Background

Doppler mean gradient (MG) may underestimate aortic stenosis (AS) severity when obtained during atrial fibrillation (AF) because of lower forward flow compared with sinus rhythm (SR). Whether AS is more advanced at the time of referral for aortic valve intervention in AF compared with SR is unknown. The aim of this study was to examine flow-independent computed tomographic aortic valve calcium scores (AVCS) and their concordance to MG in AF versus SR in patients undergoing transcatheter aortic valve replacement (TAVR).

Methods

Patients who underwent TAVR from 2016 to 2020 for native valve severe AS with left ventricular ejection fraction ≥ 50% were identified from an institutional TAVR database. MGs during AF and SR in high-gradient AS (HGAS) and low-gradient AS (LGAS) were compared with AVCS (AVCS/MG ratio). AVCS were obtained within 90 days of pre-TAVR echocardiography.

Results

Six hundred thirty-three patients were included; median age was 82 years (interquartile range [IQR], 76–86 years), and 46% were women. AF was present in 109 (17%) and SR in 524 (83%) patients during echocardiography. Aortic valve area index was slightly smaller in AF versus SR (0.43 cm²/m² [IQR, 0.39–0.47 cm²/m²] vs 0.46 cm²/m² [IQR, 0.41–0.51 cm²/m²], P = .0003). Stroke volume index, transaortic flow rate, and MG were lower in AF (P < .0001 for all). AVCS were higher in men with AF compared with SR (3,510 Agatston units [AU] [IQR, 2,803–4,030 AU] vs 2,722 AU [IQR, 2,180–3,467 AU], P < .0001) in HGAS but not in LGAS. AVCS were not different in women with AF versus SR. Overall AVCS/MG ratios were higher in AF versus SR in HGAS and LGAS (P < .03 for all), except in women with LGAS.

Conclusions

AVCS were higher than expected by MG in AF compared with SR. The very high AVCS in men with AF and HGAS at the time of TAVR suggests late diagnosis of severe AS because of underestimated AS severity during progressive AS and/or late referral to TAVR. Additional studies are needed to examine the extent to which echocardiography may be underestimating AS severity in AF.

中文翻译：

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多普勒平均梯度与接受经导管主动脉瓣置换术的心房颤动患者的主动脉瓣钙评分不一致

背景

多普勒平均梯度 (MG) 在心房颤动 (AF) 期间获得时可能会低估主动脉瓣狭窄 (AS) 的严重程度，因为与窦性心律 (SR) 相比，前向血流较低。与 SR 相比，在 AF 中进行主动脉瓣介入治疗时，AS 是否更先进尚不清楚。本研究的目的是在接受经导管主动脉瓣置换术 (TAVR) 的患者中检查与流量无关的计算机断层扫描主动脉瓣钙评分 (AVCS) 及其与 AF 和 SR 患者 MG 的一致性。

方法

从机构 TAVR 数据库中确定了 2016 年至 2020 年因左心室射血分数 ≥ 50% 的天然瓣膜重度 AS 接受 TAVR 的患者。将高梯度 AS (HGAS) 和低梯度 AS (LGAS) 中 AF 和 SR 期间的 MG 与 AVCS（AVCS/MG 比率）进行比较。AVCS 是在 TAVR 前超声心动图的 90 天内获得的。

结果

包括 633 名患者；中位年龄为 82 岁（四分位距 [IQR]，76-86 岁），46% 为女性。在超声心动图检查期间，109 名 (17%) 患者出现 AF，524 名 (83%) 患者出现 SR。AF 与 SR 的主动脉瓣面积指数略小（0.43 cm ² /m ² [IQR, 0.39–0.47 cm ² /m ² ] vs 0.46 cm ² /m ² [IQR, 0.41–0.51 cm ² /m ² ]，P  = .0003)。AF 患者的每搏输出量指数、经主动脉流速和 MG 较低（P < .0001 全部）。与 SR（3,510 Agatston 单位 [AU] [IQR, 2,803–4,030 AU] vs 2,722 AU [IQR, 2,180–3,467 AU], P  < .0001）相比，AFCS 在 HGAS 中更高，但在 LGAS 中则不然。AFCS 与 SR 女性的 AVCS 没有差异。在 HGAS 和 LGAS 中，AF 的总体 AVCS/MG 比高于 SR（所有P  < .03），LGAS 女性除外。

结论

与 SR 相比，AF 患者的 AVCS 高于 MG 的预期。在 TAVR 时患有 AF 和 HGAS 的男性中非常高的 AVCS 表明严重 AS 的晚期诊断是因为在进行性 AS 期间低估了 AS 严重性和/或延迟转诊至 TAVR。需要更多的研究来检查超声心动图在多大程度上可能低估了 AF 中 AS 的严重程度。