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Exercise Hemodynamics After Aortic Valve Replacement for Severe Aortic Stenosis
Journal of the American Society of Echocardiography ( IF 6.5 ) Pub Date : 2018-08-22 , DOI: 10.1016/j.echo.2018.07.001
Rasmus Carter-Storch , Jordi S. Dahl , Nicolaj L. Christensen , Eva V. Søndergaard , Akhmadjon Irmukhamedov , Redi Pecini , Christian Hassager , Niels Marcussen , Jacob E. Møller

Background

Severe aortic stenosis (AS) is often accompanied by diastolic dysfunction. After aortic valve replacement (AVR), the left ventricle often undergoes considerable reverse remodeling. Despite this, diastolic dysfunction may persist after AVR. The aims of this study were to determine the incidence of elevated left ventricular (LV) filling pressure at rest and during exercise among patients with severe AS after AVR and to describe factors related to elevated LV filling pressure, especially its association with LV and left atrial remodeling and myocardial fibrosis.

Methods

Thirty-seven patients undergoing AVR were included. Echocardiography, cardiac computed tomography, and magnetic resonance imaging were performed before AVR. An LV biopsy sample was obtained during AVR and analyzed for collagen fraction. One year after AVR, right heart catheterization with exercise was performed. A mean pulmonary capillary wedge pressure (PCWP) ≥ 28 mm Hg during exercise was considered elevated.

Results

Twelve patients (32%) had elevated exercise PCWP 1 year after AVR. Exercise PCWP was highest among patients undergoing concomitant coronary artery bypass graft surgery (30 ± 7 vs 25 ± 6 mm Hg, P = .04) and among patients with preoperative stroke volume index < 35 mL/m2 (28 ± 8 vs 23 ± 4 mm Hg, P < .05). Baseline LV ejection fraction was lower among patients with elevated PCWP (56 ± 8% vs 64 ± 8%, P = .01), and coronary calcium score was significantly higher (median 870 AU [interquartile range, 454–2,491 AU] vs 179 AU [interquartile range, 63–513 AU], P = .02). Conversely, exercise PCWP was not related to the presence of high LV wall mass or to the severity of AS. Among patients undergoing isolated AVR, there was a correlation between LV interstitial volume fraction and PCWP (r = 0.57, P = .01) and mean pulmonary artery pressure (r = 0.51, P = .03) during exercise.

Conclusions

Elevated filling pressure during exercise was seen in one third of patients after AVR in this population and was seen primarily among patients with coexisting ischemic heart disease or diffuse myocardial fibrosis but was unrelated to preoperative severity of AS and LV remodeling.



中文翻译:

严重主动脉瓣狭窄主动脉瓣置换后的运动血流动力学

背景

严重的主动脉瓣狭窄(AS)通常伴有舒张功能障碍。主动脉瓣置换(AVR)后,左心室经常经历相当大的反向重塑。尽管如此,AVR后舒张功能障碍仍可能持续。这项研究的目的是确定AVR后严重AS患者在休息和运动期间左心室(LV)充盈压升高的发生率,并描述与LV充盈压升高有关的因素,尤其是其与LV和左心房的相关性重塑和心肌纤维化。

方法

包括三十七名接受AVR的患者。在AVR之前进行了超声心动图,心脏计算机断层扫描和磁共振成像。在AVR期间获得了LV活检样品,并分析了胶原蛋白含量。AVR一年后,进行了右心导管锻炼。运动期间的平均肺毛细血管楔压(PCWP)≥28 mm Hg被认为是升高的。

结果

AVR 1年后有12名患者(32%)的运动PCWP升高。在进行冠状动脉搭桥术的患者中,运动PCWP最高(30±7 vs 25±6 mm Hg,P  = .04),术前卒中体积指数<35 mL / m 2的患者(28±8 vs 23± 4毫米汞柱,P  <.05)。PCWP升高的患者的基线左室射血分数较低(56±8%vs 64±8%,P  = .01),冠状动脉钙化评分显着较高(中位值870 AU [四分位间距,454–2,491 AU] vs 179 AU [四分位数范围,63–513 AU],P = .02)。相反,锻炼PCWP与高左室壁质量的存在或AS的严重程度无关。在接受孤立AVR的患者中,运动期间LV间质体积分数与PCWP(r  = 0.57,P  = .01)和平均肺动脉压(r  = 0.51,P  = .03)之间存在相关性。

结论

在该人群中,有三分之一的患者在运动后充盈压升高,主要发生在缺血性心脏病或弥漫性心肌纤维化并存的患者中,但与术前AS和LV重塑的严重程度无关。

更新日期:2018-08-22
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