高龄钙化性主动脉瓣狭窄患者的临床特点及预后分析
发布时间：2018-08-22 12:58
【摘要】：摘要一高龄钙化性主动脉瓣狭窄患者的临床特点研究[目的]分析高龄(年龄≥75岁)钙化性主动脉瓣狭窄患者的临床特征,确立与死亡相关危险因素。[方法】连续性收集2008年1月1日至2015年1月1日期间我院收治的所有年龄≥75岁且诊断为非风湿性主动脉瓣狭窄的病历共421例的临床资料。根据主动脉瓣病变程度将患者分为轻度狭窄组、中度狭窄组、重度狭窄组。随访1年观察全因及心源性死亡终点。采用Logistic回归分析与死亡相关的独立危险因素。[结果】患者平均年龄为(79.1±3.5)岁(范围75-94岁),男性57.7%。患者年龄75-80岁之间、80-85岁之间、大于85岁的比例分别为62.5%、29.2%、8.3%。其中二瓣化改变占7.4%,纽约心脏协会心功能(NYAH)Ⅲ-Ⅳ级占50.4%,58.2%合并冠心病,72%合并高血压,23.8%合并糖尿病,8.6%合并肿瘤,17.6%合并慢性肺部疾病,22.6%合并脑血管病,16.9%合并肾功能不全,6.2%合并贫血。随访1年的总死亡率及心源性死亡率为94例(22.3%)和83例(19.7%)。三组间1年全因死亡率及心源性死亡率逐渐增加但组间均无统计学差异(16.8%,22.9%,24.9%, p=0.2409,13.3%,19.3%,23.1%, p=0.0997)。Logistic多因素回归分析显示,外周血管病变(OR=2.31,95% CI:1.215-4.392)、EF值(OR=0.966,95% CI:0.942-0.991)、NT-proBNP分组(OR=2.022,95% CI:1.14-3.586)是1年全因死亡的独立危险因素；糖尿病(OR=2.157,95% CI:1.213-3.836)、EF值(OR=0.975,95% CI:0.95-1)、NT-proBNP分组(OR=2.786,95% CI:1.449-5.356)、血磷(OR=5.755, 95% CI:1.462-22.657)是1年心源性死亡的独立危险因素。[结论]高龄钙化性主动脉瓣轻度、中度、重度狭窄组组间1年全因死亡及心源性死亡率逐渐增加,但均无显著性差异。外周血管病变、EF值及NT-proBNP分组是1年全因死亡的独立危险因素；而糖尿病、EF值、NT-proBNP分组、血磷是1年心源性死亡的预测因子。摘要二 左室收缩功能下降对高龄中重度主动脉瓣狭窄患者死亡率的影响【目的】评价左室射血分数减低对于≥75岁中重度主动脉瓣狭窄(Aortic valve stenosis, AS)患者全因死亡的影响,以此明确此类患者临床治疗策略。【方法】连续收集的2008年1月1日至2015年1月1日于阜外医院住院治疗的年龄≥75岁的非风湿性主动脉瓣狭窄患者的病例,回顾性分析其中超声心动图证实狭窄程度为中重度患者共301例的临床资料。301例患者均随访至2016年1月1日观察全因死亡终点。根据超声心动图检查的EF值是否减低分为EF正常组与EF减低组,比较两组间死亡率差异。应用不同EF界值共进行5次两组间比较,分别为EF60%组与EF≤60%组,EF55%组与EF≤55%组,EF50%组与EF≤50%组,EF45%组与EF≤45%组,EF40%组与EF≤40%组。应用极限乘积法来估计生存率,使用Kaplan-Meier法估计和绘制生存曲线,使用log-rank检验进行组间生存率比较。最后选择全因存在差异的最高EF界值作为正常组与EF减低组的分组条件,观察两组间不同治疗方案药物治疗(D组)、TAVR治疗(T组)、SAVR治疗(S组)的预后差异。【结果】301例≥75岁的中重度AS患者平均年龄为78.9±3.2岁,男性共179例占59.5%,全因死亡率为24.6%。应用不同EF界值进行5次组间比较：EF≤60%组(n=171)与EF60%组(n=130)之间全因死亡率无明显差异(27.2% vs 21.2%,p=0.2187);EF≤55%组(n=101)与EF55%组(n=200)之间全因死亡率(33.5% vs20.1%,p=0.0055)存在统计学差异；EF≤50%组(n=65)与EF50%组(n=236)之间全因死亡率(42.2% vs 19.7%, p0.0001)存在明显统计学差异；EF≤45%组(n=51)与EF45%组(n=250)之间全因死亡率(45.8% vs 20.2%, p0.0001)存在明显统计学差异：EF≤40%组(n=37)与EF40%组(n=264)之间全因死亡率(48.9% vs 21.1%, p0.0001)也存在明显统计学差异。比较EF≤55%组与EF55%组的基线情况,EF减低组合并急性心肌梗死、糖尿病、慢性肺病、肾功能不全、合并二尖瓣、三尖瓣联合瓣膜病变的比例较高,NYHA分级Ⅳ级比例高、NT-proBNP数值明显升高、合并室内阻滞(LBBB/RBBB)比例高、左室舒张末期内径(LVDD)明显增大,而两组间药物治疗及TAVR、SAVR比例相当p=0.2801。矫正年龄、性别、COPD、脑血管病、跨瓣压差因素后进行的多因素回归分析显示,当EF55%时,年龄≥75岁中重度AS患者的全因死亡率明显下降[HR=0.568 (95% CI 0.34-0.947, p=0.03)]。D组在EF下降至55%或以下时全因死亡率明显增加(p=0.0003)；而无论EF是否下降,年龄≥75岁中重度AS患者全因死亡率在T组、S组或T+S组均无明显统计学差异(p0.05)。【结论】 当EF下降至≤55%时,年龄≥75岁中重度AS患者全因死亡率明显升高,其中药物治疗组全因死亡率最高。而EF值下降不影响此类患者手术(TAVR或SAVR)干预治疗的全因死亡率。摘要三高龄钙性主动脉瓣重度狭窄患者不同治疗方式的预后分析【目的】评价高龄钙化性主动脉瓣重度狭窄患者的临床特点,不同影响因素对死亡率的影响。对比不同治疗方案的预后,比较STS SCORE、EuroSCORE Ⅱ、 Logical EuroSCORE不同评分对于换瓣手术(TAVR或SAVR)结果的预测性及准确性。【方法】连续回顾性收集2008年1月1日至2015年1月1日年龄≥75岁住院诊断为非风湿性主动脉瓣狭窄病变,且超声心动图证实狭窄程度为重度患者共226例的临床资料。全部患者计算STS SCORE、EuroSCORE Ⅱ、Logical EuroSCORE。