Diastolic Blood Pressure and Heart Rate Are Independently Associated With Mortality in Chronic Aortic Regurgitation.
- 作者列表："Yang LT","Pellikka PA","Enriquez-Sarano M","Scott CG","Padang R","Mankad SV","Schaff HV","Michelena HI
BACKGROUND:The prognostic significance of diastolic blood pressure (DBP) and resting heart rate (RHR) in patients with hemodynamically significant aortic regurgitation (AR) is unknown. OBJECTIVES:This study sought to investigate the association of DBP and RHR with all-cause mortality in patients with AR. METHODS:Consecutive patients with ≥ moderate to severe AR were retrospectively identified from 2006 to 2017. The association between all-cause mortality and routinely measured DBP and RHR was examined. RESULTS:Of 820 patients (age 59 ± 17 years; 82% men) followed for 5.5 ± 3.5 years, 104 died under medical management, and 400 underwent aortic valve surgery (AVS). Age, symptoms, left ventricular ejection fraction (LVEF), LV end-systolic diameter-index (LVESDi), DBP, and RHR were univariable predictors of all-cause mortality (all p ≤ 0.002). When adjusted for demographics, comorbidities, and surgical triggers (symptoms, LVEF, and LVESDi), baseline DBP (adjusted-hazard ratio [HR]: 0.79 [95% confidence interval: 0.66 to 0.94] per 10 mm Hg increase, p = 0.009) and baseline RHR (adjusted HR: 1.23 [95% confidence interval: 1.03 to 1.45] per 10 beat per min [bpm] increase, p = 0.01) were independently associated with all-cause mortality. These associations persisted after adjustment for presence of hypertension, medications, time-dependent AVS, and using average DBP and RHR (all p ≤ 0.02). Compared with the general population, patients with AR exhibited excess mortality (relative risk of death >1), which rose steeply in inverse proportion (p nonlinearity = 0.002) to DBP starting at 70 mm Hg and peaking at 55 mm Hg and in direct proportion to RHR starting at 60 bpm. CONCLUSIONS:In patients with chronic hemodynamically significant AR, routinely measured DBP and RHR demonstrate a robust association with all-cause death, independent of demographics, comorbidities, guideline-based surgical triggers, presence of hypertension, and use of medications. Therefore, DBP and RHR should be integrated into comprehensive clinical decision-making for these patients.
背景: 舒张压 (DBP) 和静息心率 (RHR) 在血流动力学显著主动脉瓣反流 (AR) 患者中的预后意义尚不清楚。 目的: 本研究旨在探讨DBP和RHR与AR患者全因死亡率的关系。 方法: 回顾性分析2006年至2017年收治的 ≥ 中重度AR患者。检查了全因死亡率与常规测量的DBP和RHR之间的相关性。 结果: 820例患者 (年龄59 ± 17岁; 82% 例男性) 随访5.5 ± 3.5年，104死于医疗管理，400例接受主动脉瓣手术 (AVS)。年龄、症状、左室射血分数 (LVEF) 、左室收缩末期内径指数 (LVESDi) 、DBP和RHR是全因死亡率的单变量预测因子 (p均 ≤ 0.002).校正人口统计学、合并症和手术触发因素 (症状、LVEF和LVESDi) 、基线DBP (校正风险比 [HR]: 0.79 [95% 置信区间: 0.66 ~ 0.94] 每增加10毫米mmhg，p = 0.009) 和基线RHR (校正HR: 1.23 [95% 可信区间:1.03 ~ 1.45次/10次/min [bpm] 增加，p = 0.01) 与全因死亡率独立相关。在对高血压、药物、时间依赖性AVS的存在进行校正并使用平均DBP和RHR (所有p均 ≤ 0.02) 后，这些关联持续存在.与一般人群相比，患有AR的患者表现出超额死亡率 (相对死亡风险> 1)，其与DBP从0.002 Hg开始急剧成反比 (p非线性 = 70毫米)，在55毫米Hg达到峰值，与RHR从60 bpm开始成正比。 结论: 在慢性血流动力学显著AR患者中，常规测定的DBP和RHR与全因死亡密切相关，独立于人口统计学、合并症、基于指南的手术触发因素、高血压存在和药物使用。因此，应将DBP和RHR纳入此类患者的综合临床决策中。
METHODS::Relapsing polychondritis is a rare multi-system disease characterized by inflammation in cartilaginous structures and other connective tissues. Cardiovascular complications occur in 10-51% of the patients. We report a case of concomitant aortic valve replacement, mitral valve replacement, and coronary artery bypass grafting in a patient with relapsing polychondritis. A 71-year-old female with relapsing polychondritis on prednisolone (5 mg/day) for 15 years presented at our hospital for further evaluation of valvular disease. Severe aortic stenosis and severe mitral regurgitation were diagnosed. We performed aortic and mitral valve replacement. During surgery, we found connective tissue surrounding the intima of the sinus of Valsalva and stenosis of the right coronary artery ostium, which was not noted on preoperative coronary angiography. We removed the tissue and performed bypass grafting to the right coronary artery. Postoperative recovery was uneventful, and she was discharged 27 days after surgery.
