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Pulmonary Artery Systolic Pressure Response to Exercise in Patients with Rheumatic Mitral Stenosis: Determinants and Prognostic Value.
Journal of the American Society of Echocardiography ( IF 5.4 ) Pub Date : 2020-02-29 , DOI: 10.1016/j.echo.2019.11.017
Sanny Cristina de Castro Faria 1 , Henrique Silveira Costa 2 , Judy Hung 3 , André Gorle de Miranda Chaves 4 , Flávio Augusto Paes de Oliveira 4 , Jose Luiz Padilha da Silva 5 , William Antonio M Esteves 1 , Timothy C Tan 6 , Robert A Levine 3 , Maria Carmo Pereira Nunes 1
Affiliation  

BACKGROUND Pulmonary hypertension in response to exercise is a marker of the hemodynamic severity of mitral stenosis (MS). However, the factors related to elevated pulmonary pressure with exercise are not well defined. The aim of this study was to assess the parameters associated with the pulmonary pressure response to exercise in patients with pure rheumatic MS. An additional aim was to determine the impact of exercise-induced pulmonary hypertension on clinical outcome. METHODS One hundred thirty patients with MS (94% women; mean age, 45 ± 11 years) underwent exercise echocardiography. A range of echocardiographic parameters were obtained at rest and at peak exercise. Symptom-limited graded ramp bicycle exercise was performed in the supine position. The primary end point was mitral valve intervention, either percutaneous or surgical. RESULTS In the overall population, systolic pulmonary artery pressure (SPAP) increased from 38.3 ± 13.4 mm Hg at rest to 65.8 ± 20.7 mm Hg during exercise. Increases in mean mitral gradient, right ventricular function, left atrial volume, and net atrioventricular compliance were independently associated with SPAP at peak exercise, after adjusting for changes in heart rate. During the follow-up period (median, 17 months; range, 1-45 months), 46 adverse clinical events were observed. By multivariate Cox proportional-hazards analysis adjusted for age and sex, SPAP achieved at peak exercise was an important predictor of adverse outcome (adjusted hazard ratio, 1.025; 95% CI, 1.010-1.040; P = .001). New York Heart Association functional class (adjusted hazard ratio, 2.459; 95% CI, 1.509-4.006; P < .001) and the interaction between valve area and net atrioventricular compliance (P = .001) were also significant predictors of adverse events. Time-dependent areas under the receiver operating characteristic curve for the model with SPAP during exercise were better than for the model with SPAP at rest, with a significant improvement from 3 years onward. CONCLUSIONS In patients with MS, the pulmonary artery pressure response to exercise is determined by a combination of factors, including transmitral mean gradient at exercise, net atrioventricular compliance, left atrial volume, and right ventricular function. Pulmonary artery pressure at peak exercise is a predictor of clinical outcomes and adds incremental prognostic value beyond that provided by standard resting measurements, including valve area.

中文翻译:

风湿性二尖瓣狭窄患者对运动的肺动脉收缩压反应:决定因素和预后价值。

背景 运动引起的肺动脉高压是二尖瓣狭窄 (MS) 血流动力学严重程度的标志。然而,与运动引起的肺压升高相关的因素尚不明确。本研究的目的是评估与纯风湿性 MS 患者运动时肺压反应相关的参数。另一个目的是确定运动诱发的肺动脉高压对临床结果的影响。方法 130 名 MS 患者(94% 为女性;平均年龄为 45 ± 11 岁)接受了运动超声心动图检查。一系列的超声心动图参数是在休息和高峰运动时获得的。在仰卧位进行症状限制的分级坡道自行车运动。主要终点是二尖瓣介入,无论是经皮还是手术。结果 在整个人群中,收缩期肺动脉压 (SPAP) 从静息时的 38.3 ± 13.4 mmHg 增加到运动时的 65.8 ± 20.7 mmHg。在调整心率变化后,平均二尖瓣梯度、右心室功能、左心房容积和净房室顺应性的增加与运动峰值时的 SPAP 独立相关。在随访期间(中位数,17 个月;范围,1-45 个月),观察到 46 起不良临床事件。通过针对年龄和性别调整的多变量 Cox 比例风险分析,在运动高峰时达到的 SPAP 是不良结果的重要预测因子(调整后的风险比,1.025;95% CI,1.010-1.040;P = .001)。纽约心脏协会功能等级(调整后的风险比,2.459;95% CI,1.509-4.006;P < . 001) 以及瓣膜面积和净房室顺应性之间的相互作用 (P = .001) 也是不良事件的重要预测因素。运动时 SPAP 模型的受试者工作特征曲线下的时间相关区域优于 SPAP 静息模型,从 3 年起有显着改善。结论 在 MS 患者中,肺动脉压力对运动的反应由多种因素决定,包括运动时的二尖瓣平均梯度、净房室顺应性、左心房容积和右心室功能。运动峰值时的肺动脉压是临床结果的预测指标,并增加了超出标准静息测量值(包括瓣膜面积)的增量预后值。001)也是不良事件的重要预测因子。运动时 SPAP 模型的受试者工作特征曲线下的时间相关区域优于 SPAP 静息模型,从 3 年起有显着改善。结论 在 MS 患者中,肺动脉压力对运动的反应由多种因素决定,包括运动时的二尖瓣平均梯度、净房室顺应性、左心房容积和右心室功能。运动峰值时的肺动脉压是临床结果的预测指标,并增加了超出标准静息测量值(包括瓣膜面积)的增量预后值。001) 也是不良事件的重要预测因子。运动时 SPAP 模型的受试者工作特征曲线下的时间相关区域优于 SPAP 静息模型,从 3 年起有显着改善。结论 在 MS 患者中,肺动脉压力对运动的反应由多种因素决定,包括运动时的二尖瓣平均梯度、净房室顺应性、左心房容积和右心室功能。运动峰值时的肺动脉压是临床结果的预测指标,并增加了超出标准静息测量值(包括瓣膜面积)的增量预后值。运动时 SPAP 模型的受试者工作特征曲线下的时间相关区域优于 SPAP 静息模型,从 3 年起有显着改善。结论 在 MS 患者中,肺动脉压力对运动的反应由多种因素决定,包括运动时的二尖瓣平均梯度、净房室顺应性、左心房容积和右心室功能。运动峰值时的肺动脉压是临床结果的预测指标,并增加了超出标准静息测量值(包括瓣膜面积)提供的增量预后值。运动时 SPAP 模型的受试者工作特征曲线下的时间相关区域优于 SPAP 静息模型,从 3 年起有显着改善。结论 在 MS 患者中,肺动脉压力对运动的反应由多种因素决定,包括运动时的二尖瓣平均梯度、净房室顺应性、左心房容积和右心室功能。运动峰值时的肺动脉压是临床结果的预测指标,并增加了超出标准静息测量值(包括瓣膜面积)的增量预后值。肺动脉压力对运动的反应由多种因素决定,包括运动时的二尖瓣平均梯度、净房室顺应性、左心房容积和右心室功能。运动峰值时的肺动脉压是临床结果的预测指标,并增加了超出标准静息测量值(包括瓣膜面积)的增量预后值。肺动脉压力对运动的反应由多种因素决定,包括运动时的二尖瓣平均梯度、净房室顺应性、左心房容积和右心室功能。运动峰值时的肺动脉压是临床结果的预测指标,并增加了超出标准静息测量值(包括瓣膜面积)的增量预后值。
更新日期:2020-02-29
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