根据治疗方案不同分为药物治疗组、经皮球囊主动脉瓣成形术(PBAV组)、经导管主动脉瓣置换术(TAVR组)及外科主动脉瓣置换术(SAVR组)。患者均随访至2016年1月1日观察全因死亡终点。[结果]226例高龄重度AS患者平均年龄为78.9±3.1岁,其中75岁-80岁占61.5%,≥80岁占38.5%,男性共93例占41.2%,BMI为23.7±3.7 kg/m2,近-半病人合并冠心病110例(48.9%),一半以上(69.4%)患者NY HA分级在Ⅲ-Ⅳ级,10.6%合并肿瘤,18.1%合并慢性肺病,21.7%合并脑血管病,17.7%合并肾功能不全。药物治疗99例、PBAV治疗9例、TAVR治疗56例、SAVR治疗62例的死亡率分别为46.6%、44.4%、7.2%、6.5%。其中TAVR与SAVR组间无统计学差异(p=0.8963),TAVR、SAVR较药物治疗组死亡率均明显减低(p0.0001)。TAVR组平均logistic EuroSCORE、EuroSCORE Ⅱ和STS SCORE为20.5±13.4、4.6±2.7和3.8±2.9;SAVR组平均logistic EuroSCORE、EuroSCORE 、和STS SCORE为14.1±1].0、3.7±2.5和3.3±1.4。’TAVR组较SAVR组比较logistic EuroSCORE和EuroSCORE Ⅱ风险评分更高(p0.05),三种评分TAVR组与药物组比较无明显差异。TAVR组logistic EuroSCORE、EuroSCORE Ⅱ和STS SCORE ROC曲线下面积分别为0.843(95% CI 0.598-1.0)、0.855(95% CI 0.668-1.0)和0.899(95%C1 0.802-0.996),p均0.05。SAVR组logistic EuroSCORE、EuroSCORE Ⅱ和STS SCORE ROC曲线下面积分别为0.897(95% CI 0.800-0.993)、0.897(95% CI 0.774-1.0)和0.899(95% CI 0.687-1.0), p均0.05。Logistic多因素回归分析显示,糖尿病(OR=0.65,95% CI: 1.056-3.471)、EF值(OR=-0.036,95% CI:0.945-0.984)、合并二/三尖瓣病变(OR=0.742,95% CI:1.104-3.991)是1年全因死亡的独立危险因素。[结论]换瓣治疗较药物治疗可明显改善预后,TAVR与SAVR相比围术期及1年死亡率无明显差异;三个评分模型中Logical EuroSCORE过度的预测了短期AVR死亡风险,而EuroSCORE Ⅱ和STS SCORE更接近真实死亡率;TAVR较SAVR可减少住院日时间,但围术期起搏器及瓣周漏发生比例高；高龄重度主动脉瓣狭窄1年全因死亡的独立危险因素为糖尿病、EF值、合并二/三尖瓣疾病。
[Abstract]:[Objective] To analyze the clinical characteristics of elderly patients with calcified aortic stenosis (CAVS) and identify risk factors for death. The patients were divided into mild stenosis group, moderate stenosis group and severe stenosis group according to the severity of aortic stenosis. All-cause and cardiac death endpoints were observed after 1 year follow-up. The proportion of patients aged 75-80, 80-85 and over 85 was 62.5%, 29.2% and 8.3%, respectively. Divalvular changes accounted for 7.4%, NYAH class III-IV accounted for 50.4%, NYAH class III-IV accounted for 58.2%, CHD was associated with 72%, hypertension was associated with 23.8%, diabetes mellitus was associated with 8.6%, tumor was associated with 17.6%. The total mortality and cardiogenic mortality were 94 (22.3%) and 83 (19.7%) during the follow-up period of one year. 23.1%, P = 0.0997). Logistic regressianalysis showed that peripheralvascular lesions (OR = 2.31, 95% CI: 1.215-4.392, EF (OR = 0.966, 95% CI: 0.966, 95% CI: 0.942-0.942-0.991), NT-proBNP (OR = 2.022, 95% CI: 1.14-3.586) were independent risk factors for one-year all-cause morta; diabet (OR = 2.157, 95% CI: 1.157, 95% CI: 1.213-3.836, EF (OR = 0.966, 95% CI: 0.966, 95% CI: 0.942, 95% CI: 0.942-0.942-0.942-0.NT-proBNP Blood phosphorus (OR = 5.755, 95% CI: 1.462-22.657) was an independent risk factor for one-year cardiac death. [Conclusion] All-cause mortality and cardiac mortality increased gradually in mild, moderate and severe calcified aortic valve stenosis