作者：贺宇，牛毅菲，黄琼，林振乾，刘荣，袁义强

单位：

1.510515广东省广州市，南方医科大学第二临床医学院 2.450006河南省郑州市第七人民医院心血管内科 3.450008河南省郑州市，河南省胸科医院心血管内科 通信作者：袁义强，E-mail：zzqyyuanyiqiang@126.com

单位（英文）：

1.The Second School of Clinical Medical University, Southern Medical University, Guangzhou 510515, China 2.Cardiovascular Internal Medicine, the 7th People's Hospital of Zhengzhou, Zhengzhou 450006, China 3.Cardiovascular Internal Medicine, Henan Provincial Chest Hospital, Zhengzhou 450008, China Corresponding author: YUAN Yiqiang, E-mail: zzqyyuanyiqiang@126.com

关键词：

主动脉瓣狭窄; 二尖瓣关闭不全; 二尖瓣反流; 经导管主动脉瓣置换术; 预后;

关键词（英文）：

Aortic valve stenosis; Mitral valve regurgitation; Mitral regurgitation; Transcatheter aortic valvereplacement; Prognosis

中图分类号：

DOI：

10.12114/j.issn.1008-5971.2023.00.005

基金项目：

河南省医学科技攻关计划省部共建项目（SB201903031）

摘要：

目的 探讨二尖瓣反流面积（MRA）分级对重度主动脉瓣狭窄（AS）合并二尖瓣关闭不全（MR患者经导管主动脉瓣置换术（TAVR）后预后的影响。方法 选取2018年4月至2021年7月在郑州市第七人民医院、河南省胸科医院应用自膨式瓣膜行TAVR的重度AS合并MR患者156例。查阅医院电子病历系统并收集患者的临床资料，所有患者术后1、6、12个月进行门诊或电话随访，记录其主要不良心脑血管事件（MACCE）发生情况。比较患者手术前后超声心动图检查结果，有无MACCE患者性别、年龄、BMI、纽约心脏病协会（NYHA）分级、合并症发生情况、既往手术史及术后超声心动图检查结果。重度AS合并MR患者TAVR后发生MACCE的影响因素分析采用多元Cox回归分析；绘制ROC曲线以评估术后MRA分级对重度AS合并MR患者TAVR后发生MACCE的预测价值。结果 156例患者均经股动脉路径TAVR，其中6例患者术中或术后24 h内死亡，最终纳入150例患者。术后患者升主动脉内径、左心室舒张末期内径（LVEDD）、左心室收缩末期内径（LVESD）、室间隔厚度（IVST）、左心房内径（LAD）、MRA小于术前，左心室射血分数（LVEF）高于术前，主动脉瓣最大流速（Vmax）慢于术前，主动脉瓣峰值跨瓣压差（Peak-AVG）低于术前，MRA分级优于术前（P<0.05）。随访12个月，共32例患者发生MACCE。有无MACCE患者年龄、BMI、NYHA分级为Ⅲ～Ⅳ级者占比、高血压发生率、糖尿病发生率、心房颤动发生率及术后LVEF、LVEDD、LVESD、IVST、LAD、MRA分级>2级者占比比较，差异有统计学意义（P<0.05）。多元Cox回归分析结果显示，术后LVEF[HR=0.927,95%CI(0.888,0.968)]、IVST[HR=0.505,95%CI(0.362,0.703)]、LAD[HR=1.185,95%CI(1.072,1.309)]、MRA分级[HR=3.336,95%CI(1.119,9.946)]是重度AS合并MR患者TAVR后发生MACCE的独立影响因素。ROC曲线分析结果显示，术后MRA分级预测重度AS合并MR患者TAVR后发生MACCE的曲线下面积为0.869[95%CI(0.802,0.935),P<0.001]。结论 TAVR可有效改善重度AS合并MR患者的心功能及减轻其二尖瓣反流程度，术后MRA分级升高是重度AS合并MR患者TAVR后发生MACCE的危险因素，且其对患者TAVR后发生MACCE有较好的预测价值。

英文摘要：

【Abstract】 Objective To investigate the effect of mitral regurgitation area (MRA) grading on prognosis after transcatheter aortic valve replacement (TAVR) in patients with severe aortic stenosis (AS) combined with mitral valve regurgitation (MR) . Methods A total of 156 patients with severe AS combined with MR who underwent TAVR with self-expandable valves in the 7th People's Hospital of Zhengzhou and Henan Provincial Chest Hospital from April 2018 to July 2021 were selected. The electronic medical record system of the hospital was consulted and the clinical data of the patients were collected. All patients were followed up by outpatient or telephone at 1, 6 and 12 months after operation, and the occurrence of major adverse cardioc and cerebrovascular events (MACCE) was recorded. The echocardiography results of patients before and after surgery were compared. Gender, age, BMI, New York Heart Association (NYHA) grading, comorbidities, previous surgical history and postoperative echocardiography results of patients with or without MACCE were compared. Multivariate Cox regression analysis was used to analyze the influencing factors of MACCE after TAVR in patients with severe AS combined with MR. The ROC curve was drawn to evaluate the predictive value of postoperative MRA grading for MACCE after TAVR in patients with severe AS combined with MR. Results All 156 patients underwent TAVR via femoral artery. Six patients died during operation or within 24 h after operation. Finally, 150 patients were included. After operation, the internal diameter of ascending aorta, left ventricular end-diastolic diameter (LVEDD) , left ventricular end-systolic diameter (LVESD) , interventricular septum thickness (IVST) , left atrial diameter (LAD) and MRA were smaller than those before operation, left ventricular ejection fraction (LVEF) was higher than that before operation, the maximum velocity on aortic valve (Vmax) was slower than that before operation, the peak-aortic valve gradient (Peak AVG) was lower than that before operation, and MRA grading was better than that before operation (P < 0.05) . During the 12-month follow-up, MACCE occurred in 32 patients. There were significant differences in age, BMI, proportion of NYHA grading of Ⅲ-Ⅳ, incidence of hypertension, incidence of diabetes, incidence of atrial fibrillation and postoperative LVEF, LVEDD, LVESD, IVST, LAD, proportion of MRA grading ≥ 2 in patients with or without MACCE (P < 0.05) . Multivariate Cox regression analysis showed that postoperative LVEF [HR=0.927, 95%CI (0.888, 0.968) ] , IVST [HR=0.505, 95%CI (0.362, 0.703) ] , LAD [HR=1.185, 95%CI (1.072, 1.309) ] and MRA grading [HR=3.336, 95%CI (1.119, 9.946) ] were independent influencing factors of MACCE after TAVR in patients with severe AS combined with MR. ROC curve analysis showed that the area under the curve of postoperative MRA grading in predicting MACCE after TAVR in patients with severe AS combined with MR was 0.869 [95%CI (0.802, 0.935) , P < 0.001 ] . Conclusion TAVR can effectively improve the cardiac function of patients with severe AS combined with MR and reduce their degree of mitral regurgitation. Elevated postoperative MRA grading is a risk factor for MACCE after TAVR in patients with severe AS combined with MR, and it has a better predictive value for MACCE after TAVR in patients.

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