEF依旧保持不变。基线LV GLS受损(>-18.2%)的患者组对比基线LV GLS受损(≤-18.2%)的患者组，显示更高发的症状出现(P=0.02)并需要主动脉瓣置换干预(P =0.03)，
结论 亚临床心肌功能障碍，其特点是左心室GLS受损，常见于无症状严重主动脉瓣狭窄的LVEF患者。随着时间的推移，左心室整体纵向弹性和基线时LV GLS受损程度进一步恶化与进展到症状期的风险增加以及需要主动脉瓣置换干预有关。 参考文献： 1.Baumgartner H, Falk V, Bax JJ, et al; ESC Scientific Document Group. 2017 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J. 2017;38(36):2739-2791. doi:10.1093/eurheartj/ehx391PubMedGoogle ScholarCrossref 2.Nishimura RA, Otto CM, Bonow RO, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63(22):e57-e185. doi:10.1016/j.jacc.2014.02.536PubMedGoogle ScholarCrossref 3.Pellikka PA, Sarano ME, Nishimura RA, et al. Outcome of 622 adults with asymptomatic, hemodynamically significant aortic stenosis during prolonged follow-up. Circulation. 2005;111(24):3290-3295. doi:10.1161/CIRCULATIONAHA.104.495903PubMedGoogle ScholarCrossref 4.Rosenhek R, Zilberszac R, Schemper M, et al. Natural history of very severe aortic stenosis. Circulation. 2010;121(1):151-156. doi:10.1161/CIRCULATIONAHA.109.894170PubMedGoogle ScholarCrossref 5.Taniguchi T, Morimoto T, Shiomi H, et al; CURRENT AS Registry Investigators. Initial surgical versus conservative strategies in patients with asymptomatic severe aortic stenosis. J Am Coll Cardiol. 2015;66(25):2827-2838. doi:10.1016/j.jacc.2015.10.001PubMedGoogle ScholarCrossref 6.Généreux P, Stone GW, O’Gara PT, et al. Natural history, diagnostic approaches, and therapeutic strategies for patients with asymptomatic severe aortic stenosis. J Am Coll Cardiol. 2016;67(19):2263-2288. doi:10.1016/j.jacc.2016.02.057PubMedGoogle ScholarCrossref 7.Redfors B, Pibarot P, Gillam LD, et al. Stress testing in asymptomatic aortic stenosis. Circulation. 2017;135(20):1956-1976. doi:10.1161/CIRCULATIONAHA.116.025457PubMedGoogle ScholarCrossref 8.Ng AC, Delgado V, Bertini M, et al. Alterations in multidirectional myocardial functions in patients with aortic stenosis and preserved ejection fraction: a two-dimensional speckle tracking analysis. Eur Heart J. 2011;32(12):1542-1550. doi:10.1093/eurheartj/ehr084PubMedGoogle ScholarCrossref 9.Kearney LG, Lu K, Ord M, et al. Global longitudinal strain is a strong independent predictor of all-cause mortality in patients with aortic stenosis. Eur Heart J Cardiovasc Imaging. 2012;13(10):827-833. doi:10.1093/ehjci/jes115PubMedGoogle ScholarCrossref 10.Kusunose K, Goodman A, Parikh R, et al. Incremental prognostic value of left ventricular global longitudinal strain in patients with aortic stenosis and preserved ejection fraction. Circ Cardiovasc Imaging. 2014;7(6):938-945. doi:10.1161/CIRCIMAGING.114.002041PubMedGoogle ScholarCrossref 11.Klaeboe LG, Haland TF, Leren IS, et al. Prognostic value of left ventricular deformation parameters in patients with severe aortic stenosis: a pilot study of the usefulness of strain echocardiography. J Am Soc Echocardiogr. 2017;30(8):727-735.e1. doi:10.1016/j.echo.2017.04.009PubMedGoogle ScholarCrossref 12.Stokke TM, Hasselberg NE, Smedsrud MK, et al. Geometry as a confounder when assessing ventricular systolic function: comparison between ejection fraction and strain. J Am Coll Cardiol. 2017;70(8):942-954. doi:10.1016/j.jacc.2017.06.046PubMedGoogle ScholarCrossref 13.Ng ACT, Prihadi EA, Antoni ML, et al. Left ventricular global longitudinal strain is predictive of all-cause mortality independent of aortic stenosis severity and ejection fraction [published online July 28, 2017]. Eur Heart J Cardiovasc Imaging.PubMedGoogle Scholar 14.Dahl JS, Videbæk L, Poulsen MK, Rudbæk TR, Pellikka PA, Møller JE. Global strain in severe aortic valve stenosis: relation to clinical outcome after aortic valve replacement. Circ Cardiovasc Imaging. 2012;5(5):613-620. doi:10.1161/CIRCIMAGING.112.973834PubMedGoogle ScholarCrossref |
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