groups, but there was no significant difference in peripheral vascular disease, EF value and NT-proBNP. Diabetes mellitus, EF, NT-proBNP, and serum phosphorus were independent risk factors for one-year all-cause mortality. [Methods] From January 1, 2008 to January 1, 2015, patients with non-rheumatic aortic stenosis (>75 years of age) hospitalized in Fuwai Hospital were retrospectively analyzed, and echocardiographically confirmed cases were retrospectively analyzed. 301 patients with moderate or severe stenosis were followed up until January 1, 2016 to observe the all-cause endpoint. According to whether the EF value of echocardiographic examination was reduced to normal EF group and low EF group, the mortality difference between the two groups was compared. Group F < 60%, group EF55% and group EF < 55%, group EF50% and group EF < 50%, group EF45% and group EF < 45%, group EF40% and group EF < 40%. The prognosis of 301 patients with moderate to severe AS (> 75 years old) was 78.9 (+ 3.2 years old), 179 males (59.5%) and 24.6% of all-cause mortality. There was no significant difference in all-cause mortality between EF < 60% group (n = 171) and EF 60% group (n = 130) (27.2% vs 21.2%, P = 0.2187); there was significant difference in all-cause mortality between EF < 55% group (n = 101) and EF 55% group (n = 200) (33.5% vs 20.1%, P = 0.0055); there was significant difference in all-cause mortality between EF < 50% group (n = 65) and EF 50% group (n = 236) (42.2% vs 19.7%, P 0.0001). There were significant differences in all-cause mortality (45.8% vs 20.2%, P 0.0001) between EF < 45% group (n = 51) and EF 45% group (n = 250). There were significant differences in all-cause mortality (48.9% vs 21.1%, P 0.0001) between EF < 40% group (n = 37) and EF 40% group (n = 264). Acute myocardial infarction, diabetes mellitus, chronic pulmonary disease, renal insufficiency, mitral valve, tricuspid valve disease, NYHA grade IV, NT-proBNP, LBBB / RBBB, LVDD, TAVR and SAVR were higher in patients with acute myocardial infarction, diabetes mellitus, chronic pulmonary disease, and renal insufficiency. Corrected age, sex, COPD, cerebrovascular disease, and transvalvular pressure difference, multivariate regression analysis showed that the all-cause mortality of moderate to severe AS patients aged over 75 decreased significantly when EF was 55% [HR = 0.568 (95% CI 0.34-0.947, P = 0.03)]. Whether EF decreased or not, there was no significant difference in all-cause mortality between group T and group S or group T+S (p All-cause mortality after surgical intervention (TAVR or SAVR) in elderly patients with severe calcified aortic stenosis ORE, EuroSCORE II, and Logical EuroSCORE scores were used to predict the outcome of