METHODS:BACKGROUND:The effect of significant mitral regurgitation (MR) on outcomes after continuous flow left ventricular assist device (cfLVAD) implantation remains unclear. METHODS:We performed a retrospective review of prospectively collected data from 159 patients with preoperative severe MR who underwent cfLVAD implantation (2003-2017). Two-step cluster analysis using the log-likelihood distance for post-cfLVAD implantation parameters, which included right ventricular (RV) dysfunction, MR severity, and tricuspid regurgitation (TR) severity. Post-cfLVAD implantation echocardiographic parameters were obtained within the first month. RESULTS:Cluster analysis resulted in 3 groups. Group 1 (n = 67) had mild or less MR with moderate-severe RV dysfunction (RVD). Group 2 (n = 43) had moderate-severe MR with moderate-severe RVD. Group 3 (n = 49) had moderate MR with mild RVD. Group 2 had the largest proportion with Interagency Registry for Mechanically Assisted Circulatory Support score of 1 (30.2%) and 2 (41.9%). They were more likely to undergo temporary mechanical circulatory support (18.6%) and tricuspid valve procedure (62.8%). Group 2 had the highest rate of stroke (30.2%; P = .02), hemolysis (39.5%; P = .01), device thrombosis (30%; P = .01), and worst survival (46.5%; P = .01). Survival at 5 years for groups 1, 2, and 3 were 56.0%, 17.6%, and 55.8%. Regression analysis of the entire population showed that greater MR severity after cfLVAD was associated with RV failure (P < .05; odds ratio, 1.6) and RV assist device use (P = .09; odds ratio, 1.6). After excluding tricuspid valve repairs, MR severity had a positive correlation with TR severity (R = 0.33; P < .01). CONCLUSIONS:After cfLVAD implantation, moderate-severe MR and RVD predicted RV failure. Patients with preoperative moderate-severe MR and TR coupled with moderate-severe RVD might benefit the most from mitral and tricuspid valve intervention.
METHODS:BACKGROUND:Among elderly with severe aortic stenosis (AS), Comprehensive Geriatric Assessment (CGA) originally contributed to address to transcatheter aortic valve implantation (TAVI) patients not suitable to surgical aortic valve replacement(SAVR). Nevertheless, TAVI has recently been proposed also in lower surgical risk patients. AIMS:To evaluate predictors of TAVI procedure and clinical outcomes among these patients. METHODS:For each patient ≥ 65 years with severe AS referring to our Cardiac Surgery Division, CGA was performed, including functional and cognitive status, comorbidity burden, frailty, nutritional status, gait speed, hand-grip strength and number of medications. Surgical risk was evaluated according to the Society of Thoracic Surgeons (STS) score (low-risk < 4%). Post-procedural outcomes (30-day survival and post-procedural complications) were obtained by medical records and a one-year follow-up assessed survival, and functional and cognitive performance. RESULTS:Among 154 subjects (mean age 82.9 years), 52 were at low-risk according to STS score. 32 patients were addressed to TAVI, 20 to SAVR. Variables significantly associated with TAVI-approach were lower gait speed (p 0.030) and higher number of medications (p 0.015). Short and long-term outcomes did not differ between groups. DISCUSSION:Among CGA variables, gait speed and number of medications were associated with the decision to perform TAVI instead of SAVR, even in patients at low surgical risk. 30-day and one-year survival and one-year functional and cognitive decline were similar between groups, despite a relevant prevalence of frailty in the TAVI group. CONCLUSIONS:We suggest that gait speed and number of medications should be considered in selecting appropriate candidates to TAVI among low surgical risk patients.