valve replacement surgery (TAVR or SAVR). [Methods] A total of 226 patients with severe stenosis confirmed by echocardiography who were hospitalized from January 1, 2008 to January 1, 2015 and aged over 75 years were retrospectively collected. STS SCORE, EuroSCORE II, and Logical EuroSCORE were calculated in all patients. The patients were divided into three groups according to different treatment schemes: drug therapy group, percutaneous balloon aortic valvuloplasty (PBAV group), transcatheter aortic valve replacement (TAVR group) and surgical aortic valve replacement (SAVR group). [Results] The average age of 226 elderly patients with severe AS was 78.9 (+ 3.1 years). Among them, 61.5% were 75-80 years old, 38.5% were over 80 years old, 93 cases were male (41.2%), BMI was 23.7 (+ 3.7 kg/m2), 110 cases (48.9%) were near-half patients with coronary heart disease, more than half (69.4%) were NY HA grade III-IV, 10.6% with tumor, 18.1% with chronic lung disease, and 21.7% with chronic lung disease. There were 99 cases treated with drug, 9 cases treated with PBAV, 56 cases treated with TAVR, and 62 cases treated with SAVR. The mortality rates were 46.6%, 44.4%, 7.2% and 6.5% respectively. There was no significant difference between TAVR and SAVR (p = 0.8963). The mortality rates of TAVR and SAVR were significantly lower than those of drug treatment group (p 0.0001). SCORE II and STS CORE were 20.5+13.4, 4.6+2.7 and 3.8+2.9; the mean logistic EuroSCORE, EuroSCORE, and STS CORE were 14.1+1]. The sub-curves of EuroSCORE, EuroSCORE II, and STSCORE ROC were 0.843 (95% CI 0.598-1.0), 0.855 (95% CI 0.668-1.0) and 0.899 (95% CI 0.668-1.0) and 0.899 (95% C1 0.802-0.802-0.996), respectively, P 0.05. The sub-curves of logistic EuroSCORE, EuroSCORE II and STSCORE ROC were 0.897 (95% CI 0.800-0.993), 0.855 (95% CI 0.668-1.0) and 0.899 (95% CI 0.802-0.802-0.802-0.996) and 0.89899 (95% CI 0.687-1). Multivariate logistic regression analysis showed that diabetes mellitus (OR = 0.65, 95% CI: 1.056-3.471), EF (OR = - 0.036, 95% CI: 0.945-0.984) and mitral/tricuspid valve disease (OR = 0.742, 95% CI: 1.104-3.991) were independent risk factors for one-year all-cause mortality. There was no significant difference between the first and second-year mortality rates; Logical EuroSCORE excessively predicted the risk of short-term AVR mortality in the three scoring models, while EuroSCORE II and STS SCORE were closer to the true mortality rates; TAVR reduced the length of hospital stay than SAVR, but the incidence of perioperative pacemaker and pericardial leak was higher; severe aortic stenosis in the elderly was all-cause death for one year. The independent risk factor was diabetes, EF, combined with two / three cusp disease.
【学位授予单位】：北京协和医学院
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R542.5
[Abstract]:[Objective] To analyze the clinical characteristics of elderly patients with calcified aortic stenosis (CAVS) and identify risk factors for death. The patients were divided into mild stenosis group, moderate stenosis group and severe stenosis group according to the severity of aortic stenosis. All-cause and cardiac death endpoints were observed after 1 year follow-up. The proportion of patients aged 75-80, 80-85 and over 85 was 62.5%, 29.2% and 8.3%, respectively. Divalvular changes accounted for 7.4%, NYAH class III-IV accounted for 50.4%, NYAH class III-IV accounted for 58.2%, CHD was associated with 72%, hypertension was associated with 23.8%, diabetes mellitus was associated with 8.6%, tumor was associated with 17.6%. The total mortality and cardiogenic mortality were 94 (22.3%) and 83 (19.7%) during the follow-up period of one year. 23.1%, P = 0.0997). Logistic regressianalysis showed that peripheralvascular lesions (OR = 2.31, 95% CI: 1.215-4.392, EF (OR = 0.966, 95% CI: 0.966, 95% CI: 0.942-0.942-0.991), NT-proBNP (OR = 2.022, 95% CI: 1.14-3.586) were independent risk factors for one-year all-cause morta; diabet (OR = 2.157, 95% CI: 1.157, 95% CI: 1.213-3.836, EF (OR = 0.966, 95% CI: 0.966, 95% CI: 0.942, 95% CI: 0.942-0.942-0.942-0.NT-proBNP Blood phosphorus (OR = 5.755, 95% CI: 1.462-22.657) was an independent risk factor for one-year cardiac death. [Conclusion] All-cause mortality and cardiac mortality increased gradually in mild, moderate and severe calcified aortic valve stenosis groups, but there was no significant difference in peripheral vascular disease, EF value and NT-proBNP. Diabetes mellitus, EF, NT-proBNP, and serum phosphorus were independent risk factors for one-year all-cause mortality. [Methods] From January 1, 2008 to January 1, 2015, patients with non-rheumatic aortic stenosis (>75 years of age) hospitalized in Fuwai Hospital were retrospectively analyzed, and echocardiographically confirmed cases were retrospectively analyzed. 301 patients with moderate or severe stenosis were followed up until January 1, 2016 to observe the all-cause endpoint. According to whether the EF value of echocardiographic examination was reduced to normal EF group and low EF group, the mortality difference between the two groups was compared. Group F < 60%, group EF55% and group EF < 55%, group EF50% and group EF < 50%, group EF45% and group EF < 45%, group EF40% and group EF < 40%. The prognosis of 301 patients with moderate to severe AS (> 75 years old) was 78.9 (+ 3.2 years old), 179 males (59.5%) and 24.6% of all-cause mortality. There was no significant difference in all-cause mortality between EF < 60% group (n = 171) and EF 60% group (n = 130) (27.2% vs 21.2%, P = 0.2187); there was significant difference in all-cause mortality between EF < 55% group (n = 101) and EF 55% group (n = 200) (33.5% vs 20.1%, P = 0.0055); there was significant difference in all-cause mortality between EF < 50% group (n = 65) and EF 50% group (n = 236) (42.2% vs 19.7%, P 0.0001). There were significant differences in all-cause mortality (45.8% vs 20.2%, P 0.0001) between EF < 45% group (n = 51) and EF 45% group (n = 250). There were significant differences in all-cause mortality (48.9% vs 21.1%, P 0.0001) between EF < 40% group (n = 37) and EF 40% group (n = 264). Acute myocardial infarction, diabetes mellitus, chronic pulmonary disease, renal insufficiency, mitral valve, tricuspid valve disease, NYHA grade IV, NT-proBNP, LBBB / RBBB, LVDD, TAVR and SAVR were higher in patients with acute myocardial infarction, diabetes mellitus, chronic pulmonary disease, and renal insufficiency. Corrected age, sex, COPD, cerebrovascular disease, and transvalvular pressure difference, multivariate regression analysis showed that the all-cause mortality of moderate to severe AS patients aged over 75 decreased significantly when EF was 55% [HR = 0.568 (95% CI 0.34-0.947, P = 0.03)]. Whether EF decreased or not, there was no significant difference in all-cause mortality between group T and group S or group T+S (p All-cause mortality after surgical intervention (TAVR or SAVR) in elderly patients with severe calcified aortic stenosis ORE, EuroSCORE II, and Logical EuroSCORE scores were used to predict the outcome of valve replacement surgery (TAVR or SAVR). [Methods] A total of 226 patients with severe stenosis confirmed by echocardiography who were hospitalized from January 1, 2008 to January 1, 2015 and aged over 75 years were retrospectively collected. STS SCORE, EuroSCORE II, and Logical EuroSCORE were calculated in all patients. The patients were divided into three groups according to different treatment schemes: drug therapy group, percutaneous balloon aortic valvuloplasty (PBAV group), transcatheter aortic valve replacement (TAVR group) and surgical aortic valve replacement (SAVR group). [Results] The average age of 226 elderly patients with severe AS was 78.9 (+ 3.1 years). Among them, 61.5% were 75-80 years old, 38.5% were over 80 years old, 93 cases were male (41.2%), BMI was 23.7 (+ 3.7 kg/m2), 110 cases (48.9%) were near-half patients with coronary heart disease, more than half (69.4%) were NY HA grade III-IV, 10.6% with tumor, 18.1% with chronic lung disease, and 21.7% with chronic lung disease. There were 99 cases treated with drug, 9 cases treated with PBAV, 56 cases treated with TAVR, and 62 cases treated with SAVR. The mortality rates were 46.6%, 44.4%, 7.2% and 6.5% respectively. There was no significant difference between TAVR and SAVR (p = 0.8963). The mortality rates of TAVR and SAVR were significantly lower than those of drug treatment group (p 0.0001). SCORE II and STS CORE were 20.5+13.4, 4.6+2.7 and 3.8+2.9; the mean logistic EuroSCORE, EuroSCORE, and STS CORE were 14.1+1]. The sub-curves of EuroSCORE, EuroSCORE II, and STSCORE ROC were 0.843 (95% CI 0.598-1.0), 0.855 (95% CI 0.668-1.0) and 0.899 (95% CI 0.668-1.0) and 0.899 (95% C1 0.802-0.802-0.996), respectively, P 0.05. The sub-curves of logistic EuroSCORE, EuroSCORE II and STSCORE ROC were 0.897 (95% CI 0.800-0.993), 0.855 (95% CI 0.668-1.0) and 0.899 (95% CI 0.802-0.802-0.802-0.996) and 0.89899 (95% CI 0.687-1). Multivariate logistic regression analysis showed that diabetes mellitus (OR = 0.65, 95% CI: 1.056-3.471), EF (OR = - 0.036, 95% CI: 0.945-0.984) and mitral/tricuspid valve disease (OR = 0.742, 95% CI: 1.104-3.991) were independent risk factors for one-year all-cause mortality. There was no significant difference between the first and second-year mortality rates; Logical EuroSCORE excessively predicted the risk of short-term AVR mortality in the three scoring models, while EuroSCORE II and STS SCORE were closer to the true mortality rates; TAVR reduced the length of hospital stay than SAVR, but the incidence of perioperative pacemaker and pericardial leak was higher; severe aortic stenosis in the elderly was all-cause death for one year. The independent risk factor was diabetes, EF, combined with two / three cusp disease.
【学位授予单位】：北京协和医学院
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R542.5
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